Harvard adopts a disclosure and apology policy

For physicians who have erred, "sorry" isn't always an easy thing to say.

By Kevin B. O’Reilly — Posted June 12, 2006

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Harvard's 16 teaching hospitals are hoping that a policy of routine disclosure and apology after preventable adverse events can begin to heal the lasting emotional scars both patients and physicians endure in such cases.

The new Harvard policy was outlined in a March consensus statement and highlighted during a session attended by thousands of physicians, nurses, hospital administrators and researchers at the eighth annual NPSF Patient Safety Congress in May. The conference is sponsored by the National Patient Safety Foundation.

The statement, "When Things Go Wrong: Responding to Adverse Events," outlines the reasoning and evidence for every step in the process of communicating with patients and their families in the aftermath of an unexpected outcome.

"Silence is lying without words," said Lucian L. Leape, MD, a Harvard health policy analyst who chaired the working group behind the Harvard statement. "It confirms suspicion."

Dr. Leape said that for too long a "second victim" of medical error has been ignored -- the physician or other health professional responsible for it. The Harvard statement calls for hospitals to attend to the emotional aftermath of medical error for the physicians and other health professionals involved in the case.

Though routinely disclosing and apologizing after adverse events is still rare, Harvard's initiative is not the first of its kind. The Lexington Veterans Affairs Medical Center has had such a policy in place since 1987. Denver-based physician-run medical liability insurer COPIC Insurance Co. has a similar program, and the University of Michigan Health System says it is saving $2 million a year in litigation costs thanks to its initiative.

"We have absolutely no moral or legal authority to withhold information from patients," Dr. Leape said.

Still, sorry does seem to be the hardest word for a physician to tell a patient, according to Jo Shapiro, MD, chief of otolaryngology at Brigham and Women's Hospital in Boston, a Harvard teaching affiliate. She apologized to a patient after perforating his throat in surgery. "The instinct is to deny and avoid," Dr. Shapiro said. "You just want to hide, not apologize or talk to the family."

And while a policy of disclosure and apology might work to lower overall litigation costs, it's not guaranteed to work in any given case.

"I disclosed, I apologized and I got sued," Dr. Shapiro said. Though she ultimately prevailed at trial, she described the process as "humiliating."

"We can't say, 'Just do it' " when it comes to physician apologies, she added, calling for emotional and institutional support for doctors who err.

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Addressing adverse events

In March, Harvard's 16 teaching hospitals unanimously agreed to communicate with patients and their families about adverse events using this format:

Immediately after the event

  • Acknowledge the event.
  • Express regret.
  • Take steps to minimize further harm to the patient.
  • Explain what happens next.
  • Commit to investigate and find out why the adverse event occurred.

Later follow-up

  • Disclose the results of the internal investigation.
  • Apologize if there is an error or systems failure.
  • Make changes to prevent the failure from recurring.
  • Provide continuing emotional support to the patients and the health professionals involved.

Source: Lucian L. Leape, MD, The Power of Apology, presented May 11 at the NPSF Patient Safety Congress

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