When Things Go Wrong

1. When Things Go Wrong Lucian L. Leape, MD Harvard School of Public Health 2nd Annual Betsy Lehman Center Patient Safety Symposium December 5, 2005

2. When Things Go Wrong • How should we respond? • Why is apology so important? • Why doesn’t it always happen? • How can we make it happen?

3. 1. How should we respond? Initial • Acknowledge the event • Express regret • Explain what happens next • Commit to investigate to find out why

4. 1. How should we respond? Follow-up • Provide feedback of results • Apologize if there is an error or failure • Make changes to prevent recurrence • Provide continuing emotional support

5. Knowing that changes were made so that others will not suffer gives a positive meaning to the patient’s experience: their suffering was not in vain

6. When there is a serious error, apologizing is the most important thing we do

7. 2. Why is apology so important? A preventable adverse event is a major threat to the patient’s trust Apology demonstrates understanding of the impact of the event and respect for the patient

8. The power of silence • Destroys the patient’s trust • Destroys the physician’s integrity

9. The components of apology (Lazare) • Acknowledge the harm • Take responsibility for it • Explain what happened • Show remorse • Make amends

10. The components of apology • Acknowledge the harm • Take responsibility for it • Explain what happened • Show remorse • Make amends

11. Apology in health care is different • The injury is physical – often devastating • The injury is a by-product of an effort to help the patient • Complications (adverse events) happen all the time – they go with the territory • The injury is unintentional – harder for doctor to feel remorse

12. The power of apology • Acknowledges patient’s feelings of anger and loss of trust • Shows understanding of injury’s impact • Helps restore patient’s dignity • Starts the healing process, restoration of trust • Helps the physician begin to heal as well

13. How apologies fail • Vague (Schwartzenegger) “I apologize for whatever I did” • Passive (Rumsfeld) “Mistakes were made” • Conditional (Trent Lott) “If I offended anyone, I’m sorry” • Empathy “I’m sorry you were hurt”

14. 3. Why doesn’t it always happen? 1. It is very difficult to apologize - The greater the injury, the harder it is - Shame and guilt can be profound 2. The doctor may not feel responsible if someone else made the mistake 3. Many lack skills in delivering bad news

15. 3. Why doesn’t it always happen? 4. Fear of the consequences - Loss of patient trust - Loss of professional respect - Risk of being sued 5. Lawyers and RM have told us not to

16. The great enemy of the truth is very often not the lie - deliberate, contrived and dishonest - but the myth - persistent, persuasive and unrealistic. John F Kennedy 1962

17. The malpractice myth Myth: If you tell the patient what happened or apologize they are more likely to sue and it will be used against you in court Reality: Patients are less likely to sue if you are open - Plaintiff lawyer experience - Evidence: VA, U. Mich, CHW, COPIC

18. What if the lawyers are right?

19. 4. How do we make it happen? • Set expectations: hospital policy • Provide skills – training • Provide support - Experts - Peers - For patients