CompendiumVet.com | March 2009 | Compendium: Continuing Education for Veterinarians®
105
Disclosing Medical Errors:
Restoring Client Trust
*
T
he purpose of this article is to help veterinarians reach a mutually satis-fying resolution with clients when individual, team, or system errors result in an adverse outcome. It offers a model that integrates the ethics of veterinary medi-cine with specific skills and attitudes that have been shown to promote psychologic and practical resolution of these situations for clients and veterinary practices.Case Scenario
Consider the following1:
Your nephew, a recent veterinary school graduate who is newly employed at a pri-vate small animal hospital, calls you for advice. Four days ago, he admitted a dog to the hospital for vaccinations and board-ing. During the admission process, he administered a Bordetella bronchiseptica
vaccine to the dog. The dog died this morn-ing. In retrospect, your nephew realizes that he picked up a syringe of intranasal
B. bronchiseptica vaccine that still had a needle on it from being drawn from the vial, then gave the vaccine subcutaneously. This inappropriate route of administration resulted in the development of liver failure while the dog was boarded at the hospital.
Your nephew says, “I feel terrible—what should I tell my clients?”
How would you respond? What one piece of advice would you give to your nephew?
Ethics, Values, and Moral Compass
In examining this scenario and consid-ering your own opinions, you are likely relying on the values that guide the way you practice veterinary medicine. Still, this will be a very tough conversation to have. Many clinicians report feelings of shame, heartbreak, and vulnerability in situations like this one. Our natural instinct for self-preservation, coupled with advice we may have received previously, can tempt us to be very guarded when talking with clients about adverse outcomes and to use cal-culated omissions and rationalizations to conceal evidence of an error. In the above scenario, one might argue that vaccination has inherent risks. A frightened young vet-erinarian might be attracted to such seduc-tive reasoning as, “Disclosing the actual cause of death will increase the clients’ dis-tress and certainly will not bring back the animal. What good could come from tell-ing the clients what really happened?”
Rationale for Openness
The ethical positions of organizations such as the American Medical Association,2 the American College of Physicians,3 and the
❯❯ Kathleen A. Bonvicini,
EdD, MPHa
Institute for Healthcare Communication New Haven, Connecticut
❯❯ Daniel O’Connell, PhDa
Institute for Healthcare Communication Seattle, Washington
❯❯ Karen K. Cornell, DVM,
PhD, DACVS
The University of Georgia Athens, Georgia
Case Scenario
Page 105
Ethics, Values,
and Moral Compass
Page 105
Disclosure and Resolution:
A Protocol
Page 106
What to Do When
an Error Occurs
Page 108
Guidelines for Disclosure
Page 110
Establish Practice Protocol
Page 112
At a Glance
*Adapted with permission from Compendium Equine 2008;3(1):14-22.
aDrs. Bonvicini and O’Connell disclose that
their nonprofit foundation receives funding from Bayer Animal Health.
©2009 Monk
ey Business Ima
106 Compendium: Continuing Education for Veterinarians
® | March 2009 | CompendiumVet.comJoint Commission4 have clear statements that require accurate disclosure of adverse medi-cal outcomes in human medicine. Similar ethi-cal positions exist in veterinary medicine.5 Research in human medicine and other pro-fessions6–10 has described the potential advan-tages of a more open approach with patients, families, and “customers” in these situations. When applied to veterinary medicine, these
benefits include the following:
More situations can be worked out directly between the veterinarian, the client, and the insurance carrier without stimulating legal action or formal complaints to licensing boards. The AVMA Professional Liability Insurance Trust (PLIT) recommends that veterinarians call the PLIT office as soon as possible after an event that could give rise to a claim.b Rebuilding rapport and trust and resolving
disagreements can turn initial client disap-pointment into an even stronger relationship. When the practice and the insurance carrier are willing to initiate discussion of fair settlements with clients who have been legitimately affected by errors in practice, the dollar amounts tend to be easier to negotiate and more reasonable than those obtained through legal action7,8,11 because client bitterness is minimized and dol-lar amounts are focused on reasonable com-pensation rather than punishment.
