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Rapid Learning of Adverse Medical Event Disclosure and Apology

Raemer, Daniel B. PhD; Locke, Steven MD; Walzer, Toni Beth MD; Gardner, Roxane MD, MPH, DSc; Baer, Lee PhD; Simon, Robert EdD

doi: 10.1097/PTS.0000000000000080
Original Articles

Introduction Despite published recommended best practices for full disclosure and apology to patients and families after adverse medical events, actual practice can be inadequate. The use of “cognitive aids” to help practitioners manage complex critical events has been successful in a variety of fields and healthcare. We wished to extend this concept to disclosure and apology events. The aim of this study was to test if a brief opportunity to review a best practice guideline for disclosure and apology would improve communication performance.

Methods Thirty pairs of experienced obstetricians and labor nurses participated in a 3-part exercise with mixed-realism simulation. The first part used a standardized actor patient to meet the obstetrical team. The second part used a high-fidelity simulation leading to an adverse medical event (retained sponge), and the third part used standardized actors, patient, and husband, who systematically move through stages of grief response. The participants were randomized into 2 groups, one was provided with a cognitive aid in the form of a best practice guideline for disclosure and apology and the other was only given time to plan. Four blinded raters working in pairs scored subjects on a 7-point scale using a previously developed assessment instrument modified for this study.

Results Pooled ratings of the disclosure and apology discussion for the intervention group (n = 167, mean = 4.9, SD = 0.92) were higher than those from the control group (n = 167, mean = 4.3, SD = 1.21) (P < 0.0001). One specific element was rated higher for the intervention group than the control group; posture toward the patient (n = 27, mean = 5.1, SD = 0.82 versus n = 28, mean = 4.3, SD = 1.33) (P = 0.020). The elements of dealing with anger, dealing with depression, dealing with denial, bargaining, and acceptance were not different.

Conclusions Experienced practitioners performed better in a simulated disclosure and apology conversation after reviewing a cognitive aid in the form of a best practice guideline than a control group that was only given time to prepare.

From the Center for Medical Stimulation, Charlestown, Massachusetts.

Correspondence: Daniel B. Raemer, PhD, Center for Medical Simulation, 100 First Avenue, Charlestown, MA 02129 (e-mail:

The authors declare no conflict of interest.

This study was supported by Grant no. 9600674 from The Physicians Foundation.

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