At the Sharp End of the System: Disclosure and Apology in Otolaryngology

How a provider responds in these types of circumstances is important for a variety of reasons. First, said Dr. Eibling, accepting personal responsibility-be it for an error you were responsible for or an error that was facilitated by the design of the system-enables you to apologize authentically to the patient and tell them that you’re going to do whatever possible to ensure that it won’t happen to another patient. In addition, he said, it’s my belief that acceptance of responsibility for errors facilitated by the system’s defects will increase the practitioner’s ownership, and their interest and enthusiasm to change the system.

After the Error

After the systems have broken down or an incident has occurred, communication must be quick, careful, and authentic. In that way, said Dr. Shah, now with the Division of Otolaryngology at Children’s National Medical Center in Washington, DC, we are all in the same boat. What a family doctor talks about to patients is similar to the way a surgeon would speak, the only difference being that our mistakes could happen in the operating room.

Dr. Eibling, who lectures on medical errors and patient safety issues to medical staffs as well as residents in otolaryngology and other specialties, agrees. Although he uses otolaryngology-specific examples in his presentations, the concepts are not unique to otolaryngology. I think that the fundamental precepts defined in the book by Michael Woods, Healing Words: The Power of Apology in Medicine,10 remain the same, he said.

Disclosure and apology in medicine has garnered a great deal of attention in the past few years11-13 and the wording used in those interactions between providers and patients is especially important. An organization called Sorry Works!, a coalition of physicians, lawyers, hospitals and researchers, is making especially prominent headway in this sensitive area and is making an impact across specialties, settings, political bodies, and professions.

Two Kinds of Disclosure

As is apparent to anyone working in medicine today, improving the systems in which practitioners work is now a huge focus in both the scientific and lay literature.2,4,5,7,14-18 An additional focus has been the disclosure of errors and how disclosure differs from apology.

One of the most important distinctions after an error has been recognized is whether the provider reveals to the patient that there was a complication versus admitting and taking responsibility for having made a mistake. In a study conducted in 2005 by Chan et al. using standardized patients, surgeons were rated highest on their ability to explain the medical facts about errors, but they used the word error or mistake in only 57% of conversations.19 In 27% of cases, surgeons used the words complication or problem.

Dr. Eibling pointed out that the concept is nicely demonstrated by the work of Wu et al.20 as well as in the training video Wu and colleagues produced at the Johns Hopkins Bloomberg School of Public Health, titled Removing Insult from Injury: Disclosing Adverse Events. Three scenarios from the video are available for free download from the Johns Hopkins Web site (see box).