Adverse Outcomes and Medical Errors
Adverse outcome is the term used in veterinary and human medicine to indicate unanticipated harm that results from a medical treatment rather than from a disease or condition itself.12 An ethical approach to disclosure of harm
hinges on the veterinarian’s commitment to determining and then sharing the most accurate conclusions about how the harm was caused. While sometimes fairly clear, many situations
require the veterinarian to draw a bright line through a gray situation to determine whether a breach of the standard of care caused the harm (and, therefore, the harm was prevent-able) or whether the harm occurred in the con-text of care that most veterinarians would judge as reasonable in a similar instance.13,14 Practically and emotionally, this can be difficult to do, yet who is in a better position to investigate,
con-clude, and explain than the practice where the adverse event took place?
Most client disappointments with veterinary outcomes are not the result of negligent care. For instance, clients may have unreasonable expectations that were not adequately addressed or corrected. They may not appreciate the vari-ability between animals or that diagnostic and treatment plans are based on probabilities rather than certainties. The clinical picture may change as additional signs emerge and the response to treatment is assessed.15 Almost every effective treatment brings with it the potential for untow-ard side effects and complications. Unless clients are apprised of these risks, they may mistakenly believe that similarly trained clinicians would have been able to solve the problem more quickly, with less suffering, and at a lower cost. Each of the above factors is a reminder of the importance of obtaining true owner consent, recognizing and correcting unreasonable expectations, and offering adequate explanations when diagnosis and treatment are unsuccessful, even when the standard of care is met.16
Errors and Harm in Veterinary Medicine While research into the incidence, type, and
impact of errors in veterinary medicine is limited, it is clear that adverse events related to errors do occur. For instance, one small UK study17 found that 78% of recent practicing veterinary gradu-ates surveyed reported they had made a mistake that resulted in a less-than-optimal or potentially adverse outcome for a patient. Most mistakes involved failure to conduct appropriate diagnostic tests, surgical mistakes during procedures other than neutering, and administration of inappro-priate drugs or medical treatment. Forty percent reported that they had not discussed the error with the client. These mistakes caused many of the respondents considerable distress.
Disclosure and Resolution: A Protocol
Research has consistently indicated that, in human medicine, patients and families typically want to hear the following from the care provider when an adverse event or outcome occurs10,18–21:
What happened How it happened
What the immediate medical consequences are, and what impact they will have on quality of life
bEllis LJ. Personal communication, AVMA PLIT, 2007.
Most client
disap-pointments with
veterinary outcomes
are not the result of
negligent care.
QuickNotes
What can be done now
How the problem will be prevented in the future (i.e., the promise that something good will come from the adverse event)
An apology if appropriate (if errors led to the harm)
The following protocol (summarized in Box 1) provides specific approaches to assist you in organizing a thorough, appropriate, construc-tive response that meets the needs of the patient and the expectations of clients and that restores clients’ trust, regardless of the severity of the adverse event.
Tend to the patient’s immediate clinical care.
In the event of an adverse outcome, the pri-mary responsibility of the veterinarian is to address the needs of the patient and, if appro-priate, obtain medical consultation or arrange for necessary follow-up. Consider that charges for services in these circumstances may not be billable if they are addressing conditions caused by errors (including equipment fail-ures and system or procedural mistakes that caused harm).
Address your own emotions and needs. Emotional self-awareness is key to adopting the most constructive attitude and behavior. A clinician who is flooded with worries about potential complaints and possible malpractice suits may be unconsciously pushed to mini-mize or even distort the facts and explana-tion offered to the client. On the other hand, the clinician who is overwhelmed with guilt
and heartbreak for the patient’s and client’s situation may leap to self-blame too quickly, only to have the investigation determine that no deviation from the standard of care was implicated in the outcome. There is usually enough time to consult with a trusted col-league to clarify your thinking and reestablish your emotional equilibrium before needing to make a full explanation to a client about how an adverse outcome arose.
Investigate the details of the event. Develop clarity about what happened. The client is entitled to the most accurate under-standing of what happened, which may take some time and investigation to clarify. You can ask for the client’s patience while you investigate. Make—and keep—a clear prom-ise to discuss the conclusions when they are reached. In many cases, the cause of the harm is never fully determined; however, it remains the veterinarian’s responsibility to disclose the most likely causal pathway. Determining whether error was the cause of harm should be guided by asking,22 “What would have been expected of a similarly trained individual in that situation?”
Prepare for discussion with the client. Start by trying to imagine and anticipate what the client may be thinking and feeling when hearing the news. O’Connell and Reifsteck23 suggest asking yourself the following self-reflection questions to help guide you in your discussion with the client:
What is the most accurate explanation for the adverse event?
