Duties and responsibilities
How to apologize when disclosing adverse events to patients
An article for physicians by physicians
Originally published September 2006 / Revised May 2008
It is right to express sympathy after an adverse event, but an apology with acceptance of blame may be inappropriate.
Of interest to physicians dealing directly with patients
If patients experience harm, whether from the progression of their medical condition or from events related to their health care delivery, they need to know. When things have gone differently than expected, most patients want information. If mistakes were made, they also want an apology, and assurance that steps are being taken to prevent similar harm to others.
While giving news of an unanticipated adverse outcome may be difficult, disclosure of harm related to health care delivery is even more so. Whatever the reason for the harm, honest communication is important. Physicians are encouraged to recognize the ethical and professional responsibility to engage in factual, compassionate and ongoing dialogue with a patient who may have been harmed by the care received.
The question of whether physicians should say "I'm sorry" or some other expression of sympathy to patients often arises in discussions about the disclosure of adverse events. While an expression of regret and sympathy is always appropriate, when communicating the occurrence of an adverse event to a patient, physicians need to consider whether an apology is indicated, when to apologize and the extent of the apology.
Adverse event: An event which results in unintended harm to the patient and is related to the care and/or services provided to the patient rather than to the patient's underlying medical condition (CPSI 2008).
Disclosure: the process by which an adverse event is communicated to the patient by health care providers (CPSI 2008). (See Disclosing harm from healthcare delivery: Open and honest communication with patients. This is a more complete reference, and includes a checklist for disclosure.)
Adverse event does not equal medical error
Some health professionals, administrators, members of the public and the media use the term "medical error" to describe an adverse event. However, the terms "adverse event" and "medical error" are not synonymous. "Error" carries with it a sense of blame or fault that may be inappropriate, especially before all the circumstances and facts about a case are known.
An adverse event does not mean there has been error or negligence. Some adverse events may, on further analysis, be found to have been unforeseeable, such as the first time a patient experiences an allergic reaction to a medication. Such adverse events are the inherent risks of investigations or treatments. Many other adverse medical events are now increasingly recognized as system failures, in which safeguards to enhance patient safety were either absent or a series of safeguards failed in sequence, resulting in harm to the patient. Some adverse events do result from the mistakes of individuals.
Many health care institutions are currently attempting to foster a non-punitive culture to encourage the reporting of events. Many of those working to improve patient safety dislike the label "error" because it discourages the reporting of adverse events.
In the legal system, plaintiffs (patients) and their lawyers frequently allege medical error caused harm or injury. Nevertheless, the courts do not find most adverse events to be the result of negligence or, in Québec, fault.
Expressions of regret and apologies
The patient's perception is important. Patients generally view their physicians as being in charge of their care, although in Canada this relationship is evolving as collaborative practice models become more common. Patients value an explanation and, if warranted, an apology or some other expression of sympathy from the person they believe to be most responsible for their care. Patients need to feel they are not abandoned in this difficult time.
Your choice of words is important when discussing harm with patients. Expressing regret or concern for the patient's difficult experience and condition is desirable. Sincere statements such as "I'm sorry to learn of all the pain that you and your family have experienced" reflect a caring nature, and are often helpful emotionally for both the patient and caregiver. It is at this time that good communication may help restore or strengthen the patient-physician relationship.
Some patients may seek or even demand an apology that includes acceptance of responsibility and blame for what has happened. Acceptance of blame may or may not be appropriate, depending on whether the factors that contributed to an adverse event are sufficiently known. Many physicians possess a profound sense of personal responsibility (as "captains of the ship") and are taught to be immediately self-critical when it comes to problems in patient care. It is not surprising that caring physicians feel responsible, even if the outcome is not related to deficiencies in their care. Physicians rushing to apologize, however, may inappropriately shoulder blame. Most adverse events are due to many contributing factors, and are beyond the control of any single individual.
It is important to remember that it is difficult to withdraw an apology in which you accepted blame, even if other factors are later found to have contributed to or to have caused the adverse event. An apology in circumstances in which you were not actually responsible may not only be inappropriate, but may also prevent an investigation into all the factors leading to the adverse event, with a resulting loss of an opportunity to correct any systemic problems.
Canadian laws and apology
Several provinces/territories have or are considering specific legal protection for apologies. Such legislation is usually intended to allow governments, corporations and individuals to offer an apology without fear of adding to legal liability. It remains uncertain how the courts will interpret these new laws and in which proceedings these may be applied.
Apologies related to adverse events could possibly be used in legal proceedings. that do not have similar legislation. Such legal advances should be supported, particularly those providing protection for apologies that include admissions of fault in the setting of all civil legal and administrative proceedings. Such legislation would help reassure health professionals the words of an apology would not later be used against them.
When should physicians apologize?
The origins of many adverse events are complex. Contributing individual and system factors are usually not immediately clear and further analysis is necessary. The patient will require information early on — the facts that are known — to guide further care decisions and to gain an initial understanding of what has occurred.
If the situation and responsibility for what has happened are not clear, it is acceptable simply to express sincere regret the adverse event has occurred. The patient will appreciate this. If appropriate, reassure the patient an analysis into contributing reasons for the event will take place.
Following an appropriate analysis, after all the facts and circumstances are known, and if the outcome is indisputably due to deficient care, the responsible health professional may apologize and acknowledge responsibility. The use of the word negligence or fault, or reference to failing to meet the standard of care, should be avoided. Such determinations are complex and should be left for the courts or other bodies to decide. While apologizing can have a beneficial psychological healing effect both for the patient and members of the health care team, forgiveness from the patient may not necessarily follow.
After all of the contributing individual and system factors causing an adverse event are known, hospital or institutional leaders may be found to bear some responsibility for what happened and should consider apologizing to the patient on behalf of their organizations.
The bottom line
Following unexpected harm due to health care delivery:
- Communicate to the patient the facts to the extent they are known, in a gentle, non-rushed manner as soon as is reasonable to do so;
- Discuss the options for dealing with the medical condition as it now exists;
- Express your feelings of concern, empathy and regret, as appropriate;
- If, after an appropriate analysis, it is clear the outcome is indisputably due to deficient care, the responsible health professional may apologize and acknowledge responsibility;
- Members may want to obtain telephone advice from the CMPA.