Errors and Apologies

To err is human, to forgive, divine. — A. Pope Every human makes mistakes. It is likely that every practitioner understands the anxiety, fear, or outright terror that accompanies the realization that they have done something wrong when providing care to a patient. As difficult as these feelings may be in the acute aftermath of an error, the effects of having caused harm to a patient can linger for many years. While these effects can serve as the impetus for quality improvements, they can also result in feelings of shame that are less constructive. Obvious errors can also have lasting negative effects on the trust patients have in their treating practitioners and the medical system in general. Undermined trust can threaten the therapeutic alliance essential for effective partnership and cause patients to pursue treatment elsewhere. Patients’ distrust may extend to those practitioners and their skills and recommendations may be questioned. The health impact of medical errors varies. A serious error results in “permanent injury or transient but life-threatening harm,” while a minor error results in “harm that is neither permanent nor potentially life threatening.” 4 Many of the harms caused by errors in O&P involve only inconvenience to patients and caretakers and damage to the practitioner’s ego. Ordering the wrong component, not completing a device in time for a delivery appointment, and scheduling mishaps, for example, may only involve patient’s lost time and require rescheduling. Errors related to improper device design, flawed construction, and inappropriate components may cause wounds or contribute to falls, both of which directly affect the patient’s physical health and function. Errors that reduce the effectiveness of treatment, on the other hand, may be less obvious, and the patient may not even be aware a mistake was made. In addition to inconvenience and physical harm, patients may also experience emotional distress and life disruptions because of conspicuous practitioner error. 7 A medical error has been described as a “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim,” and errors in many areas of medicine involve more serious consequences than those made in O&P. 4,5 Medical errors cause millions of injuries and hundreds of thousands of deaths in the United States each year, and adverse medical events have been identified as the third leading cause of death in the United States. 2,3 Despite the frequency, estimates are that only one-third of medical errors are disclosed, and the disclosure is often done in a manner that is unsatisfactory to the patient. 1,3,5,8,9 When errors occur, practitioners must decide whether and how to disclose them and acknowledge responsibility. Apologizing for treatment errors and their consequences is fraught with personal, professional, and legal complications, and it is understandable that practitioners frequently avoid it. It is also natural to minimize our contribution to an error in any area of life and assign responsibility for a negative outcome to factors outside of our control. After a medical error, patients may express feelings of anger and harbor negative attitudes toward their physicians, which may lead to them pursue legal action, change providers, or want monetary compensation. 12,13 These significant financial and professional consequences may make it harder for practitioners to acknowledge responsibility for errors in clinical practice than in their personal lives. An unpublished review of apologies in medicine conducted in 2020 provides insights that may be helpful for O&P clinicians. Sixteen studies that involved an apology as part of medical error disclosure were included in the review. Extracted characteristics of the studies included sample size, population, types and elements of disclosure style, apology style, types of medical error, severity of the error, and how the subject reacted to or perceived the encounter. Study Designs A common structure in the reviewed studies was to show subjects video vignettes involving actors, typically portraying a physician, disclosing a medical error. In some studies, actors also portrayed the patients, and in others the participants were instructed to interpret the encounters as if they were the patient. Participants rated the encounters using questionnaires, surveys, and Likert scales. The severity of the error was manipulated in some studies. Six studies 5,25,27-30 compared a low-severity error to a high-severity error, while another three studies 1,12,15 measured how severe the participants perceived the error to be. The remaining eight studies either used a single severity error or did not manipulate the error severity. 8,9,10,13,24,26,28,31 Six articles described two different levels of apologizing. 