When unexpected events happen in the hospital, resulting in harm to a patient, having early and transparent conversations with patients and families is the key to getting to the best resolution, panelists said in a session at SHM Converge 2023.
This process—especially the conversations with the families—is difficult, but having a system in place for handling it can make it more manageable, said Elizabeth Schulwolf, MD, MBA, FHM, chief medical officer at Dell Seton Medical Center at the University of Texas, Austin; and Marsha Nichols, JD, a risk-management specialist at two Austin-area hospitals.
“They are mostly unexpected, and so it’s just a very difficult dynamic to deal with from the beginning,” Ms. Nichols said. “And then when we start disclosing to the patient and family, physicians are naturally reluctant to do that because it’s a very difficult conversation to have and they may already be second-guessing everything that they’re doing with this patient and family.”
Physicians tend to worry about embarrassment, damage to their reputations, and malpractice suits. But open communication actually reduces the risk of a lawsuit, she said.
“This standardized process of being transparent with families soon after an event, and then following up with them once we’ve been able to investigate that, actually sort of mitigate that potential because we’ve created a bond and a relationship with that family, and they’re seeing the providers as human beings who care and who are sorry,” she said.
These situations will arise frequently, so hospitals should be ready to handle them, Dr. Schulwolf said.
A recent New England Journal of Medicine report on hospitals in Massachusetts showed that 23.6% of admissions will result in at least one adverse event and that 22.7% of them were deemed to be preventable, she said. This number of events is “certainly not negligible,” she said.
Research has found that, regarding disclosure of unexpected events, patients want an “explicit admission” that the error occurred, a basic description of the error and why it happened, and an explanation of work that is being done to prevent more of the same.
“One of the things we’ve found to be most important with our patients and families is, what are we doing about this to prevent it from happening again?” Ms. Nichols said.
They also want an explicit apology—one that is specific to this incident, and not just a general “I’m sorry for your loss.”
Physicians, for their part, struggle to forgive themselves and seek forgiveness from the patient, she said.
“We really work with our providers to get them comfortable with what they’re going to say and how they’re going to say it and to be clear,” Ms. Nichols said. “Because when they are choosing their words if they are choosing their words carefully, it really comes across and it’s not very effective. It doesn’t come across as authentic.”
Conversations with patients and families should be formally conducted and not just a “drive-by conversation in the hallway,” she said. These conversations sometimes include the clinicians involved, but if the clinician is a learner, they are probably not ready for that situation, so they are not asked to be involved. If the physician is devastated, they also might not be asked to participate in the conversation, she said.
Using a “disclosure program” has been shown to reduce malpractice claims, she said. One is a “reimbursement model,” in which an institution offers to reimburse the patient for out-of-pocket expenses related to the injury and the loss of time associated with it, with predetermined amounts involved. This is an offer made without an investigation into provider negligence.
Another is an “early settlement model,” done when care is deemed inappropriate, with no pre-set limits and with patients agreeing it constitutes a final settlement.
A third is a “health court,” with a panel of experts determining whether an injury was avoidable. This is not used in the U.S.
A good method to use, the panelists said, is the CORE®️ method—for “communicate openly, resolve early.” This includes four steps:
- Identification of the event: This involves calling the risk-management team, a call to a department or hospital leader, using an event-reporting system, and case-discussion conferences.
- AID conversation: This is a conversation with the patient, family, or both within 24 to 48 hours of the event, with the attending physician disclosing the concern and informing the family of the next steps for the investigation. AID stands for acknowledging the event, promising to investigate, and a commitment to the disclosure of the results of the investigation.
- Investigation: This is often embedded in the safety-review process, with members of the team and leaders’ support engaged when needed.
“You want to come into the investigation with an open mind and not just assume,” Dr. Schulwolf said.
- CORE®️ conversation: This is the conversation involving disclosure of the investigation findings. Patients and family members should be asked what they understand about the event and what they are hoping to gain from the discussion. A risk manager, hospital administrator, and sometimes the clinician can participate in this discussion.
One of the questions should be, “What does resolution look like to you?”
“Those are hard conversations to have but at least then we’re walking together and not on the opposite sides of a lawsuit,” she said.
Ms. Nichols said she will give families her phone number and let them know this doesn’t have to be their last discussion.
“The CORE®️ framework is one way to structure a comprehensive, supportive disclosure program,” Dr. Schulwolf said. “A provider and associate support program is crucial.”
Tom Collins is a medical writer in South Florida, who has written about everything from lethal infections to thorny ethical dilemmas, runaway tumors to tornado-chasing doctors. He gathers health news from around the globe and lives in West Palm Beach.