The purpose of this article is to help

2009 Monkey Business Images/Shutterstock.com Disclosing Medical Errors: Restoring Client Trust * Kathleen A. Bonvicini, EdD, MPH a Institute for Healthcare Communication New Haven, Connecticut Daniel O Connell, PhD a Institute for Healthcare Communication Seattle, Washington Karen K. Cornell, DVM, PhD, DACVS The University of Georgia Athens, Georgia At a Glance Case Scenario Page 105 Ethics, Values, and Moral Compass Page 105 Disclosure and Resolution: A Protocol Page 106 What to Do When an Error Occurs Page 108 Guidelines for Disclosure Page 110 Establish Practice Protocol Page 112 The purpose of this article is to help veterinarians reach a mutually satisfying resolution with clients when individual, team, or system errors result in an adverse outcome. It offers a model that integrates the ethics of veterinary medicine with specific skills and attitudes that have been shown to promote psychologic and practical resolution of these situations for clients and veterinary practices. Case Scenario Consider the following 1 : Your nephew, a recent veterinary school graduate who is newly employed at a private small animal hospital, calls you for advice. Four days ago, he admitted a dog to the hospital for vaccinations and boarding. During the admission process, he administered a Bordetella bronchiseptica vaccine to the dog. The dog died this morning. In retrospect, your nephew realizes that he picked up a syringe of intranasal B. bronchiseptica vaccine that still had a needle on it from being drawn from the vial, then gave the vaccine subcutaneously. This inappropriate route of administration resulted in the development of liver failure while the dog was boarded at the hospital. *Adapted with permission from Compendium Equine 2008;3(1):14-22. a Drs. Bonvicini and O Connell disclose that their nonprofit foundation receives funding from Bayer Animal Health. Your nephew says, I feel terrible what should I tell my clients? How would you respond? What one piece of advice would you give to your nephew? Ethics, Values, and Moral Compass In examining this scenario and considering your own opinions, you are likely relying on the values that guide the way you practice veterinary medicine. Still, this will be a very tough conversation to have. Many clinicians report feelings of shame, heartbreak, and vulnerability in situations like this one. Our natural instinct for selfpreservation, coupled with advice we may have received previously, can tempt us to be very guarded when talking with clients about adverse outcomes and to use calculated omissions and rationalizations to conceal evidence of an error. In the above scenario, one might argue that vaccination has inherent risks. A frightened young veterinarian might be attracted to such seductive reasoning as, Disclosing the actual cause of death will increase the clients distress and certainly will not bring back the animal. What good could come from telling the clients what really happened? Rationale for Openness The ethical positions of organizations such as the American Medical Association, 2 the American College of Physicians, 3 and the CompendiumVet.com March 2009 Compendium: Continuing Education for Veterinarians 105 Copyright 2009 Veterinary Learning Systems. This document is for internal purposes only. Reprinting or posting on an external website without written permission from VLS is a violation of copyright laws.

Most client disappointments with veterinary outcomes are not the result of negligent care. Joint Commission 4 have clear statements that require accurate disclosure of adverse medical outcomes in human medicine. Similar ethical positions exist in veterinary medicine. 5 Research in human medicine and other professions 6 10 has described the potential advantages of a more open approach with patients, families, and customers in these situations. When applied to veterinary medicine, these benefits include the following: More situations can be worked out directly between the veterinarian, the client, and the insurance carrier without stimulating legal action or formal complaints to licensing boards. The AVMA Professional Liability Insurance Trust (PLIT) recommends that veterinarians call the PLIT office as soon as possible after an event that could give rise to a claim. b Rebuilding rapport and trust and resolving disagreements can turn initial client disappointment into an even stronger relationship. When the practice and the insurance carrier are willing to initiate discussion of fair settlements with clients who have been legitimately affected by errors in practice, the dollar amounts tend to be easier to negotiate and more reasonable than those obtained through legal action 7,8,11 because client bitterness is minimized and dollar amounts are focused on reasonable compensation rather than punishment. b Ellis LJ. Personal communication, AVMA PLIT, 2007. Adverse Outcomes and Medical Errors Adverse outcome is the term used in veterinary and human medicine to indicate unanticipated harm that results from a medical treatment rather than from a disease or condition itself. 12 An ethical approach to disclosure of harm hinges on the veterinarian s commitment to determining and then sharing the most accurate conclusions about how the harm was caused. While sometimes fairly clear, many situations require the veterinarian to draw a bright line through a gray situation to determine whether a breach of the standard of care caused the harm (and, therefore, the harm was preventable) or whether the harm occurred in the context of care that most veterinarians would judge as reasonable in a similar instance. 