To Err is Human

Cognitive errors physicians makeApology in medical practice

Safety of Health Care?

• At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented

• Error is eighth leading cause of death in the US• Preventable medical errors in hospitals exceed

attributable deaths to motor-vehicle accidents, breast cancer, or AIDS

http://www.nap.edu/books/0309068371/html/

Human Error

• An error is a failure of achieving the intended outcome in a planned sequence of mental or physical activities when that failure is not due to chance

• Slips that result from the incorrect execution of a correct action sequence

• Mistakes that result from the correct execution of an incorrect action sequence.

Medical errors

The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

• adverse drug events and improper transfusions, • surgical injuries and wrong-site surgery, • suicides, • restraint-related injuries or death, • falls,• burns, • pressure ulcers, • mistaken patient identities.

Types of Errors

Diagnostic • Error or delay in diagnosis • Failure to employ indicated tests • Use of outmoded tests or therapy • Failure to act on results of monitoring or

testing

Treatment • Error in the performance of an

operation, procedure, or test • Error in administering the treatment • Error in the dose or method of using a

drug • Avoidable delay in treatment or in

responding to an abnormal test • Inappropriate (not indicated) care

Preventive • Failure to provide

prophylactic treatment • Inadequate monitoring

or follow-up of treatment

Other • Failure of communication • Equipment failure • Other system failure

Leape et al., 1993

Diagnostic errors

• Misdiagnosis occurs in 15% to 20% of all cases; in half of these there is serious harm to the patient

• 80% of misdiagnoses are due to cognitive errors

• Can thinking about thinking help prevent these errors?

Thinkink traps

• Anchoring• Availability• Attribution• Confirmation bias• Representativeness error

Anchoring

• Fixing on a particular bit of information or data given to us and then think in a constrained linear way

• Patient´s complaint of gas cause clinicians to initially miss an abdominal aneurysm

Availability

• Being influenced by dramatic or unusual cases that are prominent in our memory and easily recalled, thus „available“ when we consider a new patient´s problem

• Crohn´s disease with initial symptom of weight loss and fatigue; each specialist who sam the patient considered diagnoses in their own particular field

Attribution error

• Being influenced by certain personal characteristics, those that correspond to social stereotypes

• Elderly woman with failure to thrive diagnosed „odl age“; poor food intake and weight loss were due to masseter claudication from temporal arteritis

• Wealthy businessman in India could not have leprosy as a cause of his neuropathy since this was a disease of the poor

Confirmation bias

• Ignoring or racionalizing contradictory data to make the pieces of the puzzle fit neatly into the presumed picture

• An unusual complaint or laboratory finding is dismissed as an outlier when it should actually rise a red flag

Remedies

Ask yourself:• What else could it be?• Does anything not fit?• Could there be more than one process at

work?

Groopman and Hartzband, 2011

Apology in medical practice

Apology in Medical Practice

• 1999 Institute of medicine Report: To Err is Human

• Physicians were encouraged to disclose medical errors

• Offering an apology = next step• The goal: to enhance patient safety and fulfill an

ethical commitment of honesty to patients• The outcome: reduction in the number and

cost of malpractice claims

Apology• An acknowledgment of responsibility for an offense coupled with

an expression of remorse.• An offense refers to a physical or psychological harm caused by an

individual or group that could or should have been avoided by ordinary standards of nehaviour.

• A failed medical procedure or action caused by a physician´s poor judgment that would be so regarded by the medical community at large would be an offense.

• An unfortunate ouctome, such as unsuccesfull surgery or other medical treatment that is widely reagrded as high risk by patient, is not regarded an offense for which aplogy should be offered. In such case consoling comments: „ I am so sorry for what happened“

Poor judgment vs. Unfortunate outcome in high-risk patient

• A failed medical procedure or action caused by a physician´s poor judgment that would be so regarded by the medical community at large would be an offense.

• An unfortunate ouctome, such as unsuccesfull surgery or other medical treatment that is widely regarded as high risk by patient, is not regarded an offense for which aplogy should be offered. In such case consoling comments: „ I am so sorry for what happened“ .

Structure and content of apology

Part 1: The acknowledgement

• Includes: The indentity of the offender, appropriate details of the offense and validation that the behaviour was unacceptable.

• The acknowledgement that the patient was not at fault.

• The acknowledgement between physician and patient of shared values , what is right and wrong.

Part 2: Explanations

An explanation of why and how the offense occured.

