Feature articles by: Lucian L. Leape, HFACHE; Richard C. Boothman; Sarah J. Imhoff; and Darrell A. Campbell, Jr.
In a superb episode of TV’s M*A*S*H, Winchester was compelled to say “I’m sorry” for a misdeed (not a medical error, but a relationship blunder). He stammered “I-I-I-I-I-I” for most of the episode, unable to let the words flow, in earnest, off his tongue. Finally, in the end, he found the poise and fortitude to say “I’m sorry.”
Though few of us may remember Winchester’s transgression some 30 years later, we remember the lesson that episode taught: Every apology involves two parties. Both parties are vulnerable; both suffer; both deserve the apology. “I’m sorry” asks something of people on each side of the equation. One takes responsibility for causing pain and commits to fix the problem; the other is called upon to forgive. Neither position is easy, but, in the end, each party must find some level of respect and trust for the other and arrive at a place of peace.
Errors in healthcare can have dire outcomes for patients and their loved ones. These errors can also devastate physicians and caregivers and break the vital trust between the organization and its patients and community. Thus, the concept of the medical apology is of special concern to those of us on the delivery side of care—we must take responsibility for the problem and attempt to fix it. In this issue, our authors share several key messages about apology:
- The apology provides the opportunity to fix care processes, reduce preventable errors, and improve patient safety. The old practice of deny and defend severely impedes discovery of causation and remedy of errors. As feature authors Richard C. Boothman, Sarah J. Imhoff, and Darrell A. Campbell Jr. observe, “One of the most significant costs of deny and defend is the chilling effect it has on patient safety.”
- Medical errors affect not only the patient and his family but also the doctors and other clinicians involved in the error. As feature author Lucian L. Leape writes, “Doctors have very high standards and strive hard to provide the highest-quality care. Most believe they can do it if they try hard enough. When they fail, they take it personally. Their self-image is threatened. They have failed not only the patient but also themselves. . . . Physicians view error not as a failure of a process but as a failure of themselves as people.” We can apply this description to nurses and other caregivers as well.
- The very foundation of medical care is shaken when medical errors occur. That foundation is trust. A trusting relationship between doctor and patient is critical to the healing mission. When trust is broken, as it is when a medical error is confined to a closet of secrecy through deny and defend, we lose credibility and invite conflict. Again quoting Leape, trust “is the cornerstone of the doctor–patient relationship—and the core of the patient’s perception of the institution.” An empty apology arising only out of the hospital’s desire to control costs is no better than deny and defend. The patient will see the hospital’s underlying motives immediately, and trust will be broken.
The wounds from medical errors go far deeper than the physical and reach far wider than the patient. The steps that rectify them can be hard to initiate. But for patients and providers alike, apology may be the first step on the path to healing.