1,8-10,15,25 A complex or complete apology included taking responsibility for the error, while a basic or partial apology deflected responsibility. An additional six articles evaluated how the presence of any type of apology influenced patient perception. 12,13,25,29-31 A study by Gu et al. manipulated both the presence and type of the apology during error disclosure. 25 Three studies interviewed physicians or prompted them with fake errors to determine how they would disclose an error. 5,24,26 Two studies interviewed patients that had undergone medical errors and asked how it had been disclosed to them. 27,28 The measure of patient perception of the physician across the 16 studies varied greatly. Common measures included forgiveness, intent to pursue legal action, changing physicians, satisfaction, and general positive/negative qualities during the disclosure (regret, sincerity, communication skills, blame, etc.). 1,8,9,10,12,13,15,25,26,29,30 Only one study, by Song et al. measured how participants felt about the doctor-patient relationship. 31 Results The results showed that apologizing had more positive results than nothing, and a complete apology was better than a basic apology. 1,8,9,10,15,24-31 The important elements of the complete apology not found in a basic apology are acknowledging the possible consequences, expressing remorse, and making a change to their clinical practice. 8,10,25 Two studies found that nonverbal engagement increased the efficacy of the apology. 14,16 A study by Hill et al. found that women were perceived more positively when they gave an affective apology, while men were perceived more positively when they gave a cognitive apology. 8 (A cognitive apology is focused on how the error occurred and how to fix it, while an affective apology focused on the patient and their emotional state. 8 ) Gu et al. screened their volunteer participants for those that had experienced a medical error and compared their acceptance of the apology with participants who hadn’t. 25 They found that those who had experienced an error were more likely to accept the apology than those who had not. Two studies found that an apology did not impact patient perception of the physician. 12,26 Nazione et al. found that an apology did not change the degree to which the participant felt the physician was responsible for the error. 12 Attitudes were generally more positive toward the apology condition but were not statistically significant. Leone et al. found that an apology did not affect whether a family would continue care with the physician for their sick family member. 26 They also noted that when the word “error” was mentioned in the disclosure, there was a decrease in care continuation. Overall, the studies showed that an apology was better than no apology, but the most positive outcomes (more favorable perception, lower rates of litigation/changing provider, forgiveness, etc.) came when there was acknowledgment of the possible consequence and expressions of remorse, and changes were made to the way the physician practiced. It is important to note that none of the reviewed studies found an apology to have a negative impact on these outcomes. The articles reviewed suggest that apologizing after a medical error improves outcomes, and taking responsibility and making changes are important for a positive patient perception that leads to forgiveness and a repaired patient-provider relationship. At the very least, apologizing was never taken negatively by the patient, so being sincere and transparent may be the thing that can repair the relationship after a medical error. Forgiveness and Shame When it comes to the patient-physician relationship, forgiveness may be an important aspect of repairing the relationship between the physician and patient. 15,16 McCullough et al. defines forgiveness as “the change process by which an individual becomes more positively disposed and less negatively disposed toward an individual who has harmed him or her at some point in the past.” 16 Forgiveness can change how the patient thinks and behaves toward the offender. When a patient forgives, there is a decrease in retribution and avoidance with an increase in benevolence. Retribution and avoidance can be tied to rumination, which leads to feeling anger for longer and more aggressive attitudes toward the offender. Forgiveness has been shown to be negatively related to rumination which leads to better outcomes. 15,16 In her book, How Doctors Feel , Danielle Ofri, MD, writes that focusing on how doctors feel after committing an error could be perceived as self-centered. “But is it precisely the doctor’s emotion—particularly shame—that stands as the major impediment to the full disclosure policies that are increasingly demanded…the desired culture of openness will come about only when we address the issue of shame…. Because shame is so global and its consequences so devastating, human beings automatically erect walls to hide their shame…hiding and covering up are intrinsic to shame.” Patients want a clear statement that an error occurred, a straightforward account of what happened, and a heartfelt apology to validate their feelings. 