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A few hours later, the administrator received an angry call from the patient’s daughter. She was upset with the physician because she felt that he had talked “at” them, had not listened, and had not answered their questions. We recommend using a consult service model in which an expert communication consultant, who has been trained to facilitate disclosure conversations and to gauge the reactions of the patient and family, aids in planning and conducting disclosure conversations. After an adverse event it should be just as routine to call for a consult about communication process as it is in other contexts to call for a cardiology or geriatrics consult. It is the consultant who can make certain that the patient and family are clear about the next steps the hospital will be taking and about whom to contact with questions and concerns. The consultant can confirm the hospital’s commitment to openness and information sharing. The consult service may also be in the best position to link the disclosure conversations and what is learned during them to other institutional processes intended to improve patient safety. Members of the communication consult service can be drawn from throughout the hospital. Chiefs of service, nurse managers, patient safety officers, risk managers, and members of bioethics committees are obvious candidates, but other individuals may have interest in and aptitude for the task. Research suggests that successful mediators are individuals who are perceived to be natural problem solvers and conflict resolvers within the institution and who exhibit the skills needed during disclosure conversations, regardless of title or status (Kressel et al. 2002). Even when time is limited, taking a few minutes to speak with a communication expert will improve the disclosure conversation. Planning a disclosure conversation in the aftermath of a medical error or adverse event is often thought of by health care professionals as an unachievable luxury. However, even when time is limited, taking a few minutes to speak with a communication expert about the following considerations will improve the disclosure conversation: Having the person with the best available information at the disclosure conversation is important for three reasons. First, patients expect to hear from the physician most involved and may become suspicious should that person not attend the meeting. Second, having the person with the best information present avoids having others succumb to the temptation to fill in the information blanks by speculating about what happened. Finally, receiving information and explanations can change the way those involved in the event view each others’ motives. If, for some reason, the physician most involved in the adverse event or error is unable to participate in the disclosure conversation, it is essential that the reason for non-attendance be made clear. In most cases an opportunity for a future conversation with that physician should be offered. Even though it is difficult for a professional to admit that he or she does not have answers to significant questions, speculation often proves wrong. The subsequent provision of correct information that is inconsistent with the initial speculation may be seen as “changing the story” or “covering up.” When patients and their family members receive information about what happened and why, they may react to an error or adverse event with less anger and blame. Attribution theory research examines both how people interpret the causes of observed behavior and the implications of attribution for their emotions and reactions (Allred 2000). Most people tend to attribute another person’s negative behavior to innate disposition or character while attributing their own behavior to circumstances. The person who is harmed assigns the negative behavior to causes under the control of the other and responds with anger. At the same time, the person who has caused injury attributes his or her own behavior to circumstances beyond his or her control. The resulting difference “in judgment of the harm doer’s responsibility … can lead to the most destructive kinds of anger-driven-conflict” (ibid.). Given attribution theory research, it seems important during disclosure conversations to provide all of the available information known at that moment. If further studies support these findings, and we anticipate that they will, physicians and hospitals will need to think carefully about the words they use when disclosing an error and apologizing. Situations in which a mistake has been made but the health care provider was not negligent, or in which the patient suffers from an adverse event after being warned that the event might occur, provide special challenges. For example, what is the appropriate response when a mistake has been made but the physician was not negligent? When a surgeon nicks the bowel during surgery, a mistake has been made but the physician’s conduct may have been well within acceptable standards of care. What is the best response when the appropriate treatment is selected and provided correctly but the patient is among that group for whom the consequence of the treatment is harm? The physician may feel he or she has nothing to apologize for since the patient and family were warned of the risks of the treatment. But the patient may have failed to hear (or have been emotionally unable to hear) the warnings and instead may believe that someone must have done something wrong. If the communication is seen as evasive, the already damaged relationship between the medical professionals and the family is likely to be further harmed and the risk of litigation and the cost of settlement will increase. More research is needed on the impact of disclosure and apology, but our advice is always to disclose when harm has occurred for several reasons. First, it is the proper thing to do. Patients have the right – legal and moral - to know what has happened to them and why. They need that information in order make informed decisions about further treatment. In addition, full disclosure invites the kind of conversation with the patient and family members that can reveal critical information for avoiding recurrent harm. Further, if the hospital and health care provider have enough information to know that they caused the adverse event or medical error, an apology is warranted from both a pragmatic and an ethical standpoint. If fault is clear, an apology of responsibility should be offered. The best course of action is a clear explanation about what happened that adjusts the mediators in non- content and pace of discussion to the ability of the malpractice cases, we patient or family to absorb what is being said and have observed the damaging effect of allows time and opportunity for questions. At the mediation, the chief of medicine was able to listen empathically to the widow and respond with a full apology, acknowledging the hospital’s complete responsibility for the misdiagnosis and explaining exactly what treatment had been administered. He became the embodiment of the hospital for the plaintiff, which gave her the opportunity to express her rage and sadness and then her gratitude for his apology, his patience, and his clarifications. The widow at one point wondered whether events might have taken a different course had she been able to persuade her husband to go the ER immediately after his fall. She was reassured that she had done all that she could have and that had he gone to the ER the night of the accident it would have been too early for the bleed to show up on tests.
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