• „I was late because of a medical emergency“: mitigate the offense

• „I left the operating room to go to the bank“: aggravate the offense

• „There is just no excuse for what happened.“• „We are still trying to find out what happened.“

Part 3: Expression of remorse and a deep regret about what happened

• Remorse: deep sense of regret• Shame: the emotion associated with failing to

live up to one´s standards• Forbearance: commitment not to repeate the

offense• Humility is the state of being humble, not

arrogant

Part 4: An offer of reparation for damages

• Early scheduling of the next appointment • Financial (canceling the bill, a financial

settlement,..)• Verbal• Otherwise

Goals of the apology

1. Restoring dignity and power2. Regaining trust3. Feeling cared for4. Extending empathy and understanding5. Letting go

patients do not want to be disrespected, humiliated or disempowered

Framework of the apology

Who is present for the apology discussionWhere the apology takes place

The nature of emotional interaction

Who should be present

• The patient• Family member or friend selected by the

patient• The attending physician• Nurse, other staff and hospital administration

need to be considered

The setting of the discussion

• A room that affords privacy and is comfortable • Cell phones turned off• Distraction and interruptions should be

avoided

The timing of the apology

• Formal and complete apologies should be witheld until the presence and nature of the offense or mistake are clear

• The suggestion by the physician for follow-up meetings to track the patient´s progress and listen to concerns that have not previously been verbalized

The nature of the interaction

Clinical Coaching

Education

Motivational Interviewing

Barrier-free Access

doctoras sparingpartner, shares knowledge,communicates comprehensibly, respects patient´s opinion, negotiates procedure,offers choice

The nature of the interaction

• The patient should have the opportunity for catharsis, verbalizing feelings about the event and the physician.

• Ask Open questions• Affirm• Listen Reflectively• Summarize

The need for a dialogue

• Dialogue!! Partnership! • Not a rapid monologue by the doctor that

prevents interruption by the patient will leave the patient dissatisfied

• The patient will have concerns, worries, questions and feelings.

Non-barrier communication!

How apologies heal

• Restoration of self-respect and dignity• Feeling cared for• Restoration of power• Suffering in the offender• Validation that the offense occured

Some patients want to see their offending physician suffer;

Patients may try to force the resignation of someone on the

treatment team

How apologies heal

• Designation of fault• Assurance of shared values• Entering into a dialogue with the offender• Reparations• A promise for the future

Patient and family need the opportunity toask questions and

express feelings: anger, fear, helplessness, frustration and

abandonment; respond with EMPATHY

Who offers and receives the apology

• The physician in charge, the nurse, the resident…

• Who receives the apology: the pacient, family members or both

Timing of Apologies

• As soon as it is ascertained that a medical error has occured

• Before such determinaniton is made and fault assigned the physician may express concern of what hapenned pending further exploration

• An unreasonable delay in communication is often perceived as disrespectful or deceitful

Apology as a Negotiation

• A back and forth between two parties over how much the physician is willing to offer and how much the patient needs

• The subject of negotiation – all structures and functions of the apology

How apologies fail

• Due to fraudulence, insincerity or disingenuousness

• Experienced as insulting or offensive, not healing

• They make the situation worse

Errors in apologizing

• The failure to adequaetely acknowledge the offense:

• Too vague: „ I apologize“ ; „ I apologize for whatever happpened“;

• Sorry is used to avoid acknowledging the offense: „ I am so sorry for what happened“

• The passive voice: „ mistakes were made“• If or but is used to mitigate the offense: „ If there

was an error“; there was a mistake, but….“

Errors in apologizing

• Unacceptable explanations: „ the alcohol made me do it“

• Arrogance instead of shame or humility „these things happen to the best people“

• Unacceptable reparations

Resistance to apologize

• The fear of consequences: angry patient, a complaint sent to the state board, malpractice suit Evidence suggest that

admissions of harm and apologies strengthen rather

than jeopardize relationships and diminish punitive

responses

Resistance to apologize

• The need for physicians to maintain a self-image for themselves and others of being strong, always in charge, unemotional and a perfectionst

• The feared loss of this self-image may lead to the unbearable emotion of shame and subsequent feelings of depression

Offenses other than medical errors

• The humiliation of medical students (especially females) by their supervisors was a ritual practice

• Physicians´ behaviour that humiliate or offend patients: excessive waiting times, failure to address the patient by his name, violations of privacy, failure to listen and explain,…

Conclusion• Effective apology = the most profound healing

process between individuals, groups, nations.• It may restore damaged relationships or

strengthen previously satisfactory relationship• For the offender, offering an apology may

diminished guilt, shame and the fear of retaliation• For the offended party receiving an apology may

remove a grudge with it anger, and facilitating forgiveness and reconciliation

• Aaron Lazare. Apology in Medical Practice. JAMA, 2006- vol 296, No 11