1 Any of us can choose to forgive an offender even in the absence of an apology, but forgiveness is most meaningful when the nature and cause of the offense is acknowledged and understood by both parties. The same choice to not disclose errors, accept responsibility, and acknowledge harm makes it more difficult for the affected person to find closure and resolution and impossible for the offender to experience the positive (and sometimes transformative) effects of being forgiven. In addition to satisfying the ethical requirement for transparency and truthfulness with patients, apologies have been shown to benefit the offender after any severity of error, suggesting that an apology can serve the interests of both parties. The Michigan Model The University of Michigan Health System has implemented a procedure for providers to follow when an error occurs. 17-19 The aim of the Michigan model is to “apologize and learn when we’re wrong, explain and vigorously defend when we’re right, and view court as a last resort.” 19 This approach was implemented in 2001, and is based upon honesty, transparency, and accountability. 18 The providers collaborate to discuss the incident and if wrongdoing is found, apologize to the patient and change protocols to reduce the chance of recurrence. Physicians speak openly and directly to patients or their representatives. They then review the incident with other physicians both in and out of their field. If it is determined that an error has occurred, the physician will apologize and work with the patient to settle on restitution and reparation. If the care is deemed appropriate, the physician explains the medical necessity of the treatment and the reasons for his or her conclusion. If the patient pursues legal action, the hospital will defend the physician and his or her treatment decisions. 17,19 The University of Michigan reports that this protocol has reduced litigations within their system. 17-19 After ten years of enacting this policy, lawsuits have declined, and legal costs have dropped. In the first year alone, the hospital estimated a savings of over $2 million. Time to resolution of complaints also decreased. 18 Possibly the most important outcome to arise from adopting this model is the decline in the severity of claims and the increase in patient satisfaction. As much as we may view medical malpractice litigation as inherently (and perhaps appropriately) self-centered, patients often have other motives for insisting on official acknowledgement of error. Patients would also like to hear what measures will be taken to help prevent similar errors involving other patients in the future. 1 When an apology is not made, they may be more motivated to take action to ensure that the practitioner is held accountable and the error is not repeated. Thirty-nine states provide some legal protection for healthcare providers who express sympathy following an adverse event. Decisions about what to disclose and how to communicate following an error, particularly one resulting in significant harm, should be made carefully and involve the advice of legal counsel. The approach adopted at the University of Michigan involves the commitment of senior leadership and system-wide implementation. Company and workplace culture will influence the choices individual O&P practitioners make related to disclosure and apology. Closing Thoughts Mistakes require only that we be human. Apologies require humility and integrity. Acknowledging minor errors with relatively simple resolutions seems like low-hanging fruit by providing a way to rebuild trust following an event that undermines it. Developing the skill of apologizing for obvious minor errors may help us build a reserve of trust with patients that preserves the relationship even in the face of more egregious errors. This transparency can help patients find resolution and may allow us to experience forgiveness rather than shame. John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center (NUPOC). He has over 30 years of experience in patient care and education. Molly Quinlan, MPO, CPO, completed the literature review as a student at NUPOC. References Hannawa AF. Disclosing medical errors to patients: effects of nonverbal involvement. Patient education and counseling. 2014;94(3):310-3. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ (Clinical research ed). 2016;353:i2139. Anderson JG, Abrahamson K. Your Health Care May Kill You: Medical Errors. Stud Health Technol Inform. 2017;234:13-7. Bari A, Khan RA, Rathore AW. Medical errors; causes, consequences, emotional response and resulting behavioral change. Pakistan Journal of Medical Sciences. 