How to Disclose Medical Errors and Unanticipated Outcomes
When a medical error occurs, every provider needs to know how to share this information with patients and families. Timely and clear disclosure builds trust and reduces the risk of litigation. Follow this practical strategy to guide your conversation, provided by an interdisciplinary team of providers and risk managers.
By Ryan Murphy, Suzetter Goucher, Carrie Sullivan, Amanda Moloney-Jones, Christina Derbidge, and Jared Henricksen | 6 minutes
LEARNING OBJECTIVES
After reading this article, you will be able to:
- Advocate for timely, transparent, and clear disclosure of medical errors.
- Identify barriers to disclosure.
- Use recommended strategies in disclosing errors to patients and families.
CASE STUDY
Shortly before shift change, a patient with cirrhosis is admitted with spontaneous bacterial peritonitis, a dangerous but treatable abdominal infection. The admitting provider orders the appropriate antibiotic, discusses the case with the hepatology specialist, and signs out care to the evening provider. Shortly thereafter, the hepatologist instructs the evening provider to increase the antibiotic dose. Unfortunately, the new medication order defaults for an administration time the following morning. The evening provider, pharmacist, and nurse caring for the patient all fail to notice the change in timing, and no antibiotics are administered. The following morning, the original provider returns to find the patient considerably worsened and discovers the error.
Errors and unanticipated outcomes are an unfortunate reality in medicine and create significant distress for all involved. Patients report feeling angry, depressed, and traumatized; they lose trust in both their providers and the healthcare system. Providers can feel similar emotions and struggle greatly with how to respond. But how they respond and the timeliness with which they do so has a profound impact on the experience and likelihood of restoring trust.1
WHAT IS DISCLOSURE?
Disclosure is the act of revealing information to a patient or family. It is a process, not an isolated occurrenceespecially after serious events. Whether the patient suffers an unanticipated outcome without clear fault or a true medical error, the process can include multiple cycles of response, disclosure, investigation, and analysis before ultimately achieving resolution.
WHEN TO DISCLOSE AN EVENT
The initial disclosure conversation should be held as soon as possible and will set the tone for subsequent investigation and follow-up.
HOW TO DISCLOSE AN EVENT
FIRST, BE AWARE OF THE UNIQUE CHALLENGES
There are general strategies to help deliver bad news that should be followed, but disclosure of medical errors presents some unique additional challenges. Providers may be embarrassed, unsure of what to say, or nervous about legal liability.2 As a result, disclosure of medical errors may be perceived as incomplete (partial disclosure) or may never happen.3 This not only fails to fulfill our responsibility for clear and consistent communication, but often leads to the very lawsuits providers hope to avoid.4
Many states, including Utah, have implemented to protect providers who express sympathy or condolences after a medical error or unanticipated outcome. While protections vary state-to-state, and providers should be careful not to admit or assign fault prematurely or inappropriately, these protections help providers better meet patient communication needs.
Beyond legal protections, multiple organizations have also found that efforts to reform their disclosure practice increase transparency and reduce litigation costs.5 The aligns with and helps individuals and the organization respond to patients and families in a timely, thorough, and just way.
SECOND, FOLLOW A PROCESS: FIVE STEPS TO SUCCESSFUL DISCLOSURE
The following Five Steps to Successful Disclosure are recommended for the initial disclosure meeting after a medical error or unanticipated outcome.
STEP 1: SET UP THE CONVERSATION
ASK FOR AND HOST A CONVERSATION
Dont wait! Do this as soon as possible after the event is discovered.
Organize. Gather as much information as possible for the patient and family. Consider which members of the patients personal support system should be present. Identify which members of the health care team should take part in the disclosure with you. The attending provider should be present if possible, but you may not be able to wait.
Set the stage. Find a private and quiet place to meet. Know and use the patients name. Introduce yourself and any other individuals in attendance. Sit down. Minimize distractions.
PREPARE THE PATIENT/FAMILY FOR SERIOUS CONVERSATION
Make an opening statement. Start from the beginning and prepare the patient/family with a shot across the bow: There has been an unanticipated event in your care and I am here to tell you everything I can.
Share the information you know. Explain objectively what occurred: You did not receive the antibiotics we intended to give you last night. Make factual conclusions and resist the urge to speculate on what may have happened.
STEP 2: LISTEN AND ASSESS UNDERSTANDING
INVITE QUESTIONS AND LISTEN OPENLY
Listen allow silence, explore emotion. After sharing a sentence or two about the event, ask if they are ready to hear more details. Allow time for a response. Throughout this conversation, there may be comments or behaviors reflecting grief responses such as anger or disbelief.
