Disclosure & Apology
"Disclosure is defined as a transparent process in which the known facts of a case are discussed with a patient, family members or both."
We have a professional ethical obligation to inform patients regarding their care. This is especially important when there has been an error. However, several research studies have shown that clinicians are not skilled in having discussions with patients and families after medical errors. It seems reasonable to assume that some of the barriers to meeting patient needs after errors might include the clinician's sense of vulnerability and emotional distress.
THE EMOTIONAL IMPACT
Grappling with a medical error that causes harm to a patient is one of the most challenging moments of any clinician's career. Many studies have documented the negative emotional impact on clinicians who have made errors. In addition to the sadness at seeing a patient experience suffering, there are professional, personal and societal expectations of perfection that, although we may know intellectually are unrealistic, we feel deeply on an emotional level. The feelings of shame may be particularly strong because of a culture that expects perfection. These emotions may be accompanied by fear of loss of the patient's trust, damaged reputation amongst colleagues, and possible litigation.
CALL TO ACTION?
Because this process can be emotionally challenging for physicians, it is important for health care institutions to provide both disclosure coaching as well as clinician peer support. Disclosure coaching is needed because few clinicians have vast experience in disclosing errors and sometimes the circumstances of the adverse event are complicated enough that it is difficult to know what to say and how to say it.
It is important for all clinicians to understand some basic principles underlying effective disclosure conversations:
Express empathy. One of the most direct ways to do so is to say " I am sorry this happened. It is not what you or we expected."
The most important principle is to do what is best for the patient and family. The question is not "What would I want my physician to do or say in this instance?" Rather it is trying to understand the needs of the patient and family in the moment and as they evolve.
Always share with the patient the known facts as soon as possible. It is inadvisable to wait until there has been a root cause analysis or any process that will flesh out all the details.
If there has clearly been an error, then apologize. For example, you might say "I am sorry we have you the wrong dose of medication."
Be aware of your emotions so that they do not interfere with your ability to be transparent and compassionate.
Disclosure & Apology Resources
PUBLICATIONS & RESEARCH
Talking with patients about other clinicians & errors. Gallagher TH, Mello MM, Levinson W, Wynia MK, Sachdeva AK, Snyder Sulmasy L, Truog RD, Conway J, Mazor K, Lembitz A, Bell SK, Sokol-Hessner L, Shapiro J, Puopolo AL, Arnold R. N Engl J Med. 2013 Oct 31;369(18):1752-7.
Disclosure and Apology. In: Case Files: Ethics and Professionalism, eds. Shapiro J. Cochrane T,
Toy E, Raines S. New York: McGraw-Hill, 2015.
Wisdom in medicine: What helps physicians after a medical error. Plews-Ogan M, May N, Owens J, Ardelt M, Shapiro J, Bell SK. Acad Med. 2015 Sep 4. [Epub ahead of print].
Emotion and coping in the aftermath of medical error: A cross country exploration. Harrison R, Lawton R, Perlo J, Gardner P, Armitage G, Shapiro J. J Patient Saf. 2015 Mar; 11(1):28-35.
The impact of adverse events on clinicians: what's in a name?. Wu AW, Shapiro J (co-corresponding author), Harrison R, Scott SD, Connors C, Kenney L, Vanhaecht K. J Patient Saf 2016 (in press).
Disclosure Coaching: An Ask-Tell-Ask Model to Support Clinicians in Disclosure Conversations. Shapiro J, Robins L, Galowitz P, Gallagher TH, Bell S. J Patient Saf. 2018 May 16.
Processes for identifying and reviewing adverse events and near misses at an academic medical center. Martinez W, Lehmann LS, Hu Y, Desai SP, Shapiro J. Jt Comm J Qual Patient Saf 2017; 43:5–15.
Approach to Medical Error and Disclosure. In: Toy EC, Toy AL, eds. Case Files Teaching Cases. Shapiro J, Galowitz P. New York: McGraw-Hill, in press (2018).
IN THE MEDIA
Disclosure and Apology. CME Webcast. PPIC (preferred Professional Company). Omaha, NE. 2012.
This is a videotaped presentation and follow-up interview discussing strategies to support clinicians in disclosing and apologizing for medical errors.
Forgiving Ourselves for Being Human: Normalizing the Isolating Experience of Adverse Events. Shapiro J. 2014. Humanism in Medicine (Arnold P. Gold Foundation Blog). (Listed as # 5 in the Top 11 Blog Posts of 2014 for The Gold Foundation) http://humanism-in-medicine.org/forgiving-human-normalizing-isolating-experience-adverse-events/
WEBINARS, PODCASTS & VIDEOS
Clinician Emotions After Medical Error and Adverse Events. Shapiro J, Luff D. 2016. OPENPediatrics. Online video.
The Role of the Disclosure Coach. Shapiro J, Luff D. 2016. OPENPediatrics. Online video.
Wisdom in Medicine, Path. Through Adversity. 2012. Disclosure to Family.
Apology and Disclosure. Hershey M and Shapiro J. 2014. Video Simulation.
Medical Error: A Case Based Approach to Apology and Disclosure. Dellaripa, PF, Smink D, Tsen LT, Shapiro J. 2014. BWH Neil and Elise Wallace STRATUS Center for Medical Simulation and BWH Center for Professionalism and Peer Support