Confronting fears of openness
Post date: 17/05/2022 | Time to read article: 6 minsThe information within this article was correct at the time of publishing. Last updated 23/05/2022
Talking to patients when something goes wrong is a skill that will constantly develop throughout your clinical career. Medical Protection outlines what to do when a patient safety incident occurs.
Not all patients are going to be forgiving of error, especially when they initially find out about it, and it takes courage to face up to others’ anger, hurt, disappointment, and feelings of betrayal. Although the fear of such consequences of openness is well-founded, it is probably exaggerated. There is a growing body of evidence to suggest that patients can be surprisingly forgiving and appreciate being given an honest account of an error.1, 3-5
Talking to patients
There’s no disputing the fact that doctors have an ethical obligation to disclose medical errors to the patient concerned or their family. There may be disputes about defining errors and near-misses, but patients must be told about incidents that have caused them harm (and relatives obviously must be told about adverse incidents that have led to a patient’s death).
A strong barrier to open disclosure to patients is the fear of litigation – there’s a widespread belief that expressing sorrow for an adverse outcome is tantamount to an admission of negligence. This is not so.6 Even if it were, the ethical obligation to tell the truth always trumps concerns about legal action.7
When you’ve made a mistake
• Ensure the wellbeing of the patient
• Establish what went wrong and why
• Identify the system failures, but don’t use them to absolve yourself of responsibility. If you are culpable, be honest with yourself
• Recognise personal factors that may have contributed to the error (eg. were you making assumptions about the patient? Did you lack sufficient knowledge? Were you overtired or distracted?). Decide what improvements you need to make in your practice as a consequence
• Talk it over with a trusted colleague. Don’t just focus on the clinical aspects – share your feelings
• Discuss how you’re going to tell the patient – rehearse it if you need to
• Be prepared for the patient to be angry – try not to behave defensively
• Express sincere regret and, if it’s appropriate, share your feelings with the patient
• Share your feelings with close family members – they need to understand what you’re going through
• Be realistic – there’s no point in adopting an over-defensive practice as a result of every slip. You may just need to be more aware of your own tendencies.
There have been quite a few studies into patients’ attitudes to disclosure and their behaviour regarding litigation the evidence strongly suggests that patients are less likely to bring a claim against a doctor or hospital if the error is fully disclosed to them, along with a sincere expression of regret and assurances that steps are being taken to prevent a reoccurrence of the error.3–5
A significant percentage of patients who’ve resorted to litigation say that they only did so because they weren’t told what had really happened, they suspected a coverup, or they felt they’d been treated with a lack of respect.1,3,4,8 This indicates that the disclosure must be made frankly, apologies must be sincere, and the patient should be given the opportunity to ask questions.
It’s natural to feel reticent about discussing an error with a patient. It takes enormous moral courage to admit to having caused someone harm, and to be open to their reaction. Painful though the experience may be, it’s the only ethical course of action. It may also offer an opportunity for confession/absolution/penitence that is otherwise absent. Not all patients are going to forgive errors though – that would be too much to expect – but they nevertheless have a right to know what went wrong and why.
Disclosure to patients: the duty of candour
Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. Healthcare professionals must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest, and not stop someone from raising concerns.
All healthcare professionals have a duty of candour – a professional responsibility to be honest with people in their care when things go wrong. The GMC’s guidance, The professional duty of candour10, is not intended for circumstances where a patient’s condition gets worse due to the natural progression of their illness. It applies when something goes wrong with a patient’s care, and they suffer harm or distress as a result. The guidance also applies in situations where a patient may yet suffer harm or distress as a result of something going wrong with their care.
When should I speak to the patient or those close to them?
Following the GMC’s guidance11, you should speak to the patient as soon as possible after you realise something has gone wrong with their care. When you speak to them, there should be someone available to support them (for example a friend, relative, or professional colleague). You do not have to wait until the outcome of an investigation to speak to the patient, but you should be clear about what has and has not yet been established.
You should also share all you know and believe to be true about what went wrong and why, and what the consequences are likely to be. You should explain if anything is still uncertain, and you must respond honestly to any questions.
Patients will normally want to know more about what has gone wrong. But you should give them the option not to be given every detail. If the patient does not want more information, you should try to find out why. If after discussion, they don’t change their mind, you should respect their wishes as far as possible, having explained the potential consequences. You must record the fact that the patient does not want this information and make it clear to them that they can change their mind and have more information at any time.
Saying sorry
An apology only has value if it is genuine. However, when apologising to a patient, you should consider each of the following points:
• You must give patients the information they want or need to know in a way that they can understand12
• You should speak to patients in a place and at a time when they are best able to understand and retain information
• You should give information that the patient may find distressing in a considerate way, respecting their right to privacy and dignity
• Patients are likely to find it more meaningful if you offer a personalised apology – for example ‘I am sorry…’ – rather than a general expression of regret about the incident on the organisation’s behalf. This doesn’t mean that you are expected to take personal responsibility for system failures or other people’s mistakes
• You should make sure the patient knows who to contact in the healthcare team to ask any further questions or raise concerns. You should also give patients information about independent advocacy, counselling, or other support services that can give them practical advice and emotional support
• You should record the details of your apology in the patient’s clinical record13. A verbal apology may need to be followed up by a written apology, depending on the patient’s wishes and on your workplace policy.14
Conclusion
Life’s full of uncertainties, and with them come reminders that, try as we might, we can never surmount all the tragedies and misfortunes of being human. Despite its enormous success, medicine will always fall short of expectations.
Talking about mistakes won’t undo them, but it does give us our best chance to put right what we can, learn from those mistakes, and prevent their reoccurrence. Talking honestly about the emotional impact of mistakes enables people to come to terms with their own fallibility, thus helping them to become better, more humane, and fulfilled doctors. Telling patients about medical errors respects their autonomy, helps to build stronger bonds of trust between patients, and doctors and may bring absolution for the ‘offending’ doctor.
References
1Bayliss F, Errors in Medicine: Nurturing Truthfulness, J Clin Ethics 8 (4): 336-40 (1997).
2Seel R, New Insights on Organisational Change, Organisations & People 7 (2): 2-9 (2000).
3Kraman SS and Hamm G, Risk Management: Extreme Honesty May Be the Best Policy, Ann Int Med 131 (12): 963-7 (1999).
4Wu AW, Handling Hospital Errors: Is Disclosure the Best Defence?, Ann Int Med 131 (12): 970-2 (1999).
5Boyte WR, Casey’s Legacy: Finding Generosity When Admitting to an Error in Judgment, Health Affairs 20 (2): 250-54 (2001).
6Australian Open Disclosure Project, Legal Review, compiled by Corrs Chambers Westgarth, Jan (2002).
7Herrin VE and Fato M, Must You Disclose Mistakes Made by Other Physicians? ACP Online
8Vincent C et al., Why Do People Sue Doctors? A Study of Patients and Relatives Taking Action,
Lancet 343: 1609-13 (1994).
9Duty of Candour. Public Health England. https://www.gov.uk/government/publications/nhs-screening-programmes-duty-of-candour/duty-of-candour
10The professional duty of candour https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/candour---openness-and-honesty-when-things-go-wrong/the-professional-duty-of-candour
11Duty of candour and reporting concerns https://www.medicalprotection.org/uk/articles/duty-of-candour-and-reporting-concerns
12Decision making and consent https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent
13Good medical practice, paragraph 21https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice
14Appendix 2: The statutory duty of candour for care organisations across the UK https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/candour---openness-and-honesty-when-things-go-wrong/~/link.aspx?_id=A4E4AAE187C84A0A839DC5376E70AB9B&_z=z