How would I want the situation to be han-dled if I were in the client’s position?
How would I feel if I suspected or later learned that the provider had not been forthright with me about the injury and its causes?
It is helpful to rehearse the actual words you will use in explaining the adverse event because hearing them will help you determine whether they are likely to be adequate to address the cli-ent’s expected thoughts and feelings.
Consider carefully who should attend the disclosure conversation. The veterinarian who is primarily responsible for the care of the animal should be there and take the lead in
Emotional
self-awareness is key
to adopting the most
constructive attitude
and behavior.
QuickNotes
Box 1
1. Care for the patient.
2. Compose yourself and investigate the details of the event.
3. Disclose to the client what occurred and apologize, if appropriate.
4. Discuss with the client the plan of care for the animal.
5. Be accountable and discuss methods of reparation.
6. Share how you plan to keep this from happening in the future.
What to Do When an Error Occurs
©2009 Phase4Phot ogr aph y/Shut ter st oc k.com
110 Compendium: Continuing Education for Veterinarians
® | March 2009 | CompendiumVet.comthe discussion, even if the adverse event was primarily caused by another staff member’s actions. The presence of a person who was not directly involved with the adverse event and who has credibility, maturity, and strong communication skills, such as the practice manager, can help facilitate and mediate what can be a difficult conversation. Plan when and how to begin the discussion. An initial discus-sion with the client should take place as soon as possible after the adverse event.
Disclose to the client what occurred and apologize.
Disclose what you know, but guard against premature conjecture until you are as certain as you can be about causes and consequences. When possible, make an initial phone call to set up an in-person meeting rather than have the discussion over the phone. If a phone dis-closure cannot be prevented, start the discus-sion by acknowledging how sorry you are to have to be sharing the news over the phone. In person, start the discussion by offering a frame for the information to follow:
“I have some difficult news to share with you. I’m very sorry to have to tell you…”
Then explain the situation by addressing each of the issues listed above. Box 2 offers some additional guidelines to approaching the disclosure conversation.
Elicit and acknowledge client reactions. Frequently throughout the discussion, you should solicit the client’s perspective through questions and statements such as, “What thoughts or questions do you have about what I have explained so far?” and “I imag-ine you have many emotions and questions, and I want to hear from you first before going on.” Eliciting reactions serves to validate the client’s perspective on the medical error and adverse outcome and sets the stage for effec-tive interaction.
Voice tone and body language are as important as actual words in conveying empa-thy for the client’s experience. Showing your “human side” through genuine expressions of empathy can strengthen the bond and trust between you and your client. An empathetic veterinarian is not defensive, even when a cli-ent expresses anger and makes accusations. Acknowledging the client’s reaction as a
legiti-mate one by making a statement such as, “It is normal to feel shocked and angry to learn that something like this has happened,” does not indicate that you agree with the conclusions that prompted it.
Apologize appropriately.
After an adverse event or outcome, the proper type of apology can have a powerful effect on the client, making him or her less angry and suspicious. There are two types of apol-ogy: an apology of sympathy and an apology of responsibility. An apology of sympathy is:
“I’m sorry this happened to you and your pet.”
An apology of responsibility is:
“I am terribly sorry for this error we made that has caused more problems for your pet.”
Mazor and colleagues6,24 demonstrated that in situations in which a breach of the standard of care caused harm, respondents reported more trust and satisfaction and less likelihood of changing doctors when they received full disclosure with an apology of responsibility. In instances in which an adverse event is not the result of medical error, an apology of sym-pathy is appropriate.
Disclose what you
know, but guard
against premature
conjecture until
you are as certain
as you can be
about causes and
consequences.
QuickNotes
Guidelines for Disclosure
1. Choose a quiet place.
2. Ensure that there will be no distractions (e.g., turn cell phones and pagers off). 3. Provide a warning (e.g., “ I have difficult
news to share.”).
4. Be attentive to your own and your client’s nonverbal messages.
❯ Make eye contact. ❯ Sit at the client’s level.
❯ Respond appropriately to client nonverbal cues (e.g., “I see that this is shocking to you. Should I go on or do you need a moment?”). 5. Facilitate discussion and encourage questions. 6. Finish with a plan for the next contact.
