After a medical mistake, an apology is both simple and difficult

Elton John had it right: “It’s sad, so sad.  Why can’t we talk it over. Oh, it seems to me that sorry seems to be the hardest word.”

Mistakes are all to common in medicine, but can we say the “hardest word” when we’re involved?

Example 1: There’s a diagnosis of recurrent lymphoma in the ICU. The oncologist gives a phone order for cytoxan, prednisone, and vincristine. The recorder, working a double shift, mistakenly writes the vincristine daily for 5 days similar to the prednisone order. The fatal dosage is given to the patient over the ensuing days. He dies in bone marrow failure.  The oncologist met with the family and apologized.  A review was carried out.  Systems were improved.  There was no lawsuit.

Example 2: In a radiology department, a cleaning solution rather than a dye is accidentally injected into a patient’s femoral artery leading to a painful death.  The hospital representatives and physicians promptly met with the family, admitted a mistake, apologized, and a financial settlement was offered and eventually accepted.

Example 3: A pharmacist fills a prescription for a patient with asthma. Instead of prednisone, the pharmacist mistakenly counts out digoxin, a pill given for heart disease. Digoxin can have severe side effects even at a dosage of one a day. The prescription is followed by the patient: take 8 a day for 3 days, 6 a day for 3 days, etc. The patient calls the MD about the symptoms of severe nausea and notes the pills look different than usual. The medication is stopped and with treatment the patient luckily survives digoxin poisoning.  No apology was forthcoming and the patient lost confidence in the integrity of his providers.

Medical errors frequently hit the headlines. Magazine articles, such as “How the American Health Care System Killed My Father,” can be both thought provoking, and provocatively accusatory. Stress and fatigue often play a role.

Medicine is a proud profession, with medical ethics at its core.  But it’s complex and fragmented.  Atul Gawande promotes improvements in standards of practice but implementation is difficult.  Medicine is highly regulated in attempts to control quality. Currently doctors, nurses, pharmacists and others can face hospital sanctions, medical disciplinary boards, media scorn, and malpractice threats when they make mistakes. In most situations, a number of things have to go wrong at the same time in order for the mistake to occur. None of the above are my personal mistakes, but “I’ve been there, done that!”

On a personal level it’s humiliating and devastating to be involved in a serious mistake. I sat down with a psychiatrist friend after a significant mistake and it helped to talk it out, but the hospital’s legal department had to be notified, affected family members met with, and eventual reports to the state dealt with (and this is in the middle of a 60+ hour week). Fortunately I was not sued, but the worry was palpable.

There’s pretty good data now, that fessing up is the best thing to do from a legal standpoint and certainly from the moral view. But believe me, it’s not easy when you’d rather hide. When one patient died after a procedure that I probably shouldn’t have attempted because he was so sick, I sat down with the family and explained the whole sequence. The son had lots of questions, but then looked reflective and said “It must be hard to be a doctor sometimes. Look it’s okay. Dad was going nowhere and he’s in a better place now.” Basically, he had let me off the hook.

On the prevention side, there’s good data from systems engineers (like Toyota and Boeing) that critical mistakes can often be prevented with good quality management and systems surveillance. All hospitals and major clinics have extensive quality control and review. The answers can be simple or complex. For example, for some recent eye surgery I had, I was asked my name and birth date three times by three separate people (even though they all knew me) – along with what operation I was having and on which side. These quality/safety techniques require constant review, updating, and reporting.

There are quality ratings of hospitals by procedures that can be reviewed. The hospital that does large numbers of, for example, carotid surgeries will almost always have better outcomes and fewer mistakes than the hospital that only does a few. It brings into question the future role of the smaller hospitals. The issue is not so much mistakes as the inability to match the experience and quality of an institution that does large number of a complex procedure.

How do we deal with all the parties involved in a mistake (the patient, family, providers, institution, legal, insurer, etc.)? The answer is both simple and difficult - apologize!   Mistakes can be honestly dealt with.  A good example of this are the tort reforms successfully instituted in the state of Michigan. In many states, a doctor’s initial discussion with the patient and family about a mistake is not discoverable in a lawsuit.

