Dealing honestly with medical errors: Should we say we are sorry?

When there is a problem it should be shared and explained, even though honestly admitting a medical error is difficult.

Issue: November 2004

ByDouglas W. Jackson, MD

Douglas W. Jackson, MD [photo] --- Douglas W. Jackson, Chief Medical Editor

Orthopedic surgeons — like all other physicians and health care providers — are involved in and impacted by the recognition of and accountability for medical errors. Almost every physician has experienced the anguish of knowing or thinking, “If only I had done something different, the patient would have been better off.” As individuals we try hard to never make any mistakes and strive to follow one of the oldest principles for physicians to “first do no harm.”

When we are involved in a medical error, we are ashamed. This event can challenge a patient-physician relationship and how the physician handles an explanation. When a medical error has occurred and is recognized, both the patient and the physician may think about its potential legal ramifications. This makes assessing who is to blame and how can it be prevented in the future a central issue.

A study in the American Journal of Nursing reported that even when there was overwhelming agreement among participants (97%) that an error had occurred, only 64% would disclose the error to the patient affected.

Admitting a mistake

We all understand that honesty is at the core of good patient-physician communication. When there is a problem it should be shared and explained, even though honestly admitting a medical error is difficult. In conflict with this position is the advice we have heard over the years: “No shame, no admittance of blame, and there will be no claim.” Some still feel that is the best strategy in the current medical-legal climate.

During my career I have been associated with medical errors — untoward incidents — in which I told the patient involved, explained my understanding of how the error occurred and what needed to be done to address it. These were some of the more awkward discussions I have been part of during my years of caring for patients. Those incidents resulted in settlements with the patient in the range of $20,000 each. Two of the three patients continued under my care and the other chose to find another physician.

Medical errors are just one of many situations that can result in a legal action. Others include postoperative complications, an unplanned outcome, a delay in recognition of a problem, a broken instrument, an error in judgment, etc.

I agree that the lawsuit and medical liability environment we work in is out of control. We work in a field where medical errors, problems and complications will occur in surgical practice if one does enough cases. An older partner told me when I was starting my practice, “If you do not want to deal with the problems and complications associated with surgery, do not operate because they will occur.” So we do the very best that we can do and try to minimize the chance and occurrence of medical errors.

When we are involved in a medical error, should we say we are sorry? When I did it, I felt I owed that to the patient and I found it helpful in dealing with the necessary treatment.

Accepting responsibility

Donald J. Palmisano, MD, JD, president of the American Medical Association, wrote in a recent issue of the Wall Street Journal: “The fact that so much attention is spent on whether to apologize goes to show how deep America’s medical liability crisis has become. The AMA is saddened that our legal system creates so much animosity that some physicians are discouraged, even by their own attorneys, from offering an honest apology to a patient when they make a mistake.

“Apologizing should not be considered a breakthrough. The AMA supports patients and physicians being able to discuss all issues openly and honestly, but we also understand many physicians fear that the acknowledgment of error is often used against them in the courtroom. This ‘shame and blame’ mentality must be stopped because it does nothing except breed fear and mistrust — elements that have no place in health care.”

“Physicians work every day to improve patient safety, but sometimes honest mistakes do occur. When that happens, physicians should be encouraged to openly discuss them with their patients, and we applaud those physicians who do. Yet until we rein in the nation’s broken medical liability system, and the fear and mistrust it fosters, we will continue to see physicians justifiably afraid.”

Harvey F. Wachsman, MD, JD, president of the American Board of Professional Liability Attorneys, wrote in a letter to the Wall Street Journal: “Even when a medical malpractice lawsuit has obvious merit, when the negligence is apparent and the damage clear — insurance companies, defense lawyers and doctors and hospitals themselves usually fight it tooth and nail. Apart from insensitivity to the victims, these frivolous tactics cost a lot of money.

“The best physicians and hospitals aren’t afraid to do the right thing. They know that the best way to prevent mistakes and build public trust is by determining very clearly what went wrong and taking responsibility.”

This is not a straightforward issue. Medical errors damage and cost the patient, and they will probably cost the physician both emotionally and financially. We are an unusual profession because of the standards we and others hold ourselves to. In dealing with other professions, one of the things I find most frustrating is when they react to errors by not accepting responsibility.

As physicians we need to remain honest and accountable and that has a price. However, the price of not being honest and accountable to our patients is even higher.