Assess understanding. Depending on the situation, patients and families may misinterpret or not hear information discussed. Be ready to repeat information or give information in another way if needed. Encourage patients and families to ask questions so they gain understanding. Anticipate varied responses from different people. Be prepared to listen and offer support.
STEP 3: APOLOGIZE SINCERELY
APOLOGIZE WITH SINCERITY
Allow yourself to be vulnerable. Vulnerability is sincerityits okay to feel uncomfortable. You should offer words of apology and condolences such as, I am sorry this happened. Apologize more than once. When appropriate, use phrases of reassurance such as, We are going to take care of you.
Avoid blame. Be careful not to prematurely assign blame with phrases like we screwed up, or this is _____s fault. Subsequent conversations after additional investigation will better address this.
STEP 4: DISCUSS NEXT STEPS
DISCUSS NEXT STEPS IN CARING FOR THE PATIENT
Console. You can promise patients will receive the ongoing medical care they need. We will monitor you closely and provide any further care you need.
DISCUSS NEXT STEPS FOR INVESTIGATION AND PREVENTION OF RECURRENCE
Introduce investigation and what to expect. If certain details remain unclear, explain that further investigation will take place. You can assure the patient that results of this investigation will be shared with them and inform specific actions to prevent a similar event from happening again.
DISCUSS WHO WILL SPEAL TO THE PATIENT/FAMILY NEXT AND WHEN
Provide a contact. Identify a contact for patients and families who will manage follow-up communication to discuss the situation. Be as specific as possible.
STEP 5: SUPPORT THE PATIENT/FAMILY, YOURSELF, AND YOUR TEAM
OFFER SUPPORT SERVICES TO THE PATIENT/FAMILY
Spiritual and emotional support. Consider inviting a behavioral health provider or clergy to the meeting. Otherwise, offer to facilitate services afterwards.
Financial support. If finances are raised as a concern, acknowledge that as a legitimate concern and explain that this will be addressed by the organization.
NAVIGATE A PATIENT DEATH
If a patient dies unexpectedly, be sure to use the word dead, died, or death to be clear about what you are saying. Use the patients name.
Death of a patient is a significant event and will result in numerous coordinated actions from members of the healthcare team. , leverage support services, and take your time to walk family through the next steps.
SEEK SUPPORT FOR YOU AND YOUR TEAM
Recognize the impact medical errors, especially those resulting in death, will have on you and your team. 泫圖弝け care providers can become the second victim of medical error. Be proactive about seeking support from local resources like the Resiliency Center.
Contact for any general assistance with disclosure or after any serious unanticipated outcome.
CONCLUSION
Let's return to our patient with cirrhosis. From the moment the error was discovered, immediate actions were taken to care for the patient and disclose the event to the patients family. A report was filed in the organizations event reporting system, and further investigation identified the various failures that allowed the error to lead to harm. The patient unfortunately suffered complications from her abdominal infection and passed away in the hospital. A formal interprofessional review identified strategies to reduce the risk of a similar event in the future. The patients family was deeply saddened, but was regularly updated and included throughout the entire process.
ADDITIONAL LEARNING
Read the 泫圖弝け of Utah 泫圖弝け complete .
Watch the introductory video on "" from as part of the UACT training series.
REFERENCES
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. J Am Med Assoc. 2003;289(8):1001-1007.
- Mcdonnell WM, Guenther E. Ann Intern Med. 2008:811-816.
- Gallagher TH, Garbutt JM, Waterman AD, et al. Arch Intern Med. 2006;166(15):1585. doi:10.1001/archinte.166.15.1585
- Vincent C, Young M, Phillips A. Lancet. 1994;343(8913):1609-1613.
- Mello MM, Studdert DM, Kachalia A. JAMA - J Am Med Assoc. 2014;312(20):2146-2155. doi:10.1001/jama.2014.10705
CONTRIBUTORS
RYAN MURPHY
Hospitalist and Associate Editor, Accelerate, 泫圖弝け of Utah 泫圖弝け
Suzette Goucher
Senior Director, Risk Management, 泫圖弝け of Utah 泫圖弝け
Carrie Sullivan
Associate Director, Risk Management, 泫圖弝け of Utah 泫圖弝け
Amanda Moloney-Johns
MPAS, PA-C
Christina Derbidge
Psychologist, Physical Medicine and Rehabilitation, 泫圖弝け of Utah 泫圖弝け
Jared Henricksen
Associate Professor, Division of Critical Care, Department of Pediatrics, 泫圖弝け of Utah School of Medicine, 泫圖弝け of Utah 泫圖弝け
