Author: James Padilla, JD
PIPSQC Ambassador Assistant Lead
Board Member (liaison, Mothers Against Medical Error), Nursing Alliance for Quality Care
Dean, School of Business, Tiffin University
The other day, my friend and colleague, Dale Ann Micalizzi, posted on her Facebook page a note about a doctor friend who was going to engage in an apology and disclosure following a tragic outcome. Knowing her story and having a similar one, I could only consider thinking - do we as patients and impacted family ever encourage such a difficult undertaking? I mean do we REALLY encourage it from the doctor, nurses and other healthcare providers!
When we lost our son, Christian, under very tragic and questionable circumstances, our immediate reaction was disbelief and questions. How could this happen? How did this happen? What happened? Everything happened so quickly - early in the morning, Christian and I were talking. Approximately twelve hours later, doctors were delivering the horrible news that Christian’s brain had herniated. This following a successful surgery on his aorta. Three days later, Christian was officially pronounced brain dead.
Without going into the details that led to Christian’s death, we knew immediately all we wanted were answers, and those answers could not come fast enough. The root cause analysis would take time. Over the next few months, we would call Christian’s surgeon and ask questions. These phone calls were the most important opportunity for Christian’s surgeon and us to reconfirm our trust relationship between us. An opportunity to share updates and information, but also for us to ask questions. The most reassuring response we would receive from his surgeon was sometimes simply, “I don’t know the answer yet, but I will call you when I do.” Most importantly, he did call. These phone discussions led to major developments in the root cause analysis which could not be discovered simply from the nursing notes. It resulted in my wife and I traveling back to the hospital over a hundred miles away to meet with Christian’s surgeon, one of the neurologists who cared for him, the Director of Nursing, an Assistant General Counsel and others. This incredible meeting allowed for a very open and honest discussion, sharing of valuable information and critical points of eye witness factual testimony. We finally had completed the root cause analysis puzzle to a point where more definitive answers could be provided, answers for our family and the providers. If you listen closely, you can hear a giant sigh of relief and a soothing feeling of comfort. We now understood, and the apologies began to flow.
I remember vividly, Christian’s surgeon saying to us, “I know this may not mean much, but is there anything I can do?” The only thing I could think of was simply, “Don’t let this happen again to anyone.”
To doctors, nurses and other healthcare providers, we understand you can never undo some things. We know you make mistakes, we all do. However, no matter how difficult, no matter the hurdles - continue the conversations. Talk about the circumstances and share the information. You have the opportunity to continue the relationship with the family, provide them with some relief and comfort. You have the opportunity to learn from this, and do everything you can to prevent similar things from happening again.
You cannot undo some things, but you can make sure you do the next thing right! You have the opportunity to make a tremendous positive impact in the family’s lives and your own - provide relief, comfort and direction.
1. ACSQHC - Open Disclosure
2. AHRQ PSNet - Error Disclosure
3. CPSI - Canadian Disclosure Guidelines: Being Open with Patients and Families
4. IHI - Respectful Management of Serious Clinical Adverse Events
5. MIPS - Critical Incidents and Disclosure
6. NHS NRLS - Guide to investigation report writing following Root Cause Analysis of patient safety incidents
7. PFPSC - Disclosure Principles
8. PIPSQC Blog - Partnering with Parents to Save Children's Lives (by Dale Ann Micalizzi)
9. Disclosing Medical Errors and Adverse Events (by Dr. Marjorie Stiegler)
10. Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors. (by Dr. Anne Matlow et al.)
11. Including Patients on Root Cause Analysis Teams: Pros and Cons (by Matthew Grissinger)
12. The Power of Apology (by Dr. Marie Bismark)
13. Structuring Patient And Family Involvement In Medical Error Event Disclosure And Analysis (by Dr. Jason Etchegaray et al.)