Discuss the plan for care of the animal. In many instances, by the time the disclosure conversation takes place, steps have already been taken to care for the animal, and the veterinarian is thinking about other poten-tial consequences of the error. However, it is important to remember that the client has just received the news. Discuss the recommended plan for continuing care of the animal, includ-ing the potential short- and long-term out-comes. Often, clients are unclear about what lasting effect the error will have on their pet and may not comprehend the gravity or—in some cases—the limited impact of the error. It is critical that immediate concerns as well as the potential long-term impact be discussed in a manner the client understands.
Be accountable and offer reparation. Finally, the practice must acknowledge respon-sibility to help the client recover as much as possible from the harm that has been caused. Appropriate fees for the animal’s care should be waived. The veterinarian should anticipate discussion of who will pay for follow-up care before the disclosure conversation. Again, the AVMA PLIT recommends that it be contacted early on to discuss how best to approach this situation.
Being accountable and willing to make rep-arations is crucial in the disclosure process; however, it does not mean immediately offer-ing money. Rather, it means openoffer-ing up the conversation:
“Can we do more to resolve this with you? We stand ready to do what we can to help you recover from this as much as possible.”
According to the Sorry Works! Coalition,25 a leading advocacy organization for disclosure after adverse medical events, paying for errors is the ethical thing to do. However, there may be a fear that it will appear as if you are “buy-ing” clients off. This is an understandable con-cern. In veterinary medicine, all of the steps of disclosure—admission of error, explanation, apology—can still be delivered sincerely, and PLIT or your liability carrier can be consulted on how to offer reparation.
Describe plans to fix the behavior or sys-tem that contributed to the harm.
Consumers who are affected by a medical error want to know that something good has
come from the harm they have experienced. It is unacceptable to clients to think that a veterinarian’s failure to change or reflect on the incident means that others are likely to suffer similarly.23 These sentiments become expressed as complaints to licensing boards as well as malpractice suits. Therefore, the vet-erinarian’s goal is to convey to the client that he or she has learned everything that can be learned from the adverse event:
“I can promise you that we’ll all be meeting later today to review every step of our proce-dures. We want to immediately change any-thing that makes it more likely that this could happen again to any other animal in our care.”
Don’t rush.
Keep in mind that all these elements of dis-closure may take more than one meeting or conversation to deliver effectively to the client. Discussion of reparation may take the longest to resolve in cases in which the impact of the harm on the surviving animal and the extent of needed ongoing treatment are uncertain. However, if a client has suffered serious loss or even financial harm (e.g., economic impact on a breeding kennel), he or she is going to want to promptly hear that you (with your liability carrier’s guidance) intend to offer fair compensation.
The heart of all effective and ethical disclo-sure is to provide the client with an accurate understanding of what has happened. The form an apology takes and the offers made to help a client recover from an injury caused by medical error should flow naturally from the veterinarian’s own understanding of his or her degree of responsibility for the injury.
Summary
Consider your recommendations to your nephew in the scenario at the start of this col-umn. Ask yourself the following questions: Are my recommendations based on ethical stan-dards of openness, transparency, and integ-rity? Would I be satisfied if I were the client?
Despite our best efforts, animals will occasion-ally be harmed by problems that occur while they are in our or our staff’s care. Having a standard approach to disclosure and resolu-tion that is consistent with our values, despite
The heart of all
effective and ethical
disclosure is to
provide the client
with an accurate
understanding of
what has happened.
QuickNotes
112 Compendium: Continuing Education for Veterinarians
® | March 2009 | CompendiumVet.comthe fears and vulnerabilities we are likely to feel at these times, can help us earn our cli-ents’ forgiveness and enable us to forgive our-selves. Box 3 lists some questions to ask when developing a disclosure protocol.
We believe in using ethical standards and values of openness and honesty as a spring-board for conversations about medical errors. However, many veterinary practices may
hesi-tate to embrace such openness for fear that it may increase malpractice risk. Acknowledging errors has been evaluated positively, leading to increased trust and lessening the possibility of negative impact7; however, clinicians may still worry about the potential costs of openness and transparency. Although disclosure discus-sions are difficult and may still result in formal complaints and malpractice suits, evidence8 tells us that acknowledging errors can signifi-cantly reduce litigation costs, reduce bitterness and mistrust, and avoid unnecessarily lengthy legal proceedings with the accompanying emo-tional pain for consumers and clinicians alike. We encourage all veterinarians, whether joining a practice or established in one, to engage in conversations with their colleagues about the practice’s approach to and protocol for disclosure discussions in the event of a medical error. In addition, it is crucial to con-sult your malpractice liability insurance carrier to establish its position on the management of disclosure and resolution.
