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Quality Matters: Talking the Talk: What to Say When Things Go Bad

Welch, Shari J. MD

doi: 10.1097/01.EEM.0000396896.24998.98
Quality Matters
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Scripting for Apologies



  • “I'm sorry this has happened to you, and I want to assure you I'll do everything possible to get at how this happened.” (Recognition)
  • “I really regret this happened. I know it is not what either of us wanted or expected, and I want you to know how sorry I am for what you are going through.” (Regret)
  • “I am responsible for your care, and I will find out what happened, and if possible why it happened. I will keep you posted of what I learn and how it can be used to prevent this from happening again. At this point I am not sure if I would have done anything differently, but I intend to explore this thoroughly.” (Responsibility)
  • “While it is still too early to tell, I don't think you will have any long-term health problems, but I will verify this over time. I want you to know the problem occurred because of a communication error, and I am looking into changes that will keep it from happening again.” (Clinical Remedy)
  • “I am responsible for your care and will be completely available to you. Here is my card; please call me directly if you have any problems.” (Remain Engaged)

Source: Healing Words: The Power of Apology in Medicine. Doctors in Touch; 2007.

The cultures of medicine, risk management, and medical malpractice are like a gag order to health care providers when a bad outcome has occurred. Last month, I reviewed the five elements of an apology, and described one study that incorporated apology into a risk-management program with positive effects on personnel and the bottom line. But how does one pull off a successful apology?

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Apology and Disclosure

Increasingly, health care is moving toward early disclosure of medical adverse events or errors, with full disclosure of the facts. Patients and their families want information, but they particularly want reassurance that they will recover. It is also surprisingly important to them that efforts are being made to prevent the problem from occurring again. Organizations that have processes in place outlining how such episodes should be managed are helping patients and their families cope, and helping staff recover as well.

Provider training and leadership in how to apologize and disclose have been successful at the University of Michigan and the VA Hospital in Lexington. Although the organization and insurers can't micromanage the interpersonal relationship between provider and patient, they can provide basic principles and approaches.

It is well recognized that 80 percent of communication is nonverbal. The recognition of a medical error or bad outcome is an emotionally charged event for everyone involved. The communication should be scripted and controlled on all fronts to avoid having it veer into negative or regrettable encounters. Tips for the communicating the apology include:

  • Make full eye contact.
  • Relax your hands at your sides (do not cross arms across the chest).
  • Sit down, and consider sitting on the edge of the bed after asking the patient's permission.
  • Use open hand gestures.
  • Give the patient and family ample time to ask questions.
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Scripting for Adverse Events

Scripting has long been recognized as a useful and effective tool in emergency departments. A 2010 article in Academic Emergency Medicine applied scripting to prevent walkaways from the ED. (2010;17[5]:495.) The use of triage scripting was found to reduce elopement rates significantly in patients placed in the ED waiting room, even after controlling for other confounding variables. Scripting is a simple and underutilized technique that can have a positive effect on patients and on the ED. Other areas for scripting include drug seekers, complaints, angry physicians, requests for information, distressed family members, and long waits.

Michael Woods, MD, wrote a useful book, Healing Words: The Power of Apology in Medicine, that offers language that should be used when adverse events occur in health care. ( Similar scripts could be developed and taught by the risk management department of each organization. Some providers also will need coaching in the delivery of the script. (See table.)

Often the events in the ED may not be catastrophic errors with bad outcomes but waits and delays leading to less favorable outcomes. Often the waits and delays are system failures, but it is important nonetheless for the emergency physician to take ownership and responsibility instead of blaming other departments or personnel. This is very important to patients. Begin the ED apology with regret for the delays, but take responsibility. Then quickly explain the clinical and financial remedies. Finally, offer a plan for how you will ensure that this doesn't happen again. It is very important that this is addressed in real time and in a genuine fashion.

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A Success Story

The VA Medical Center in Lexington, KY, had one of the worst records for malpractice claims in the system. In 1987 after losing two large suits, the risk management committee decided that a new approach was needed. The goal was to change the culture so that a more humanistic attitude was fostered among clinicians, particularly after a patient had been harmed. Rather than respond in a defensive or adversarial way, they wanted caregivers to respond in a care-giving way.

As the new policies and program were implemented, the risk management committee had to map out the details for timing and disclosure at the organizational level. They opted for a rapid full disclosure of adverse events, and they ramped up their patient safety efforts. All employees were expected to report not only errors but near-misses to the hospital risk management committee. The committee acts promptly to determine the root cause. If a patient is harmed, it makes quick recommendations for remedy including financial compensation. At a face-to-face meeting, representatives of the hospital apologize for the event, explain what is being done to correct the system that allowed the error, and the chief of staff answers all questions from the patient and his family. The hospital attorney offers a fair settlement.

Lexington's VA Medical Center found that this approach helped diffuse the anger of the patient and family members, and effectively curbed the motivation for litigation, reducing legal fees. Following implementation of this program, the medical center reported 88 malpractice claims in seven years, but the average cost of each claim ($15,622) was one-twentieth of the cost reported by the National Practitioner Data Bank ($270,854).

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Dr. Welch

Dr. Welch

© 2011 Lippincott Williams & Wilkins, Inc.