American College of Physicians: Internal Medicine — Doctors for Adults ®


How to tell patients you've made a serious mistake

Copyright 2003 by the American College of Physicians.

By Jason van Steenburgh

SAN DIEGO—It's one of the hardest things you'll ever do: Sit down with a patient or family member and talk about a mistake.

Errors can destroy patient trust, engender animosity and lead to legal action. During an Annual Session panel discussion on disclosing medical mistakes, however, experts stressed that when done well, discussing errors can bring relief to both patients and physicians and mitigate many of those other effects.

The workshop reviewed legal, ethical and risk management guidelines and communication strategies. Perhaps most importantly, it gave participants an opportunity to role play discussions about errors.

Physicians discuss techniques for communicating empathy while explaining errors.

Michael G. Goldstein, MD, associate director of clinical education and research at the Bayer Institute for Health Care Communication in West Haven, Conn., said that before approaching a patient or a family member, prepare yourself emotionally.

"Mistakes provoke guilt, shame, anxiety and anger," he explained. "They challenge our integrity, our identity as competent physicians and our egos."

He suggested first forgiving yourself and talking to colleagues and friends about the incident. "Look at how you express distress and be self-aware," he said.

Once you get a handle on your emotions, prepare to answer some tough questions. Gather as much information as you need, Dr. Goldstein said, and think about questions you might face so you'll have some ready answers when the situation turns emotional.

Expect the patient to ask you to explain in detail what happened, he suggested. The patient may also want to know what would have been different if you had not made the mistake.

Even if the patient becomes accusatory, he said, avoid becoming defensive. Do not prepare remarks with the goal of deflecting blame. Even when the system has gone wrong, prepare to say "I" instead of "we" to take full responsibility.

Establish empathy

Begin the conversation by trying to establish a bond with the patient. Dr. Goldstein recommended starting off by saying something like "I wish this had turned out differently" or "I'm very sorry your family has been through so much pain."

Show that you care and empathize. Maintain eye contact, and don't sit too far away. Keep your tone soft and your pace slow.

One audience member said that it's important to take responsibility, but physicians need to be careful that they don't invite attacks from patients. "Don't lead with your chin," he said.

While you should acknowledge responsibility if appropriate, Dr. Goldstein said, don't claim more blame than is due, and don't extend an apology simply to fill an awkward silence. Use silences and natural pauses to give patients time to organize their thoughts.

Ask patients or their family members what they know about the case. If they already know what you were going to tell them, be prepared to explain why you weren't able to talk about the mistake sooner.

Keep in mind that patients may be misinformed. When emotions run high, he explained, so does the potential for miscommunication.

Explain the error

When explaining exactly what went wrong, avoid jargon and stick to key facts, Dr. Goldstein said. Never omit or color facts because that can hurt you if the patient or family pursues legal action.

Always provide the opportunity for questions and check for understanding as you go. If the mistake was the result of a diagnostic error, explain your thought process as simply as possible without making excuses.

When you have addressed the person's questions, again express your empathy and support. "Empathy legitimizes the patient's feelings and it is the key to repairing the bond and re-establishing trust," he explained. One good way to show you care is to ask about the future.

Another audience member said it's important to be prepared to discuss what you have learned from the experience. At the end of the conversation, "you should show them that their loved one did not suffer in vain and explain the steps you have taken to make sure you won't repeat the same mistake," the internist said.


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