Breaking the Silence: Disclosing Medical Errors

In circumstances where a medical error results in an adverse outcome, a thoughtful response on the part of the veterinarian, staff, and practice is required. The insurance carrier should be contacted as soon as possible. The fear of formal complaints and potential malpractice suits can cloud judgment when considering the best course of action. This presentation will review communication techniques for constructively responding to these difficult situations. Author’s address: University of Florida, College of Veterinary Medicine, 2015 SW 16th Ave., Gainesville, FL 32610; e-mail: housea@ufl.edu.

1. Introduction

There has been increasing public awareness of patient safety in human healthcare and attention on a disturbing rise in medical errors. Further, research on the relationship between communication and malpractice risk has shown that the majority of malpractice litigation in human medicine is related to poor communication between the patient and the physician.^1–3 In addition, the importance of having open and frank discussions when medical errors occur in healthcare has been highlighted by several professional organizations and institutions and published in the scientific and news media.^{4 –10}

In human medicine, there have been numerous changes that have taken place to address the complex problem related to the rise in medical errors and patient safety through accreditation standards, state legislation, and professional expectations. One notable change has included human hospital requirements implemented in 2002 requiring that healthcare providers have open discussions with patients or their representatives whenever outcomes differ significantly from the anticipated. Many organizations and states have come forward to encourage forthrightness when there has been a disappointing outcome due to medical error. These requirements have fueled the call for specific training for healthcare providers in meeting the challenge of engaging in such honest yet difficult conversations. While many healthcare providers are adept at sharing bad news with their patients in a sensitive and empathic manner, when the bad news is an adverse outcome due to a medical error it requires additional tools, insight, and practice. 

In veterinary medicine, it is also evident that veterinarians and healthcare staff must possess the necessary skills and understanding to communicate effectively when clients and families are disappointed with the outcome of care. In order to address this constructively, clinicians must understand what caused the disappointing outcome, how the client and family feel and think about it, and then respond in a timely and empathic manner. When the adverse outcome is the result of medical error, it requires a particularly thoughtful response on the part of the veterinarian, staff, and practice. To be clear, an adverse outcome is unanticipated or unexpected harm caused by medical care. An example of an adverse outcome would be a horse breaking its leg during anesthetic recovery. As we know, this is a potential complication of anesthesia that can occur without any veterinary error. A veterinary error is failure to complete a plan as intended or the use of a wrong plan to achieve a clinical result. Examples of a veterinary error would include administering the wrong medication or wrong dose to a patient.

In addition to their sensitivity to the client and family’s experience of disappointment when there have been adverse outcomes in care, clinicians and healthcare organizations are deeply fearful of formal complaints and potential malpractice suits. As a result, simply telling clinicians that they “ought” to disclose an unanticipated outcome or error is ineffective. Recognizing this, Breaking the Silence: Disclosing Medical Errors, was developed in conjunction with the American Veterinary Medical Association Professional Liability Insurance Trust (AVMA PLIT) to enable veterinarians to identify, appreciate, and practice using a model and techniques that are essential in responding to clients constructively when there has been an adverse outcome due to error.

The model recommended for disclosure discussions is the TEAM model:

• Truth, teamwork, transparency 
• Empathy
• Apology and accountability
• Management through to resolution

2. Discussion: The Team Model

Truth, Teamwork, Transparency

Truth

The client is entitled to an accurate understanding of what happened and its consequences. The key to that understanding is the practice’s candid investigation to sort through factors until reaching the most probable explanation. Reluctance to accept responsibility unless 100% certain is setting a much higher standard of certainty than was used to recommend and undertake the treatment in the first place and will likely seem very self-serving to the client.

Transparency

Trust is rebuilt most effectively when the client senses that nothing is being hidden from them. The practice willingly shares relevant information and elicits and answers clients’ questions without the client needing to do her own investigation and come up with the “right questions.”

Teamwork

The practice team must feel empowered to recognize and report problems that could potentially compromise patient safety so that the practice may take action to correct the problem. Team members are most likely to feel that they can do this when the practice team has shared values, adopts a nonpunitive approach to errors, and a commitment to honesty with each other and with clients. The ultimate resolution of the harm with the client may involve a number of staff members working together to recognize, elicit, and then follow through on the steps needed to resolve the situations as well as possible with the client.

Empathy

Empathy involves the ability to share one’s appreciation for the client’s perspective, feelings, and experience. When clients experience disappointing outcomes related to the health of their animal, they may express a range of emotions that require effective and sensitive communication skills by the veterinarian and staff. When the disappointment is related to a medical error on the part of the practice, the emotions may be heightened particularly if the practice gives any suggestions that they are withholding information or are insensitive to the client’s feelings and needs. Core skills such as reflective listening and empathy are critical in such discussions, for example, “I know you are angry and that is perfectly understandable.”

The veterinarian must be willing to acknowledge and act based on an appreciation of the consequences of the error to the patient and the client. Rationalization and minimization can undermine our ability and willingness to empathize with the full range of impacts. The veterinarian and practice team must be willing to appreciate the impact that recognizing and reporting an error may have on the staff involved. Their fears, heartbreak, perhaps defensiveness, and concern for consequences for themselves are all normal and need to be acknowledged. Creating a nonpunitive approach to errors that focuses on understanding and addressing latent vulnerabilities to error rather than punishing individuals is a key to empathizing with staff.

Apology and Accountability

When error has caused harm, a sincere and complete apology is necessary for resolution.¹¹ "I am so sorry for the error that we made that caused this to happen to Sandy.” Studies of apology reveal 4 critical components:

• Acknowledging the error
• Explaining how it occurred
• Holding oneself accountable to prevent its recurrence
• Offering reparation for the harm the other has experienced

The client wants to know that some good will come from the harm for other animals treated by the practice through correcting the procedures that led to the error. [...]