All Together, Now: 'We're Sorry'

Jay Moore, for HealthLeaders Media , February 19, 2009

Your hospital is going to harm a patient. I know you don't want to hear that, but unfortunately it's true. It might be an improper medication dosage. A surgical infection. A nasty fall on a slippery floor. Whatever the case, no matter what extensive safeguards a provider organization implements, when human beings are involved, true perfection is not attainable. Errors might be minimized or even rendered almost nonexistent, but they will happen. Sooner or later.

And then comes the complicated part: fessing up. Error disclosure historically has been a touchy subject for many providers leery of legal repercussions and fearful that disclosure generally can cause more harm than good. While such concerns persist in some circles, hospitals and health systems have certainly made strides in their efforts to discuss medical mistakes with patients and families. Still, according to at least one study, one component of the disclosure process remains lacking: nurse involvement.

A survey of roughly 100 nurses found that they were often excluded when physicians talked to patients about serious errors. Or to be more precise, they might have disclosed their own errors to patients, but participating in the discussion of others' mistakes was another story. The consequences of not having nurses involved in the disclosure process, contends the study in last month's issue of The Joint Commission Journal on Quality and Patient Safety, affect patient and nurse alike. The patient doesn't get as complete of an explanation and is left with more questions. And later, when the nurse is still attending to the patient while the rest of the team has moved on, the nurse appears evasive when he or she can't answer those follow-up questions because he or she wasn't included in disclosure planning sessions.

The study's contentions make sense in many ways—nurses shouldn't be put in comprising situations because they haven't been given adequate information, and patients deserve a complete explanation when a mistake occurs, not a partial one. At the same time, though, it seems to me that having multiple people explaining an error could actually be confusing for a patient if the caregivers have different assessments of the situation. I've thankfully never had to hear a provider's explanation of a medical error, but I'm trying to picture myself sitting in a hospital in that exact situation. Would I rather see and hear one person explaining the situation to me, or would I rather see and hear a group of people? And another question: Are all nurses trained in talking to patients and families about serious mistakes?

Such training is actually part of the study's recommendations, along with a team-based disclosure process that follows specific guidelines. Ultimately, as long as the patient hears a compassionate, accurate version of what happened, the question of how many caregivers actually participate in the discussion with the patient may be less important than the way caregivers communicate with each other: what happened, why it happened, and what can be done to keep it from happening again. That's a discussion in which every caregiver should play a part.

Jay Moore is managing editor for HealthLeaders magazine. He can be reached at

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