13,14 Practically and emotionally, this can be difficult to do, yet who is in a better position to investigate, conclude, and explain than the practice where the adverse event took place? Most client disappointments with veterinary outcomes are not the result of negligent care. For instance, clients may have unreasonable expectations that were not adequately addressed or corrected. They may not appreciate the variability between animals or that diagnostic and treatment plans are based on probabilities rather than certainties. The clinical picture may change as additional signs emerge and the response to treatment is assessed. 15 Almost every effective treatment brings with it the potential for untoward side effects and complications. Unless clients are apprised of these risks, they may mistakenly believe that similarly trained clinicians would have been able to solve the problem more quickly, with less suffering, and at a lower cost. Each of the above factors is a reminder of the importance of obtaining true owner consent, recognizing and correcting unreasonable expectations, and offering adequate explanations when diagnosis and treatment are unsuccessful, even when the standard of care is met. 16 Errors and Harm in Veterinary Medicine While research into the incidence, type, and impact of errors in veterinary medicine is limited, it is clear that adverse events related to errors do occur. For instance, one small UK study 17 found that 78% of recent practicing veterinary graduates surveyed reported they had made a mistake that resulted in a less-than-optimal or potentially adverse outcome for a patient. Most mistakes involved failure to conduct appropriate diagnostic tests, surgical mistakes during procedures other than neutering, and administration of inappropriate drugs or medical treatment. Forty percent reported that they had not discussed the error with the client. These mistakes caused many of the respondents considerable distress. Disclosure and Resolution: A Protocol Research has consistently indicated that, in human medicine, patients and families typically want to hear the following from the care provider when an adverse event or outcome occurs 10,18 21 : What happened How it happened What the immediate medical consequences are, and what impact they will have on quality of life 106 Compendium: Continuing Education for Veterinarians March 2009 CompendiumVet.com

2009 Phase4Photography/Shutterstock.com Emotional selfawareness is key to adopting the most constructive attitude and behavior. Box 1 What can be done now How the problem will be prevented in the future (i.e., the promise that something good will come from the adverse event) An apology if appropriate (if errors led to the harm) The following protocol (summarized in Box 1) provides specific approaches to assist you in organizing a thorough, appropriate, constructive response that meets the needs of the patient and the expectations of clients and that restores clients trust, regardless of the severity of the adverse event. Tend to the patient s immediate clinical care. In the event of an adverse outcome, the primary responsibility of the veterinarian is to address the needs of the patient and, if appropriate, obtain medical consultation or arrange for necessary follow-up. Consider that charges for services in these circumstances may not be billable if they are addressing conditions caused by errors (including equipment failures and system or procedural mistakes that caused harm). Address your own emotions and needs. Emotional self-awareness is key to adopting the most constructive attitude and behavior. A clinician who is flooded with worries about potential complaints and possible malpractice suits may be unconsciously pushed to minimize or even distort the facts and explanation offered to the client. On the other hand, the clinician who is overwhelmed with guilt What to Do When an Error Occurs 1. Care for the patient. 2. Compose yourself and investigate the details of the event. 3. Disclose to the client what occurred and apologize, if appropriate. 4. Discuss with the client the plan of care for the animal. 5. Be accountable and discuss methods of reparation. 6. Share how you plan to keep this from happening in the future. and heartbreak for the patient s and client s situation may leap to self-blame too quickly, only to have the investigation determine that no deviation from the standard of care was implicated in the outcome. There is usually enough time to consult with a trusted colleague to clarify your thinking and reestablish your emotional equilibrium before needing to make a full explanation to a client about how an adverse outcome arose. Investigate the details of the event. Develop clarity about what happened. The client is entitled to the most accurate understanding of what happened, which may take some time and investigation to clarify. You can ask for the client s patience while you investigate. Make and keep a clear promise to discuss the conclusions when they are reached. In many cases, the cause of the harm is never fully determined; however, it remains the veterinarian s responsibility to disclose the most likely causal pathway. Determining whether error was the cause of harm should be guided by asking, 22 What would have been expected of a similarly trained individual in that situation? Prepare for discussion with the client. Start by trying to imagine and anticipate what the client may be thinking and feeling when hearing the news. O Connell and Reifsteck 23 suggest asking yourself the following selfreflection questions to help guide you in your discussion with the client: What is the most accurate explanation for the adverse event? How would I want the situation to be handled if I were in the client s position? How would I feel if I suspected or later learned that the provider had not been forthright with me about the injury and its causes? It is helpful to rehearse the actual words you will use in explaining the adverse event because hearing them will help you determine whether they are likely to be adequate to address the client s expected thoughts and feelings. Consider carefully who should attend the disclosure conversation. The veterinarian who is primarily responsible for the care of the animal should be there and take the lead in 108 Compendium: Continuing Education for Veterinarians March 2009 CompendiumVet.com

