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THIS WEEK'S EDITION:
- Question and Answer
- Great Progress in the Volunteer State
- On the road again!
- Sorry Works! Audio Conference - Register Now!
- Texas Sorry Works! Legilsation
- Progress in Bay State/Boston Herald Article
QUESTION AND ANSWER
Question: What role can/should nurses play in disclosure and apology?
Geri: Nurses have a very important role in disclosure and apology, but it may not be the role you are expecting. Different situations may support different involvement. In an effort to keep this response brief, we will highlight the most typical situations.
Let's begin by reiterating that the goal of disclosure is to give patients and families information they need to make informed decisions about their care and what they need to do in response to that care. By keeping that goal in mind, the role of the nurse becomes somewhat clearer.
1) Has there has been a potential medical error or unanticipated outcome having a nursing action at the sharp end? If the answer is yes, then the nurse's role may be one of active participation in the conversation. This should not happen without discussion with risk management and the physician representative (whether the attending or CMO) primarily because we need to ensure that the nurse involved in the conversation is psychologically and emotionally prepared to have the conversation. If there has been serious injury or harm to the patient, it is also likely that the nurse involved in the event may not be the nurse involved in the conversation. Often it may be the nursing supervisor or CNO who will participate in the conversation. We still recommend that the attending or a representative of the medical staff participate in the conversation to answer medical questions that may arise.
2) Has there has been a potential medical error or unanticipated outcome with no nursing action at the sharp end? The role of a nurse representative in these conversations could be more of support for the patient or family who might know the nurse and trust her/him. Also, the nurse might be the liaison with the unit where continued care is taking place and might be able to support actions for follow-up that came up during the disclosure discussion.
3) Has there been an error that resulted in little or no harm that was precipitated by a nursing action at the sharp end?
In this situation, then, assuming hospital policy allows, the nurse might be the discloser and the one to apologize. It is not the goal of disclosure to create an articificial wedge between the patient/family and the caregivers. It is the goal to generate trust and enhance communication.
Regardless of whether a nurse is involved in the disclosure of an unanticipated outcome, all nurses where care is being given have a special role of supporting a blame-free, supportive, and humble interaction. This means that nursing staff must avoid gossip, speculation about cause of the event or assigning blame. They should refer questions and concerns to the identified nurse and/or physician who has been identified.
This is a high level response to a question that must be evaluated by case regarding active involvement in the actual disclosure discussion.
Doug: Geri provided a very thorough and complete answer. I am going to take a slightly different but complimentary approach in my answer.
The main thesis of The Sorry Works! Coalition is that the med-mal crisis is a customer service crisis - not a legal problem - to be fixed by medical professionals anytime they wish. If you subscribe to this philosophy then you should believe that nurses play a big role in disclosure and apology and an even larger role of providing excellent customer service to patients and families. After all, nurses are usually the front-line employees who have the most frequent contact with the customers.
Nurses need to be taught to be on the look-out for small problems and address them quickly with good customer service. TV won't work in the patient's room? No problem - we'll get a technician up to fix it right away. Food is slow coming to the patient's room? We'll get the food there right away and provide a free plate with dessert for the patient's spouse. These events may sound trivial, but small problems can lead to a major blow up if an adverse event occurs. An already strained relationship may break and a lawsuit will be in the offing:
"Oh, that nurse has been so cold and uncaring. It seemed like she never answered the call button, and when she did she acted like she was doing us a favor. Now this! Something has gone wrong. I just know she and that Doctor Smith screwed up!"
Good customer service is so important and will lay the ground for successful disclosure and apology, when needed and appropriate, as Geri discussed. And nurses can lead the way!
GREAT PROGRESS IN VOLUNTEER STATE
Last week Sorry Works! spokesperson Doug Wojcieszak paid a visit to Nashville , Tennessee (the state capitol) to discuss Sorry Works! legislation which will encourage hospitals to pilot disclosure and apology programs. We had several great meetings with state leaders and local hospitals and medical professionals, and there is great momentum building for Sorry Works! in Tennessee . We expect more progress this Spring and we will keep you posted.
For our friends in Tennessee , please let your legislators know to support HB 1334/SB 1337. Thank you!
ON THE ROAD AGAIN!
Willy's Nelson classic tune "On The Road Again" could become the theme song of the coalition. Trips to Las Vegas (RM&PSI Conference), Oklahoma City (PLICO Insurance and Oklahoma Medical Society), and Columbia, MO (Missouri Patient Safety Center) are on tap for the next 10 days. Furthermore, a new speaking engagement with the Canadian Ombudsman in Montreal has been added in late May.
We already have speaking engagements booked for April, May, and June, but dates are still available. To request a Sorry Works! speaker, please contact doug@sorryworks.net or call 618-559-8168. Thank you!
SORRY WORKS! AUDIO CONFERENCE - REGISTER NOW!
Plan to join us for the next Sorry Works! audio conference on May 9th from 1pm EST to 2:15pm EST. The title of the audio conference is "A Deeper Look At Apology and Its Role in Disclosure." As the title indicates, this conference will dig into the deeper issues of apology and disclosure and how the process impacts patients, families, and physicians. This is a "can't miss" conference.
