Annals of Emergency Medicine
Volume 39, Issue 3 , Pages 344-346, March 2002

Dealing with failure: The aftermath of errors and adverse events☆

Department of Emergency Medicine, University of Florida Health Science Center Jacksonville, Jacksonville, FL

Departments of Health Policy and Management, Epidemiology, and Medicine, Johns Hopkins University, Baltimore, MD

Article Outline

Abstract 

Wears RL, Wu AW. Dealing with failure: the aftermath of errors and adverse events. Ann Emerg Med. March 2002;39:344-346.

 

See related articles, p. 287 , and p. 329 .

The ongoing discussion about errors and adverse events in health care has, until recently, concentrated largely on prevention and detection; in short, what happens before an injury. In this issue of Annals, 2 articles address an issue that is equally important: what happens after an injury has occurred, or the “aftercare” of the victims of adverse events. Goldberg et al1 lay out general principles for coping with mistakes and adverse events, while Yee's2 personal narrative in “Change of Shift” makes these issues real and hard to forget.

There are 2 sets of victims after a system failure or human error has led to injury, and we have not done a good job of helping either. The first group of victims is patients and their families; the second is the health care workers involved in the incident. Patients and families, who are most obviously affected by medical errors, need several things from their caregivers after an adverse event.

•First, they need to know what happened. All too often, once things start going wrong, caregivers become unavailable or uncommunicative with patients and families. We must recognize that uncertainty itself is painful and that silence is easily interpreted as lack of respect and compassion.

•Second, they need an apology. They need to hear someone say that they are truly sorry for what they have suffered. Unfortunately, although communication after an adverse event is often technically correct, it may not convey the deep sense of sorrow and regret felt by caregivers who have been involved.

•Third, some will need medical and financial assistance and compensation to help them deal with their loss.

•And finally, they need to know that something is being done to prevent similar tragedies in the future. For many, knowing that some good may come despite their tragedy helps mitigate their suffering.

The second set of victims, the health care professionals involved in the incident, need help as well. Their pain and devastation are no less real. Initially, they need emotional support and empathy. However, our professional culture and training do not support disclosure, even to peers; feelings of shame and fears of appearing less than competent prevent open exchange. Although we are generally noncritical of colleagues after an error, the reassurance given is frequently grudging, and the unconditional support that is needed is uncommon. The opportunity to explore the incident in safety is important to their accepting responsibility, which can be necessary for constructive change.3 Health care professionals need to be able to talk to the patient, and when appropriate, to apologize. Finally, they too need to know what can be done to prevent future tragedies.

Yee2 expresses the pain, chagrin, and regret felt by clinicians involved in adverse events, and also illustrates a defense commonly used by emergency physicians—ironic encoded idiom, dark humor, and false bravado. Although these provide some comfort, there is a danger of descent into callous cynicism. After reading this account, it is easy to understand how, without any well-developed system of support, some physicians adopt pathological coping mechanisms, lose their self confidence, and feel permanently wounded or unworthy.

It is liberating to know that both patient and physician victims of medical errors can be helped by the same actions—disclosure and apology—but, despite a clear ethical duty to disclose,4, 5, 6 it does not happen as often as it should.3 Why is disclosure so hard? There are several reasons: the discomfort we feel in dealing with failure; a lack of knowledge of how best to proceed in addressing these sensitive issues; and by no means least, fear of litigation.

Our legal system complicates the process. Risk managers and defense attorneys sometimes go so far as to advise caregivers not to talk to the patient and family after an incident. Ironically, patients or families sometimes turn to a lawsuit as a last resort because they could not get answers to their questions in any other way.7 The stance, supported by lawyers, that any expression of regret is tantamount to an admission of liability also hinders healing of both parties. There is a huge disconnect between the legalistic perspective of attorneys and risk managers and the moral, humane perspective of simply apologizing and asking forgiveness and understanding. Although it is imperative that legal impediments be recognized and addressed, these are not the only barriers to healing. Even if the legal system were reformed overnight, there are additional barriers to overcome.8

The first barrier is that physicians do not possess the crucial skills to help them handle these incidents. Our training virtually ignores the issue and has only recently begun to address the more general problem of how to break bad news to patients and families.9, 10, 11, 12, 13 In addition, these skills will be particularly difficult for the emergency physician, whose contact with the patient and family is brief and lacks the benefits of an ongoing relationship.

