Talking with Patients after a Medical Error: What to do? What to say?

1. Talking with Patients after a Medical Error:What to do? What to say? Julie Crosson, MD, Evans Educator Communication Skills Thomas Barber, MD, Evans Educator, Department of Medicine ML Hannay, M.Ed., Communication & Leadership Specialist Medicine Grand Rounds, January 6, 2012 Boston University School of Medicine Thank you to The American Academy on Communication in Healthcare, and to Dr. Robert Truog, Exec. Dir. Institute for Professionalism and Ethical Practice, HMS

2. Disclosure I have made medical errors that affected patients.

3. Why a grand rounds on errors? • Increase patient trust • Decrease doctor isolation and burnout • Improve patient safety by talking to colleagues about errors to improve safety outcomes

4. Overview • Present case of a medical error • Review current data on “Disclosure Gap” • Identify benefits and barriers to disclosure and apology 4. Review steps for talking about medical errors with patients and families 5. Reflect on the case

5. Case presentation • 66 yr old man with complex PMH admitted to medical service in May 2011 for nausea and abdominal pain. • History of IDDM, CAD s/p CABG and AVR for AS, CVA, PVD, OSA, HTN, hyperlipidemia, anxiety, COPD w 50 pack-year tobacco history • On 27 medications • Retired, worked unloading trains; lives w daughter and wife

6. History and Exam • Admitted for ? CVA vs. TIA 3/10. Since then, c/o persistent nausea, burping, bloating and epigastric pain w/o vomiting. No change in diet or appetite. Normal BM. Confused about meds. • VS: 197/115, 88, 20 (O2 sat 95% RA) Afebrile • Not acutely ill but uncomfortable. RRR S1S2 normal, 3/6 systolic ejection M, lungs clear, abd w active BS, soft, nondistended, nontender • Labs: WBC 5.7, hgb 12.5, lytes normal, Gluc 266, amylase, LFTs, cardiac enzymes normal.

7. Imaging • KUB moderate amount of stool, no obstruction. • CT abd/pelvis: no obstruction. Cholelithiasis, colonic diverticula w/o diverticulitis, rim enhancing splenic lesion likely hemangioma, oval soft tissue mass in RLL adjacent to the esophagus.

8. Impression • Probable diabetic gastroparesis. He had been prescribed metaclopromide but was unsure if he was taking this. • Metaclopromide, ondansetron, simethicone given • Control of hyperglycemia • Gastric emptying scan as outpatient • Lactose free diet “Other issues per house staff. We will try to simplify his complex regimen but defer major decisions to his new PCP and his cardiologists.”

9. Outcomes • Pt discharged after 36 hours, ? improved. • Frequent visits with PCP, endocrinology, cardiology over the summer • Gastric emptying scan normal. • 23 lb unexplained weight loss between May and September 2011: Weight loss w/up, including CXR 9/7 normal. • 9/21/11 PCP paged me: “did you know about the mass in the RLL? It’s documented in the admit note and in the DC summary that this needed f/up. I didn’t know about it till today.”

10. Readmitted to hospital • Pt readmitted to my service 9/21/11 for urgent w/up. • CT chest w IV contrast: “interval growth of the RLL spiculated, centrally necrotic soft tissue mass adjacent to the esophagus, now with possible invasion into the esophageal wall. Findings very suspicious for cancer.” • Metastatic work up initiated.

11. If you were Tom… • What would your feelings/emotions be? • What do you think you should do or say? • What do you think you would do or say?

12. What does a patient want/expect? • If this occurred to your father/brother, how would he feel? • What would he want/expect the doctor to do or say?

13. Patients’ Emotions Dread Fear (retribution form HCWs) Isolation Guilt (family: feel they didn’t keep close enough watch on the pt) Anger Powerlessness Worry NEJM 2007 Doctors’ Emotions Dread Fear of Punishment (sued) Isolation Guilt/Shame (harming a pt) Anger (poor system set them up) Powerlessness Worry (job, reputation) Self-doubt “The Second Victim” Wu AW BMJ 2000;320:726-7

14. OLD LADY

15. The Recent History of Medical Errors IOM report 1999: ‘To Err is Human’ • 98,000 deaths/year due to medical errors • Hospital Safety Movement, systems-based changes: EMR, procedure check lists • ACGME competencies include quality improvement and improving patient safety

16. Definitions A Medical Error : Failure to complete an action as intended, or the use of a wrong plan to achieve an aim. May or may not result in adverse outcome. Unanticipated Outcome: A result that differs significantly from what was anticipated. Omission: Something left undone, neglect of duty. Institute or Medicine, To Err is Human 1999 Webster Dictionary

17. Gallagher et al. JAMA 2003;289:1001.

18. Gallagher et al. JAMA 2003;289:1001.

19. Disclosure GAP 90% of Doctors support the principle of disclosure but Only 30% actually do disclose

20. Barriers to Disclosure Skeptical of benefits Unnecessary distress to patient and family Patients unlikely to find out Lawsuits Lack of training in error disclosure NEJM 2004

21. Benefits of Disclosure Evidence suggests that skillful conversations and follow-up may reduce the risk of litigation Harvard Medical Practice Study only 3-5% of patients injured by negligent care actually sue, NEJM 2004

22. Full disclosure policy, University of Michigan NEJM, May 25, 2006

23. Benefits of Disclosure Staying engaged with patients and restoring trust results in better outcomes for both patients and clinicians The right thing to do Dr. Robert Truog, Institute for Professionalism and Ethical Practice, Harvard Medical School.