Disclose what you know, but guard against premature conjecture until you are as certain as you can be about causes and consequences. the discussion, even if the adverse event was primarily caused by another staff member s actions. The presence of a person who was not directly involved with the adverse event and who has credibility, maturity, and strong communication skills, such as the practice manager, can help facilitate and mediate what can be a difficult conversation. Plan when and how to begin the discussion. An initial discussion with the client should take place as soon as possible after the adverse event. Disclose to the client what occurred and apologize. Disclose what you know, but guard against premature conjecture until you are as certain as you can be about causes and consequences. When possible, make an initial phone call to set up an in-person meeting rather than have the discussion over the phone. If a phone disclosure cannot be prevented, start the discussion by acknowledging how sorry you are to have to be sharing the news over the phone. In person, start the discussion by offering a frame for the information to follow: I have some difficult news to share with you. I m very sorry to have to tell you Then explain the situation by addressing each of the issues listed above. Box 2 offers some additional guidelines to approaching the disclosure conversation. Box 2 Guidelines for Disclosure 1. Choose a quiet place. 2. Ensure that there will be no distractions (e.g., turn cell phones and pagers off). 3. Provide a warning (e.g., I have difficult news to share. ). 4. Be attentive to your own and your client s nonverbal messages. Make eye contact. Sit at the client s level. Respond appropriately to client nonverbal cues (e.g., I see that this is shocking to you. Should I go on or do you need a moment? ). 5. Facilitate discussion and encourage questions. 6. Finish with a plan for the next contact. Elicit and acknowledge client reactions. Frequently throughout the discussion, you should solicit the client s perspective through questions and statements such as, What thoughts or questions do you have about what I have explained so far? and I imagine you have many emotions and questions, and I want to hear from you first before going on. Eliciting reactions serves to validate the client s perspective on the medical error and adverse outcome and sets the stage for effective interaction. Voice tone and body language are as important as actual words in conveying empathy for the client s experience. Showing your human side through genuine expressions of empathy can strengthen the bond and trust between you and your client. An empathetic veterinarian is not defensive, even when a client expresses anger and makes accusations. Acknowledging the client s reaction as a legitimate one by making a statement such as, It is normal to feel shocked and angry to learn that something like this has happened, does not indicate that you agree with the conclusions that prompted it. Apologize appropriately. After an adverse event or outcome, the proper type of apology can have a powerful effect on the client, making him or her less angry and suspicious. There are two types of apology: an apology of sympathy and an apology of responsibility. An apology of sympathy is: I m sorry this happened to you and your pet. An apology of responsibility is: I am terribly sorry for this error we made that has caused more problems for your pet. Mazor and colleagues 6,24 demonstrated that in situations in which a breach of the standard of care caused harm, respondents reported more trust and satisfaction and less likelihood of changing doctors when they received full disclosure with an apology of responsibility. In instances in which an adverse event is not the result of medical error, an apology of sympathy is appropriate. 110 Compendium: Continuing Education for Veterinarians March 2009 CompendiumVet.com

Discuss the plan for care of the animal. In many instances, by the time the disclosure conversation takes place, steps have already been taken to care for the animal, and the veterinarian is thinking about other potential consequences of the error. However, it is important to remember that the client has just received the news. Discuss the recommended plan for continuing care of the animal, including the potential short- and long-term outcomes. Often, clients are unclear about what lasting effect the error will have on their pet and may not comprehend the gravity or in some cases the limited impact of the error. It is critical that immediate concerns as well as the potential long-term impact be discussed in a manner the client understands. Be accountable and offer reparation. Finally, the practice must acknowledge responsibility to help the client recover as much as possible from the harm that has been caused. Appropriate fees for the animal s care should be waived. The veterinarian should anticipate discussion of who will pay for follow-up care before the disclosure conversation. Again, the AVMA PLIT recommends that it be contacted early on to discuss how best to approach this situation. Being accountable and willing to make reparations is crucial in the disclosure process; however, it does not mean immediately offering money. Rather, it means opening up the conversation: Can we do more to resolve this with you? We stand ready to do what we can to help you recover from this as much as possible. According to the Sorry Works! Coalition, 25 a leading advocacy organization for disclosure after adverse medical events, paying for errors is the ethical thing to do. However, there may be a fear that it will appear as if you are buying clients off. This is an understandable concern. In veterinary medicine, all of the steps of disclosure admission of error, explanation, apology can still be delivered sincerely, and PLIT or your liability carrier can be consulted on how to offer reparation. Describe plans to fix the behavior or system that contributed to the harm. Consumers who are affected by a medical error want to know that something good has come from the harm they have experienced. It is unacceptable to clients to think that a veterinarian s failure to change or reflect on the incident means that others are likely to suffer similarly. 