Second is the barrier of unrealistic expectations. We live in an age in which the only universally acceptable cause of death is decapitation—all else is considered reparable. Patients have an understandable need to consider their physicians infallible, but the medical profession has colluded with them to deny the existence of error.14 When communicating with patients, it is difficult to validate their desires for a miracle while compassionately steering expectations into the realm of the possible. In addition, it is particularly difficult to communicate the uncertainty that surrounds many adverse events, the causes of which may not be immediately clear and may require some time to become known.

Third, disclosure requires leadership and organizational commitment. It is unreasonable to expect people to be heroically forthright without unstinting institutional endorsement and support. If heroism is required for the right thing to be done, it will not get done very often.15 What is required are explicit policies of openness, honesty, and an expectation of disclosure from the highest levels of our health care organizations. A few organizations, such as the VA Medical Center in Lexington, Kentucky,16 and Catholic Healthcare West,17 are pioneering this kind of leadership by providing sustained, clear commitment to organizational policies and practices that tangibly support frank disclosure and fair settlement.

Finally, we are sometimes legitimately uncertain about whether an error was responsible for an adverse outcome. In these situations, the individual caregiver should not be solely responsible for decisions about disclosure. Ideally, an opinion on the need for disclosure should come from an experienced institutional body.

A safer health care system needs to include systems of care that continue after an adverse event to care for and support the patient, family, and involved caregivers in as many ways as possible. There is reason to hope that this change is already underway. The Third Annenberg Conference on Patient Safety, held in May 2001, was largely devoted to the exploration of issues surrounding aftercare18 and provides a push in the right direction. A great deal of work remains to be done, but we should be motivated by remembering that, however bad the truth is, denial will not make it better. The real remedy is honest communication with our patients and the creation of a culture that affords us this necessity.

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References 

  1. Goldberg RM, Kuhn G, Andrew LB, et al.  Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002;39:287–292
  2. Yee P. Brain cramp: the emergency physician's worst nightmare. Ann Emerg Med. 2002;39:329–330
  3. Wu AW, Folkman S, McPhee SJ, et al.  Do house officers learn from their mistakes?. JAMA. 1991;265:2089–2094
  4. American College of Physicians . Ethics Manual. Available at http://www.acponline.org/ethics/ethicman.htm #discloseJuly 6, 2001; Accessed
  5. National Patient Safety Foundation . Talking to patients about health care injury: statement of principle. Available at http://www.npsf.org/html/statement.htmlDecember 24, 2001; Accessed
  6. Joint Commission on Accreditation of Healthcare Organizations . Revisions to Joint Commission Standards in Support of Patient Safety and Medical/Health Care Error Reduction. Available at http://www.jcaho.org/standards_frm.htmlJuly 7, 2001; Accessed
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  12. Marrow J. Telling relatives that a family member has died suddenly. Postgrad Med J. 1996;72:413–418
  13. Schmidt TA, Norton RL, Tolle SW. Sudden death in the ED: educating residents to compassionately inform families. J Emerg Med. 1992;10:643–647
  14. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320:726–727
  15. Berwick DM. You cannot expect people to be heroes. BMJ. 1998;316:1738
  16. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131:963–967
  17. Bailey C. Turning the Titanic: changing the way we handle mistakes. HEC Forum. 2001;13:148–159
  18. National Patient Safety Foundation . Let's Talk: Communicating Risk and Safety in Health Care. In: Third Annenberg Conference on Patient Safety. July 6, 2001; Available at http://www.mederrors.org/ Accessed

☆ Reprints not available from the authors. Address for correspondence: Robert L. Wears, MD, MS, Department of Emergency Medicine, University of Florida Health Science Center Jacksonville, 655 West 8th Street, Jacksonville, FL 32209; 904-244-4124; E-mail: wears@ufl.edu.

PII: S0196-0644(02)08255-0

doi:10.1067/mem.2002.121996

Refers to article:

  • Coping with medical mistakes and errors in judgment

    Richard M. Goldberg, Gloria Kuhn, Louise B. Andrew, Harold A. Thomas
    Annals of Emergency Medicine March 2002 (Vol. 39, Issue 3, Pages 287-292)

  • Brain cramp: The emergency physician's worst nightmare

    Paul Yee
    Annals of Emergency Medicine March 2002 (Vol. 39, Issue 3, Pages 329-330)

Annals of Emergency Medicine
Volume 39, Issue 3 , Pages 344-346, March 2002

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