It is best for all involved to personally make a face to face apology! Sometimes one is forgiven, then sometimes not. But if animosity can be decreased, often a settlement can be reached after an honest admission of a mistake.. Involving the patient and/or loved ones in a case review with all present can be very powerful. It’s very hard to stay angry or want to punish someone who can look you in the eye and sincerely apologize, plus actively listening to all your concerns. There comes a point that we all recognize that we’re only human.

Jim deMaine is a pulmonary physician who blogs at End of Life – thoughts from an MD.

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  • Guest

    I’ve often wondered. What is a medical mistake? Is it a medical situation that doesn’t quite turn out as planned? Is it a clinical misdiagnosis? It is a failure to treat appropriately? Is it doing your best but the patient passing away prematurely anyway? I’ve tortured myself considering what exactly constitutes a mistake.

    • James deMaine

      Interesting question. I know that most lawsuits are generated when there’s a bad outcome. That said, bad outcomes can occur even when the doctors adhere to good medical practice guidelines. Likewise mistakes can be made and there’s no change in the outcome (for example, the nurse administering a medication to the wrong patient with no ill effect). Mistakes can be in making a wrong diagnosis, delaying diagnosis or treatment, wrong treatment, bad surgical judgment, etc. Medicine is an art as well as a science so each “mistake” needs to be judged in context. Also, serious mistakes can be made in communication (or lack thereof). Atul Gawande”s book, The Checklist Manifesto, is the best dialogue I’ve seen for medical people – a great effort to avoid mistakes. Hope this helps.

      • Guest

        Thanks for replying. I still go over cases in my mind where I wonder “did I screw up? Or would the patient have done badly anyway? Did the patient do well in spite of me?”

  • http://warmsocks.wordpress.com/ WarmSocks

    Difficult as it might be for doctors, an apology is appreciated by patients. I received a phone call last week from the chief of staff at a hospital I recently had a bad experience with. He told me that he’d reviewed my chart and interviewed the doctor responsible. He clearly admitted that the doctor had made a mistake, and apologized. He also assured me that they were reviewing their procedures to prevent that type of mistake happening again. I was pretty impressed to hear 1) we were wrong, 2) we are sorry, 3) we’d like to make things right. I am no longer warning everyone I know to stay away from that hospital.

    • James deMaine

      I’m very impressed by your experience. This is the way things should happen when a mistake occurs. Kudos to you and the chief of staff.

    • Kaya5255

      Too bad it was the chief of staff and not the physican who made the error offering the apology. The one who made the mistake is the one who should be seeking your forgiveness.

      • http://warmsocks.wordpress.com/ WarmSocks

        In theory, I agree that individuals ought to apologize for their own mistakes. Oddly enough, in this situation I don’t feel that it’s necessary. I am satisfied with how things were handled.

        • Suzi Q 38

          If you are satisfied, that is all that matters.
          I am sure that the doctor knows he/she made the error and is not rejoicing in your pain. Maybe for legal reasons, he/she is not able to apologize directly.

    • Suzi Q 38

      I guess hat happened to you is what I am hoping for myself.
      I am glad that it turned out so well!

  • http://www.thehappymd.com/ Dike Drummond MD

    The best resources for apologizing for medical errors … for doctors and all other staff members is SorryWorks Materials here.

    http://www.sorryworks.net

    Learning how to structure your conversation and your energy for addressing errors and bad outcomes is a hole in our medical education. Doug Wojcieszak created sorryworks to address this based on his own experience of a family member’s tragedy.

    Saying sorry works. It is a skill you can learn that will help everyone involved reach resolution and lower malpractice risk and hard feelings.

