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Communication with Patients and Families

Conversations with patients who have been harmed by the care they received serve more than one important purpose. Among other things, these conversations demonstrate respect for the individual harmed, provide an opportunity for patients to be heard, and reinforce trust between the patient and provider. Often, these conversations will include members of the patient’s family.

What kinds of errors should be shared with patients?

The best practice is to disclose the error if:

  1. You would want to know about the event if it had happened to you or a relative; or
  2. Disclosure might result in a change in process or treatment, now or in the future.

Minor errors that do not reach the patient generally are not disclosed.

Note that in Massachusetts, when a health care provider’s mistake results in an unanticipated outcome with significant medical complication, the provider must fully inform the patient and, when appropriate, the patient's family, about the unanticipated outcome.

Is the timing of the initial conversation with the patient important?

It is. Patients should be told as soon as the error is recognized and the patient is ready physically and psychologically to hear the information. Ideally, this would be within 24 hours of the event. According to experts, early disclosure is an essential element of trust between a patient and his or her care providers.

Which clinicians should participate in this conversation?

Consider their level of involvement in the event, their emotional state, and their capacity to present themselves as an engaged member of the team. If they are not capable of making a positive contribution, their involvement should be deferred until later. Others who are not clinically involved (such as a risk manager) should usually not participate in the initial meeting.

Should others be present to support the patient and family?

Try to determine whether it would be helpful to have chaplains, friends, or other family members present. If English is not the patient's primary language, arrange for the services of an interpreter.

How should our team prepare for the first meeting?
  1. Remember that this conversation is solely for the benefit of the patient and family. Discuss the need for the team to present themselves in a unified manner. No finger-pointing or debate about the event should take place during this conversation.
  2. Agree on the core information that will be communicated. Anticipate questions that may be asked and know how the team will answer them. Practicing key aspects of the conversation in advance may be helpful.
  3. Determine an optimal time and setting for the conversation.
  4. Decide who will take primary responsibility for following up after the meeting, so that this can be clearly communicated to the patient and family.
What are the most important things to tell a patient?

Experts agree that the conversation should include:

  • Acknowledgment and explanation of what happened
  • Expression of genuine regret and a commitment to investigate further to prevent similar events from happening in the future
  • Discussion of how the event affects the patient’s prognosis and the care options for mitigating the effects of any injury
  • Assurance for the patient that the event will be thoroughly investigated and that all relevant facts will shared. Many patients seek reassurance that what happened to them will not happen to someone else.

If an error was made, the provider should admit it and apologize for it. In the initial conversation, it’s best not to speculate about root causes of the event or assign blame to another member of the care team. To the degree possible, avoid medical jargon.

Who is best suited to lead the conversation?

The best person to lead the conversation is almost always the physician most responsible for the patient’s care. There may be circumstances when it’s equally appropriate for someone else to lead the conversation, such as the member of the care team who committed the error or a medical professional the patient knows well and trusts. A physician who feels he or she cannot appropriately lead a conversation with a patient should consider asking a supportive colleague or other appropriate person from the organization to assist.

Should the care plan be discussed at this meeting? What if the patient wants to seek care elsewhere?

Outline a care plan for the patient's health needs going forward and offer other support services, such as chaplains, social workers, patient advocates, etc. Consider whether the patient's trust of the existing care team can be supported and maintained by involvement of additional sub-specialists or by requests for second opinions, and respect the patient's choice to have alternative care providers if necessary.

Is there additional guidance that can help assure a successful first conversation?

Yes. Medically Induced Trauma Supports Services (MITSS) — a nonprofit with extensive experience supporting patients and caregivers after a serious medical injury — developed a model known as LEND.

Listening. The goal is not to placate. Demonstrate a genuine desire to understand how the patient/family member feels.

Empathetic Response. Allow the patient/family member to express their pain; the focus here is not on fixing the problem. Show a desire to understand and a willingness to be supportive.

Needs Assessment. Try to pinpoint the person/family’s needs. Stress may be related to:

  • fears around loss of income (need may be for housing assistance);
  • triggering of a previous traumatic event (a mental health referral may be necessary);
  • feelings of isolation and worthlessness (validation may be important).

Direct to Service. Follow through with commitments made and direct the patient or family member to any and all services that may benefit them.

Are follow-up conversations a good idea?

Yes. The care team or facility administration should maintain an open line of communication with the patient. There should be an ongoing expression of support and concern, and — when appropriate — coordination of follow-up care related to the medical injury. In addition, any significant learning from the event investigation should be shared with the patient as promptly as possible.

Remember that rebuilding the relationship with the patient and family may take time. Disclosure is the right thing to do even if the patient does not immediately acknowledge your efforts to be honest, straightforward and compassionate with thanks or "forgiveness."

Are there local support services for patients and families who have experienced medical harm?

Yes. The Betsy Lehman Center offers a Patient and Family Peer Support Network that connects people who have recently experienced medical harm or other traumatic event related to their health care with a peer who has had a similar experience. Visit this page on the Center's website or call (617) 701-8271 for more information.

Are there special laws in Massachusetts that govern disclosure of adverse events to patients?

Yes. As noted earlier, under Massachusetts law, when a health care provider’s mistake results in an unanticipated outcome with significant medical complication, the provider must fully inform the patient and, when appropriate, the patient's family, about the unanticipated outcome.

In addition, when an adverse event occurs at a hospital or ambulatory surgery center — and meets the state's criteria to be classified as a serious reportable event (SRE) — there are special rules about informing the patient during at least two stages of the reporting process:

  1. Within 7 days of discovering the adverse event, the patient and/or family member should be told about the incident both verbally and in writing. The patient should also be given a copy of the facility's 7-day report filed with the Department of Public Health (DPH) about the SRE. See a sample 7-day patient letter that is appropriate for this notification step.
  2. Within 30 days of filing the preliminary report to DPH, a follow-up letter should be sent to the patient and/or family member to describe what the organization learned in its internal investigation of the SRE. See a sample 30-day patient letter that is appropriate at this stage.