2016;32(3):523-8. Dahan S, Ducard D, Caeymaex L. Apology in cases of medical error disclosure: Thoughts based on a preliminary study. PloS one. 2017;12(7):e0181854. Aronson JK. Medication errors: what they are, how they happen, and how to avoid them. QJM: An International Journal of Medicine. 2009;102(8):513-21. Mazor KM, Goff SL, Dodd KS, Velten SJ, Walsh KE. Parents’ perceptions of medical errors. Journal of patient safety. 2010;6(2):102-7. Hill KM, Blanch-Hartigan D. Physician gender and apologies in clinical interactions. Patient education and counseling. 2018;101(5):836-42. Wu AW, Huang IC, Stokes S, Pronovost PJ. Disclosing medical errors to patients: it’s not what you say, it’s what they hear. Journal of general internal medicine. 2009;24(9):1012-7 Allan A, McKillop D, Dooley J, Allan MM, Preece DA. Apologies following an adverse medical event: The importance of focusing on the consumer’s needs. Patient education and counseling. 2015;98(9):1058-62. Slocum D, Allan A, Allan MM. An emerging theory of apology. Australian Journal of Psychology. 2011;63(2):83-92. Nazione S, Pace K. An Experimental Study of Medical Error Explanations: Do Apology, Empathy, Corrective Action, and Compensation Alter Intentions and Attitudes? Journal of health communication. 2015;20(12):1422-32. Hannawa AF. Shedding light on the dark side of doctor-patient interactions: verbal and nonverbal messages physicians communicate during error disclosures. Patient education and counseling. 2011;84(3):344-51. Giraldo P, Sato L, Castells X. The Impact of Incident Disclosure Behaviors on Medical Malpractice Claims. Journal of patient safety. 2017. Hannawa AF, Shigemoto Y, Little TD. Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes. Social science & medicine (1982). 2016;156:29-38. McCullough ME, Bono G, Root LM. Rumination, emotion, and forgiveness: three longitudinal studies. J Pers Soc Psychol. 2007;92(3):490-505. Boothman R, Hoyler MM. The University of Michigan’s early disclosure and offer program. Bulletin of the American College of Surgeons. 2013;98(3):21-5. Boothman RC. Apologies and a strong defense at the University of Michigan Health System. Physician executive. 2006;32(2):7-10. The Michigan Model: Medical Malpractice and Patient Safety at Michigan Medicine [Internet]. [cited 2019Dec1]. Available from: https://www.uofmhealth.org/michigan-model-medical-malpractice-and-patient-safety-umhs#summary Smith FL, Young JL. Some Aids To Reduce Failures Of Orthopedic Parts. Orthotics and Prosthetics [Internet]. 1955 [cited 2019Sep1];9(2):43–6. Available from: http://www.oandplibrary.org/op/1955_02_043.asp?searchquery=failure Mu K, Lohman H, Scheirton L. Occupational therapy practice errors in physical rehabilitation and geriatrics settings: a national survey study. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2006;60(3):288-97. ABC Practice Analysis [Internet]. American Board for Certification in Orthotics Prosthetics and Pedorthics. 2015 [cited 2019Nov19]. Available from: https://www.abcop.org/individual-certification/Documents/Practitioner Practice Analysis.pdf Sherwood A, Brinkmann J, Fatone S. Review of Benefits to Practitioners of Using Good Patient-Practitioner Communication. Journal of Prosthetics and Orthotics. 2017;30:1. Gillies RA, Speers SH, Young SE, Fly CA. Teaching medical error apologies: development of a multi-component intervention. Family medicine. 2011;43(6):400-6. Gu X, Itoh K. Patient views and attitudes to physician’s actions after medical errors in China. Journal of patient safety. 2012;8(4):153-60. Leone D, Lamiani G, Vegni E, Larson S, Roter DL. Error disclosure and family members’ reactions: does the type of error really matter? Patient education and counseling. 2015;98(4):446-52. Lyu HG, Cooper MA, Mayer-Blackwell B, Jiam N, Hechenbleikner EM, Wick EC, et al. Medical Harm: Patient Perceptions and Follow-up Actions. Journal of patient safety. 2017;13(4):199-201. Mazor KM, Greene SM, Roblin D, Lemay CA, Firneno CL, Calvi J, et al. More than words: patients’ views on apology and disclosure when things go wrong in cancer care. Patient education and counseling. 2013;90(3):341-6. Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, et al. Health plan members’ views about disclosure of medical errors. Annals of internal medicine. 2004;140(6):409-18. Mullet E, Riviere S, Sastre MT. Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments. The American journal of psychology. 2007;120(1):25-46. Song DJ, Choi JW, Kim K, Kim MS, Moon JM. Quasi-Experiment Study on Effectiveness Evaluation of Health Communication Strategies. Journal of Korean medical science. 2016;31(7):1027-36. Mccullough ME, Rachal KC, Sandage SJ, Worthington EL, Brown SW, Hight TL. Interpersonal forgiving in close relationships: II. Theoretical elaboration and measurement. Journal of Personality and Social Psychology. 1999Jan;75(6):1586–603.

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