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

I apologized to a patient and his family the day before yesterday because I forgot to do the tracheal esophageal (TE) puncture that I’d told the patient I was going to perform. The pharyngeal closure was difficult and at the completion of the procedure, I realized I had forgotten to place the TE puncture. I did not tell the patient and family that I had decided not to do it because the closure was difficult, because that was not true. I told them, I was focused on the fact that the closure was difficult and because my brain was working with that, I just plain forgot and I’m very sorry because it now means that you are going to need another operation at some time in the future to place this tracheal esophageal puncture. To me this represents the fundamental essence, if you will, of apology. With the patient and family, I went over the 4 R’s: recognition [that there was an error], regret, responsibility, and remedy. I also pointed out to them that I have now changed my system in the OR: every time I request the NG tube, which you use at the same time of the procedure, I will also be handed the instrument and catheter to perform a TE puncture.

Resources on the Web

SorryWorks!

www.sorryworks.net/media.phtml

Doctors, insurers, patients, lawyers, hospital administrators, and researchers joining together to provide a ‘middle ground’ solution to the medical malpractice crisis

Johns Hopkins scenarios

www.jhsph.edu/dept/hpm/research/Wu_video.html

Removing Insult from Injury: Disclosing Adverse Events

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