Our featured speakers are Dr. Aaron Lazare and Dr. John Banja. Dr. Geri Amori of the Risk Management & Patient Safety Institute (RM&PSI) will be hosting and leading the conference call.
Dr. Lazare is the Chancellor of the UMASS Medical School and author of "On Apology," published by Oxford University Press in 2004. Dr. Lazare is an expert on apology and how it can harm or heal. He is a frequent speaker on apology to a wide variety of groups around the United States.
Dr. John Banja is a professor of bioethics at Emory University and the author of "Medical Errors and Medical Narcissism," published by Jones and Bartlett in 2005. Dr. Banja is also a frequent speaker on narcissism, medical errors, and disclosure before medical and insurance organizations around the United States.
Drs. Lazare and Banja will delving into the important issues surrounding effective and meaningful apology, and they will also be answering your questions live. Please join us for this important audio conference.
The audio conference counts for CME/CEU credits. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of The Risk Management and Patient Safety Institute (RM&PSI) and The Sorry Works! Coalition. RM&PSI is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. RM&PSI designates this educational activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)TM. Application for 1.25 contact hours has been submitted to the Michigan Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.
The cost of the conference or CD is $225 (with a special rate of $150 for educational institutions and MHAIC/WCC insureds). Also, a special combo rate of $275 is available for both the live conference and CD. To register or for more information, please contact Melanie Gober at 517-886-8226.
TEXAS SORRY WORKS! LEGISLATION
Texas Representative Mark Strama has introduced some very creative Sorry Works! language. In short, the bill provides apology immunity - including admission of fault - for any hospital in Texas that pilots a Sorry Works! disclosure and apology program, which will include providing upfront compensation to patients/families harmed by medical errors. This bill goes one step further than so many of the traditional "sorry" bills, which usually provide some form of immunity from words being used in court. Complete language of HB 2837 can be found at this link.
PROGRESS IN BAY STATE/BOSTON HERALD ARTICLE
In January we paid a visit to Boston to meet with several groups and organizations, and are happy to see the progress continues with this Sunday (yesterday) article in the Boston Herald. Read below.
'Sorry' solution: Malpractice bill frees doc to apologize
By Jessica Fargen
Boston Herald Health & Medical Reporter
Sunday, March 18, 2007
A proposed law in Massachusetts would give doctors more freedom to be honest with patients about medical errors without fear that their apologies might be used against them in court.
It's just one part of a national and local push to get more physicians to say "I'm sorry."
"Patients say, 'If I'd had an apology, it would have helped my own healing,'" said Deborah Wachenheim, coordinator of a consumer health quality group at Health Care for All, and backer of a proposed bill that would legally protect doctors who apologize. "Just hearing the apology can make such a huge difference."
The Bay State legislation, proposed by state Sen. Richard T. Moore (D-Uxbridge), chairman of the health care financing committee, would make doctors’ statements of regret or admissions of errors to a patient or family inadmissible in court.
The bill is only one part of a cultural shift in the health care system in response to rising malpractice costs and a growing patient right-to-know movement.
Hospitals across the country, including many in the Boston area, have adopted so-called apology and disclosure policies, which can allow a physician to admit an error, explain what happened and apologize. Sometimes, the hospital offers money upfront to cover associated costs.
Doug Wojcieszak, spokesman for SorryWorks! Coalition, which advocates for apology and disclosure policies, said health systems around the country are slowly embracing the idea, which has cut down on malpractice claims and saved money at some hospitals.
"They've had this risk-management strategy for years - deny and defend," Wojcieszak said. "They think that's the way to limit lawsuits. What the experience has been is that doesn't prevent a lawsuit, it encourages one. They make people angry."
Medical errors also kill. About 100,000 people in this country die each year as a result of medical errors, according a national study.
Last year, the 14 Harvard-affiliated hospitals in Massachusetts agreed in principle to a consensus agreement that laid out an apology and disclosure policy, although hospitals have instituted their own individual procedures. Wojcieszak said some studies have shown that even with moderate to severe errors, patients are less likely to sue if a physician acknowledges a medical error.
"We've got to quit playing games with patients, said Dr. Lucian Leape, an adjunct professor at the Harvard School of Public Health and national patient-safety expert.
"A patient has a right to know absolutely everything. We have no right to keep anything from patients," said Leape, one of the authors of the Harvard agreement.
Dana-Farber Cancer Institute adopted a policy in 2001 that requires the hospital staff to acknowledge a medical error within 24 hours of its occurrence, prior to any investigation.
Maureen Connor, Dana-Farber's vice president of risk management, said the document gives doctors guidance and makes patients feel informed.
"Simply put, this is the right thing to do," said Connor, who also worked on the Harvard agreement.
Some physicians and attorneys say hospital policies must go hand-in- hand with legal protections, such as the one contained in Moore's bill, for true malpractice reform to work. Massachusetts doctors pay some of the country's highest medical malpractice insurance rates.
"The health-care providers need to be assured that they will be reasonably protected under those policies," said John P. Ryan, a Boston attorney who defends physicians in malpractice cases.
Added Dr. Kenneth Peelle, president of the Massachusetts Medical Society, who supports Moore’s legislation: "We think it's a different way of approaching some of the problems with malpractice claims than what we've been seeing in the last couple years."
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