23 These sentiments become expressed as complaints to licensing boards as well as malpractice suits. Therefore, the veterinarian s goal is to convey to the client that he or she has learned everything that can be learned from the adverse event: I can promise you that we ll all be meeting later today to review every step of our procedures. We want to immediately change anything that makes it more likely that this could happen again to any other animal in our care. Don t rush. Keep in mind that all these elements of disclosure may take more than one meeting or conversation to deliver effectively to the client. Discussion of reparation may take the longest to resolve in cases in which the impact of the harm on the surviving animal and the extent of needed ongoing treatment are uncertain. However, if a client has suffered serious loss or even financial harm (e.g., economic impact on a breeding kennel), he or she is going to want to promptly hear that you (with your liability carrier s guidance) intend to offer fair compensation. The heart of all effective and ethical disclosure is to provide the client with an accurate understanding of what has happened. The form an apology takes and the offers made to help a client recover from an injury caused by medical error should flow naturally from the veterinarian s own understanding of his or her degree of responsibility for the injury. Summary Consider your recommendations to your nephew in the scenario at the start of this column. Ask yourself the following questions: Are my recommendations based on ethical standards of openness, transparency, and integrity? Would I be satisfied if I were the client? Despite our best efforts, animals will occasionally be harmed by problems that occur while they are in our or our staff s care. Having a standard approach to disclosure and resolution that is consistent with our values, despite The heart of all effective and ethical disclosure is to provide the client with an accurate understanding of what has happened. CompendiumVet.com March 2009 Compendium: Continuing Education for Veterinarians 111

2009 Sarah Salmela/Shutterstock.com Box 3 Establish Practice Protocol How will the practice handle an error? Who will discuss it with the client? Who will be present during the discussion? Will individuals involved be identified? What time frame do we recommend? Where is the contact information for our liability carrier? When and how will we discuss this with staff members? the fears and vulnerabilities we are likely to feel at these times, can help us earn our clients forgiveness and enable us to forgive ourselves. Box 3 lists some questions to ask when developing a disclosure protocol. We believe in using ethical standards and values of openness and honesty as a springboard for conversations about medical errors. However, many veterinary practices may hesitate to embrace such openness for fear that it may increase malpractice risk. Acknowledging errors has been evaluated positively, leading to increased trust and lessening the possibility of negative impact 7 ; however, clinicians may still worry about the potential costs of openness and transparency. Although disclosure discussions are difficult and may still result in formal complaints and malpractice suits, evidence 8 tells us that acknowledging errors can significantly reduce litigation costs, reduce bitterness and mistrust, and avoid unnecessarily lengthy legal proceedings with the accompanying emotional pain for consumers and clinicians alike. We encourage all veterinarians, whether joining a practice or established in one, to engage in conversations with their colleagues about the practice s approach to and protocol for disclosure discussions in the event of a medical error. In addition, it is crucial to consult your malpractice liability insurance carrier to establish its position on the management of disclosure and resolution. References 1. 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How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med 1996;156:2565-2569. 20. Lazare A. Apology in medical practice: an emerging clinical skill. JAMA 2006;296(11):1401-1404. 21. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med 2002;347(24):1933-1940. 22. Reason J. Human Error. New York: Cambridge University Press; 1990. 23. O Connell D, Reifsteck SW. Disclosing unexpected outcomes and medical error. J Med Pract Manage 2004;19(6):317-323. 24. Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Arch Intern Med 2004;164:1690-1697. 25. Question and answer. Sorry Works! Coalition Newsletter; December 4, 2006. Accessed January 2009 at www.sorryworks.net/ newsletter20061204.phtml. 112 Compendium: Continuing Education for Veterinarians March 2009 CompendiumVet.com Copyright 2009 Veterinary Learning Systems. This document is for internal purposes only. Reprinting or posting on an external website without written permission from VLS is a violation of copyright laws.