    Dike

    Dike Drummond MD
    http://www.thehappymd.com

    • B. Andrews

      Thank you for mentioning SorryWorks–it provides compelling evidence of the power of apology. Making an effective apology is not always easy or obvious, however. Check out the brief training opportunities offered by the Institute for Healthcare Communication (IHC). Highly interactive half-day workshops help individual clinicians and organizations learn specific skills to become more accountable to their patients. A good place to start is “Disclosing Unanticipated Medical Outcomes”.

      • James deMaine

        Great, thanks for the links!

    • Suzi Q 38

      So true.

    • karen3

      Sorry works is an insurance company sponsored scam. Sorry, without accountability and compensation, does not work.

  • guest

    Once during a hospitalization, I had a nurse give me another patient’s medication by mistake. I actually questioned the nurse about the medication, but he assured me the doctor had ordered it, so I swallowed it. Come to find it was a mistake. The nurse actually came back into the room, admitted it, and apologized. The only thing the medication did was make me a little sleepy, no harm done. I thought it took a lot of guts for that nurse to come back in and own it. I was very appreciative of him, and did not make any kind of complaint. Mistakes happen.

    Contrast that with my grandfather going to an ER with a broken hip. The doctor sent him home (by ambulance) unable to walk or care for himself, and with no pain medication. (He was in his 80′s and had no h/o drug abuse). My parents flew back home to help take care of him. He had surgery the next day (at another hospital). Never an apology for sending my grandfather home alone in that condition. My mom reported the doctor and he was reprimanded. The issue for our family was not that he missed the broken hip on the xray or missed his history of osteopenia on record at that hospital. It was his rude, dismissive behavior coupled with the fact that he sent my grandfather home alone, unable to even walk to the sink to get a drink of water, with untreated pain. He was helpless.

    Mistakes happen, and I think most patients will be understanding if someone who made the mistake is genuinely remorseful. If there is no indication that the person who screwed up cares about what happened, that’s when you usually get complaints and/or lawsuits

    • James deMaine

      Lack of an apology leaves an open wound. I’m glad the doctor was reported. I wish he had been asked to meet with your family, and to apologize – that might have helped him to truly grow as a person.

    • Suzi Q 38

      You had every right to complain.

  • SarahJ89

    Both my doctor and my pharmacist have made mistakes. Both apologized. It actually deepened the relationships since it made it abundantly clear we were all humans.

    • James deMaine

      It’s almost magical isn’t it, when we show human compassion.

  • Janice Lynch Schuster

    As someone who has been on the receiving end of a medical mistake–although it may not have been, it may have simply been a peculiar adverse event–I can attest to how important it has been that the surgeon involved has sat eye-to-eye with me and apologized. Not so much for what he did, but for his role in creating a condition that has led to chronic nerve pain, and his regret that what he had anticipated as being a minor “snip” escaled into this. He noted that in recommending the procedure, which he had performed scores of times in children, may have had a different effect on an adult physiology. He has contacted other specialists to see me, and follows up with them in phone calls to check on how I’m doing. I have no doubt that he is sorry for what has happened–or that he and his colleagues have gained something from my experience. It is not likely to happen again, not on their watch.

    • James deMaine

      Thanks. The doctor acting with integrity and you show a lot of compassion.

    • Suzi Q 38

      At least he cared.
      I hope you are doing better.

  • Kaya5255

    As someone who has been involved in healthcare administration for many years, rarely are physicians disciplined, discharged or denied privileges for errors. Hospitals routinely cover up errors especially those committed by impared physicians. Their professional colleagues also do a great job of covering them.
    Neither the hospital or the physician offer any apology
    Incident reports are not included in the medical record and are usually difficult, if not impossible, to obtain.
    Nurses are disciplined when errors occur and they are usually reported to the State. Termination from employment is standard practice.
    Pharmacists are disciplined, but not as frequently as nurses. We always referred to them as the “teflon professionals” because nothing stuck to them!!
    When you’re hospitalized, you really need to have an advocate with you. You shouldn’t rely on the nursing staff to perform that function.
    A family member or friend should stay with you at all times. You can make such a requirement in you health proxy.
    You and you alone are responsible for your well-being when hospitalized.
    Always check your medications before leaving the pharmacy. Most people who take medication regulary know what the pills look like and should question anything that doesn’t appear correct.
    Remember the old adage; “an ounce of prevention is more valuable then a pound of cure”.