24. What Is the Threshold for Disclosure? “You would want to know about the event, if it had happened to you or a relative, or It may result in a change in treatment, now or in the future.” - Dr. Robert Truog, Executive Director Institute for Professionalism and Ethical Practice, Harvard Medical School

25. What Information to Disclose

26. How to Disclose an Error

27. Role of Apology

28. When to Have the Conversation

29. Back to the case….. The conversation

30. Next steps • Primary data collected, information confirmed with PCP • Evidence of failure to identify very abnormal radiologic finding and to communicate this effectively to PCP • Requirement to disclose information to patient • Discussion with Risk Management • Stars report • Preparation • Meeting with patient and family • Documentation in record

31. How is our patient now? • Dx Squamous Cell CA Lung, locally advanced Stage IIIB (T4N1M0), on Gemcitibine protocol • Tolerating chemo fairly well, but low functional status • Weight 147 lbs on 1/3/11

32. What are the steps for discussion?

33. What are the steps for discussion? 1. Preparation • Self check-in • Seek assistance from trusted colleague • Review available medical facts • Consult risk management • page 31-SAFE • Patient Advocate: x4-1778 • Prepare for strong emotions, both from yourself and patient/family

34. 2. State What Happened Simply Slowly Avoid medical jargon Use pauses

35. 3. Apologize Focus on patient’s welfare “I’m sorry”

36. Two meanings of the words “I’m sorry” Dr. Robert Truog, Institute for Professionalism and Ethical Practice, Harvard Medical School. • Expression of compassion: “I’m so sorry that this has happened.” 2. Expression of responsibility: “I gave you the wrong dose. I am truly sorry.” • The first is always appropriate • The second is appropriate only when it is true

37. How Apologies Fail Lazare JAMA 2006; 296:1401, Berlinger After Harm. Johns Hopkins, 2005 “If there was an error…” “There was a mistake, but…” “The mistake certainly didn’t change the outcome…” “Sometimes these things happen…”

38. 4. Take Responsibility Use “I” statements Do not blame or speculate Do not accept fault unnecessarily

39. 5. Assurance The steps you are going to take to avoid this error occurring in the future

40. 6. Invite questions 40% of patients stated they wished they had opportunity to ask questions “What questions do you have?”

41. 7. Make a Follow-up plan Discuss together how to meet needs of patient and family Plan for next meeting Remain accessible

42. 8. Document Rationale for clinical decisions Clinical outcome and plan of care Discussion with patient/family Names/relationships of those present Questions posed and the answers given

43. 9. Debrief Back to self check-in Discuss with colleague Reflection helps us improve

44. The steps for discussion Preparation- check-in State what happened simply Apology Take responsibility Assurance/Problem Solving Invite questions Make follow up plan together Document Debrief Gallagher, JCOM 2005l12l5:253-259

45. How to take what you know into what you can do You cannot force yourself to feel something you do not feel But you can make yourself do right in spite of your feelings Pearl S. Buck

46. Build on what you already do You already use the skills--Giving bad news re: a diagnosis Instincts are to show empathy, to tell the truth, to listen to their fears Use the relationship building strategies that data shows work to enhance outcomes/compliance Build trust prior to as well as after an error

47. Starting the conversation • Set up—where, when, who? • 1-1, Doctor/patient , start the conversation 30 seconds • Debrief patient to doctor, 30 seconds • What worked/didn’t work? • Words, Voice Tone/Speed, Non Verbal? • What % for each (must equal 100%)?

48. 55-70% 25-35% 7-15% Verbal/Nonverbal Communications face to face conversation impact: 60 50 40 Body Language 30 Tone of Voice 20 10 Words 0

49. Common Sense • Is not common practice • 80% of doing this well is • Showing up to do it—with behavior that demonstrates your empathy, caring, and concern

50. Authentic Apology: in addition to helping both doctor and patient heal…. • …“nothing is more effective in reducing liability than an authentically offered apology” Michael Woods, MD (Colorado surgeon) • …my job is much more difficult when doctors fall on the sword….”“The hardest case for me to bring is the case where the defense has admitted error and apologized to the injured patient.” Andrew Meyer, Boston area Medical Malpractice lawyer