References
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Infectious Diseases of the Dog and Cat. St. Louis: Elsevier Saun-ders; 2006:1097.
2. Council on Ethical and Judicial Affairs. Code of Medical Eth-ics—Current Opinions, 2006–2007 Edition. Chicago: American Medical Association; 2006.
3. American College of Physicians. Ethics Manual. 5th ed. Ann Intern Med 2005;142:560-582. Accessed January 2009 at www. acponline.org/ethics/ethicman5th.htm.
4. Joint Commission on Accreditation of Healthcare Organiza-tions. 2006 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission Resources; 2005.
5. American Veterinary Medical Association. Principles of Veteri-nary Medical Ethics. 2003. Accessed January 2009 at www.avma. org/issues/policy/ethics.asp.
6. Mazor KM, Simon SR, Yood RA, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med 2004;140(6):409-418.
7. Kraman S, Hamm G. Risk management: extreme honesty may be the best policy. Arch Intern Med 1999;131:963-967.
8. Boothman R. Apologies and a strong defense at the University of Michigan Health System. Physician Exec 2006;32(7):7-10.
9. American Society for Healthcare Risk Management. Disclosure of Unanticipated Events: The Next Step in Better Communication with Patients. Chicago: American Society for Healthcare Risk Man-agement; 2003.
10. Schneider B, Bowen DE. Understanding customer delight and outrage. Sloan ManageRev 1999;41(1):35-45.
11. COPIC Insurance Company. A success story. COPIC’s 3Rs Program Newsletter 2007;4(2). Accessed January 2009 at www. callcopic.com/resources/custom/PDF/3rs-newsletter/vol-4-iss-2-oct-2007.pdf.
12. Halbach JL, Sullivan L. Medical Errors and Patient Safety: A Curricu-lum Guide for Teaching Medical Students and Family Practice Residents.
New York Medical College, Department of Family Medicine; 2003.
Ac-cessed January 2009 at www.nymc.edu/fammed/medicalerrors.pdf.
13. Nunalee MM, Weedon GR. Modern trends in veterinary mal-practice: how our evolving attitudes toward non-human animals will change veterinary medicine. Animal Law 2004;10:125-161. Accessed January 2009 at www.animallaw.info/journals/jo_pdf/ vol10_p125.pdf.
14. Wilson JF. Limited legal liability in zoonotic cases. NAVC Clin Brief May 2005. Accessed January 2009 at www.cliniciansbrief. com/?p=articles&newsid=678.
15. O’Connell D, Bonvicini KA. Addressing disappointment in veterinary practice. Vet Clin North Am Small Anim Pract 2007;37(1):135-149.
16. Bonvicini KA. Are clients truly informed? Communication tools and risk reduction. Compend Equine 2007;2(2):74-80.
17. Mellanby RJ, Herrtage ME. Survey of mistakes made by recent veterinary graduates. Vet Rec 2004;155:761-765.
18. Liebman CB, Hyman CS. A mediation skills model to man-age disclosure of errors and adverse events to patient. Health Aff
2004;23:22-32.
19. Witman AB, Park DM, Hardin SB. How do patients want physi-cians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med 1996;156:2565-2569.
20. Lazare A. Apology in medical practice: an emerging clinical skill.
JAMA 2006;296(11):1401-1404.
21. Blendon RJ, DesRoches CM, Brodie M, et al. Views of prac-ticing physicians and the public on medical errors. N Engl J Med
2002;347(24):1933-1940.
22. Reason J. Human Error. New York: Cambridge University Press; 1990.
23. O’Connell D, Reifsteck SW. Disclosing unexpected outcomes and medical error. J Med Pract Manage 2004;19(6):317-323.
24. Mazor KM, Simon SR, Gurwitz JH. Communicating with pa-tients about medical errors: a review of the literature. Arch Intern Med 2004;164:1690-1697.
25. Question and answer. Sorry Works! Coalition Newsletter; De-cember 4, 2006. Accessed January 2009 at www.sorryworks.net/ newsletter20061204.phtml. ©2009 Sar ah Salmela/Shut ter st oc k.com
Establish Practice Protocol
How will the practice handle an error? Who will discuss it with the client? Who will be present during the discussion? Will individuals involved be identified? What time frame do we recommend? Where is the contact information for our
liability carrier?
When and how will we discuss this with staff members?
Box 3