    • James deMaine

      I can understand your advice from your experience. I’d hope that with training, that the fear of and by medical providers can abate. Otherwise we’re doomed to a continuing system of distrust – which won’t benefit anyone including the most important person, the patient.

      • Kaya5255

        It truthfully isn’t a matter of training. It is matter of moral compass, accountability, responsibility and simply “doing the right thing”! You can’t change behavior, at best you can modify it. Why do you think lawyers have a field day in malpractice situations?
        If hospital administration acted as the conscience of the organization, held physicians and others accountable for their errors and punished those who aid and abet in covering up errors, we probably wouldn’t be having these conversations.

        • James deMaine

          As you know, there’s almost an universal inbred atmosphere of distrust between doctors and administrators. Both tend to see the worst in each other. I spent years in medical administration and saw good and bad on both sides. Docs can be demanding, but administrators can be bottom line oriented – two worlds both thinking “if only they would see it my way”.

          One of the worst meetings I saw was when an administrator (under pressure from the business office) told a group of specialists that they just weren’t doing enough procedures. The docs balked saying they were doing all appropriate procedures. The administrator then said “Hey, If you have a patient in the office with a billable procedure, then do it!” Half of the docs left this practice structure. I’m glad that that administrator wasn’t the “conscience” of my organization.

          My point is that docs and administrators see the world differently. There are good ones and bad ones, but most are quite good and ethical –
          at least in my humble opinion.

          The best “balance of power” I’ve seen is where the consumer has an equal voice with the administrator and medical group. Sound impossible? Not really. Just take a look at Group Health in Puget Sound. There’s no perfect structure or set of incentives but doctors and administrators tend to work together better with a consumer voice at the table, the incentives are transparent, and the organization itself has a clear moral compass.

    • Suzi Q 38

      I did not know that it was this bad.
      Thanks for letting us know.

  • rbthe4th2

    I had one group that didn’t do this. I am no longer with them. Do I warn people now? Yes I do. I had another experience that I complained about, and stated I’m not looking for $$, but I would want to see an apology, fix it, and don’t shoot the person involved, but teach them so no one else gets this.
    This place did it. I told them *in writing* that I appreciated their honesty, their courage in speaking up and that they would not just “shoot” the person who did it. As far as I’m concerned, they’ve done just that. I’m happy and will actually tell others, look these people have the courage to fix things. Do you want a doc who covers up & his admin staff lie or someone who actually puts your healthcare first?

  • petromccrum

    I have been saying this for years. In many cases an apology is all that is wanted by the patient. Most people will not sue if someone would just own up to a mistake, if possible make ALL efforts to correct, and apologize.

    This applies to ALL medical personnel not just doctors.

    • James deMaine

      Completely agree. On thing I noticed in hospitals is that the nurses seemed fearful of reporting mistakes. Punishment was often the outcome, black marks in their personnel files, shame, etc. Hopefully “All medical personnel” can learn that honesty and apology can benefit the patient and the whole system.

    • Suzi Q 38

      I agree. Suing takes a lot of time, money, effort and emotions.
      The person has to bee really angry to pay the retainer to get a lawsuit going.
      Just apologize quickly and get the patient to correct care.

  • lotzakids

    Because my son needs care 24/7 (trached/vent & O2 dependent) we have nurses at night so I can sleep. One of the things I make sure to stress when I’m orienting a new one is that they will make mistakes, it’s when, not if. And when it happens, I expect to be told immediately. That way, we can mitigate them. Unless there is something truly egregious (like removing the trach and watching him suffer), that will be the end of it. But try to hide it, and there are no second chances. My son’s life depends on me being able to trust them. We all make mistakes. But I have to know when they happen.

    • James deMaine

      This is a wonderful method you’re using. Transparency is so important in medical care. I hope others can follow your example.

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