SAYING SORRY IN SAYING SORRY IN CLINICAL PRACTICE CLINICAL PRACTICE

R. GyaneshwarCombined UOF/Sathya Sai Service Organisations

Fiji Medical Seminar

August 16, 2009.

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Case 1Case 1

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Patient’s PerspectivePatient’s Perspective

Baby damagedBaby damaged

Doctor not competentDoctor not competent

Doctor didn’t say anythingDoctor didn’t say anything

Doctor didn’t careDoctor didn’t care

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Doctor’s PerspectiveDoctor’s Perspective

I avoided a CaesarI avoided a Caesar

Mother and baby are wellMother and baby are well

Forceps marks are commonForceps marks are common

How ungrateful can people be ?How ungrateful can people be ?

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Who is Right ?Who is Right ?

The baby has a markThe baby has a mark

The mother and baby are alive and wellThe mother and baby are alive and well

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What About Consent ?What About Consent ?

When should we obtain consent?When should we obtain consent?

What are our obligations legally/ethically?What are our obligations legally/ethically?

Is a signed consent form essential?Is a signed consent form essential?

What are the consequences of not getting What are the consequences of not getting consent?consent?

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Informed consentInformed consent

More than a signed formMore than a signed formProcess of communicationProcess of communicationQuestions of detailQuestions of detail

- Diagnosis- Purpose of procedure- Risks / benefits- Alternatives

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Material RiskMaterial Risk

High Court ( Rogers v Whitaker, 1992)High Court ( Rogers v Whitaker, 1992)

Material risks are those to which a Material risks are those to which a reasonable person in the patient’s position reasonable person in the patient’s position is likely to attach significance, or those to is likely to attach significance, or those to which the doctor knows or ought to know which the doctor knows or ought to know the particular patient is likely to attach the particular patient is likely to attach significance.significance.

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When things go wrongWhen things go wrong

Clinicians feel badClinicians feel badSense of vulnerability / fearSense of vulnerability / fearTemptation to ignore or trivialiseTemptation to ignore or trivialiseTendency to blameTendency to blameUrge to run awayUrge to run away

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HINDSIGHHINDSIGHT BIAST BIAS

Before the Accident

After the Accident

Modified from presentation by Charles Vincent, Clinical Safety Research Unit

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Patients Want :Patients Want :

To know the truthTo know the truthHave the Health authority accept Have the Health authority accept

responsibilityresponsibilityApology for the hurt causedApology for the hurt causedApology from the doctorApology from the doctor

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What is the Truth ?What is the Truth ?

Our perception is our truth regardless of Our perception is our truth regardless of the facts.the facts.

Patients often believe that an unexpected Patients often believe that an unexpected outcome is due to outcome is due to MEDICAL ERRORMEDICAL ERROR

Patient expectations are often unrealisticPatient expectations are often unrealistic

ignoring side effects and complicationsignoring side effects and complications

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Saying SorrySaying Sorry

? Admission of fault? Admission of fault

Hence may lead to liabilityHence may lead to liability

Expression of sympathy for hurt causedExpression of sympathy for hurt caused

Remorse for possible mistakeRemorse for possible mistake

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Sorry Works CoalitionSorry Works Coalition

Reduces angerReduces anger

Reduces risk of law suitsReduces risk of law suits

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Apology in Medical PracticeApology in Medical Practice

Acknowledgement of event of injuryAcknowledgement of event of injuryExplanation of the circumstancesExplanation of the circumstancesHumilityHumilityReparationReparation

Lasare, JAMA 2006, 296(11):1401-4.Lasare, JAMA 2006, 296(11):1401-4.

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When things go wrong !When things go wrong !

What is our responsibility :What is our responsibility : - - to the patient ?

- to ourselves ? ?What is the responsibility of the Medical What is the responsibility of the Medical

Board ?Board ?What is the responsibility of the What is the responsibility of the

professional body ?professional body ?

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Why do people sue doctors ?Why do people sue doctors ?Vincent C. Lancet 1994;343(1):609-13Vincent C. Lancet 1994;343(1):609-13

Patients desire human interaction and Patients desire human interaction and communication when things have gone communication when things have gone wrong.wrong.

Malpractice suits correlate poorly with Malpractice suits correlate poorly with actual occurrence of negligenceactual occurrence of negligence

Most patients injured don’t sueMost patients injured don’t suePoor communication is a greater risk for Poor communication is a greater risk for

litigationlitigation

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Medical Negligence LitigationMedical Negligence Litigation

Negligence is a claim that the doctor did Negligence is a claim that the doctor did not provide care to the standard expected not provide care to the standard expected by the lawby the law

Courts are guided but not bound by the Courts are guided but not bound by the standards of the professionstandards of the profession

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The law expects a doctor to exercise The law expects a doctor to exercise

reasonable care and skill in providing reasonable care and skill in providing

advice and managementadvice and management

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To err is humanTo err is human

US Institute of Health 1999US Institute of Health 1999Kohn LT, Corrigan JM. Kohn LT, Corrigan JM.

To err is human : building a safer health system. To err is human : building a safer health system. Washington DC. National Ac press; 1999.Washington DC. National Ac press; 1999.

““Mistakes are part of the human condition” Mistakes are part of the human condition”

Healthcare is a risky business.Healthcare is a risky business.

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Conditions That Lead to ErrorConditions That Lead to Error

Unfamiliarity with task Unfamiliarity with task (x17)(x17)Shortage of time Shortage of time (x10)(x10)Poor human equipment interface Poor human equipment interface (x8)(x8) Inexperience Inexperience (x4)(x4)Poor procedures Poor procedures (x3)(x3) Inadequate checking Inadequate checking (x3)(x3)

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Making Us SaferMaking Us Safer

Recognise limitsRecognise limitsProvide assistance - check listsProvide assistance - check listsAvoid interruptionsAvoid interruptionsRealistic workloadRealistic workloadWork within competenceWork within competence Improved work environment/conditionsImproved work environment/conditions

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Understanding Medical ErrorUnderstanding Medical Error

Uncertainties of clinical practiceUncertainties of clinical practice- Stressed staff

- Difficult patient

- Inadequate resources

Nature of clinical decisionsNature of clinical decisions

Activity levelsActivity levels

Time pressuresTime pressures

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Clinical Governance ModelClinical Governance Model

Education & TrainingEducation & Training

Providing Quality

Healthcare

Risk Management

Risk Management

Clinical Effectiveness

Clinical Effectiveness

Consumer Participation

Consumer Participation

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Case 2Case 2

Instead of Hep B immunoglobulin, Instead of Hep B immunoglobulin, Anti-D given to babyAnti-D given to baby

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How Is Safety Achieved?How Is Safety Achieved?

Analysing near missesAnalysing near missesReviewing adverse eventsReviewing adverse eventsErrors/mistakes are opportunities for Errors/mistakes are opportunities for

improvementimprovementEstablishing an environment which is patient Establishing an environment which is patient

focussed and safety consciousfocussed and safety conscious

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SummarySummary

Talk / listen to your patientsTalk / listen to your patients

You are human , you will make mistakesYou are human , you will make mistakes

Learn from your mistakesLearn from your mistakes

Be honest and upfrontBe honest and upfront

Don’t be frightened to say sorryDon’t be frightened to say sorry

Maintain good clinical notesMaintain good clinical notes