How to Talk With a Patient after a Medical Error

CHICAGO - Explaining a medical mistake to a patient is among the most difficult conversations a physician can have.

There are the inherent difficulties of admitting an error and its implications for a patient’s life, plus physicians may fear legal consequences and struggle with how much they can say, said speakers at RSNA 2013.

“For a long time we’ve thought of disclosure as a risk-management activity. People are now recognizing it’s an important part of quality and safety,” said Thomas Gallagher, MD, associate professor in the department of medicine and the department of medical history and ethics at University of Washington.

He described a movement away from disclosure being just a conversation that a doctor has with a patient but rather a process of preparing, having the conversation and following up.

There are many reasons physicians shy away from disclosure. Among them are:

• Fear of litigation
• Not understanding how much the patient wants to know
• Low confidence in communication skills
• The concern that errors may only be identifiable in retrospect and subject to considerable hindsight
• Very little opportunity for a pre-existing relationship between the radiologist and the patient
• The radiologist/patient relationship being viewed as secondary to the referring physician/patient relationship

Physicians also worry that disclosing errors proactively is a rush to judgment, that you shouldn’t talk with patients until all the facts are known, Gallagher said. Instead, he said, physicians must consider what stage the investigation is in when they prepare what to say to a patient.

Elaine Meyer, RN, PhD, a clinical psychologist at Boston Children’s Hospital, gave tips for having these conversations with patients.

The first priority should be assuring the patient that the clinical team will stay fully attentive to the medical needs of the patient.

In preparing for talking with the patient, you must first determine whether the event meets the threshold for disclosure by asking whether you would want this information as a patient or family member. Secondly, ask yourself whether the disclosure would change the treatment of the patient Meyer said.

Other things to consider, according to the experts:

• Determine who needs to be in the disclosure meeting and who should lead the conversation. If a particular clinician is angry or distraught by the circumstances, that person may not be best to lead the conversation.
• Agree on the core information to be conveyed. What are the facts? Do not speculate.
• Decide who will take primary responsibility for the follow-up. The patient/family want to know what happens next and who will contact them. Let the patient know as more facts are known the patient will be the first to know.
• When it comes time for the actual conversation, be authentic above all else. Patients will see through insincerity.
• Acknowledge the patient’s and family’s suffering. But be careful about saying you understand how they feel. Say that you want to hear what they’ve been experiencing or “help me understand.”
• Assure them that though you stand by the quality of care of the team, there are other qualified care teams you could refer them to and the patient is certainly welcome to choose different clinicians.
• Assure the patient that the institution takes this very seriously and will review all the facts to see how it could have been prevented.
• Even though gaps of silence will be awkward, let the patient talk and think. Take your cues from their pace and thoughtfully move the conversation forward.
• Document the conversation in the medical record. Who was present? What facts were discussed? What promises were made? If you promise to check back in two days, make a note of it. You should exclude from the record conversations you have had with risk managers.

It’s OK to say, “If I were in your shoes I would be upset and angry.”

And above all, be sorry, not just say you’re sorry, Meyer said. “If a patient doesn’t hear ‘I’m sorry,’ it’s hard to hear anything else,” she said.