It's important to say you're sorry: healthcare's "shame and blame" culture deemphasizes apologies, but they are important for improving patient care and avoiding liability.

Admitting a mistake, whether personal or professional, is difficult. The "blame and shame" environment that has long existed in healthcare frequently makes caregivers fearful of admitting errors. Mistakes can occur in many common processes in behavioral and physical healthcare, especially in 24-hour settings, but identifying a mistake in behavioral healthcare services often can be more complicated than in physical healthcare settings. Yet regardless of the setting, silence about mistakes means that lessons learned by an individual are not shared with others who could benefit. In addition, the individual served and his/her family may never have the closure that can come from being informed that they have been the victim of a mistake.

Fortunately, the tradition of silence is changing. More and more healthcare organizations are looking to shift to a more open and honest way of dealing with a problem that has long been pushed underground due to fears of professional castigation and costly litigation. Disclosing mistakes and offering apologies are ethical responsibilities supported by various professional, regulatory, and accrediting organizations, including The Joint Commission. This shift in culture--a shift to reporting, documentation, and discussion--is vital to achieving the highest standard of care and an overall culture built upon respect, trust, and the goal of providing effective and safe care, treatment, and services.

When a mistake occurs, it is both our right and our human nature to want to know what happened and why. (1) The Joint Commission requires (Standard RI.2.90) that accredited behavioral healthcare organizations inform clients, and their families when appropriate, about unanticipated outcomes of care, treatment, and services that relate to sentinel events and outcomes of care, treatment, and services that should be considered in current and future care, treatment, and service decisions. The Joint Commission also encourages organizations to report sentinel events to its Sentinel Event Database for the purpose of analyzing errors, learning from them, disseminating the results of lessons learned, and advising institutions of changes needed to prevent such events in the future.

Disclosing and Apologizing

Why then is discussion of errors, apology, and disclosure one of the most difficult issues in healthcare? To be sure, tensions exist between the quest for transparency and the behavioral health organization's need to protect itself from legal liability. According to health policy analyst and Harvard Professor Lucian L. Leape, "Ironically, despite warnings of some insurers, data indicate that the likelihood of a lawsuit falls by 50 percent when an apology is offered and the details of a medical error are disclosed immediately." (2) Yet many behavioral health professionals, despite their training, have had little experience communicating mistakes because of feelings of shame and guilt.

Organizations and providers need to develop and implement policies that ensure all individuals harmed by their care, treatment, or services receive timely, open, complete information on the causes and circumstances that led to that harm. (3) Behavioral health organizations may look for ideas from the experience of some hospital systems and private liability insurance companies that have adopted a policy of robust disclosure with thorough analysis and intervention, apology, and early compensation for injury. These policies have resulted in greater patient trust and satisfaction, fewer malpractice suits, and significantly reduced administrative and legal costs for providers, insurers, and hospitals. (4) Behavioral healthcare organizations and providers can look to these hospital-based initiatives for strategies that can be adapted to their particular setting. The most important component of such a strategy is creating an environment of open communication where errors and their causes can be candidly discussed. Such an environment enhances safety and empowers staff and consumers.

While there is no single right way or standard for how to disclose an error, the fundamental elements include the following (2,5):

* An apology

* A prompt explanation of what is understood about what happened and its probable effects

* An assurance that the error will be analyzed to learn what went wrong

* Follow-up conversations to explain what is being done to prevent the error from happening again

From those essential elements, behavioral healthcare professionals and the array of organizations in which they provide services can work together to consider the consequences of a mistake in their setting and what to say when disclosing an error. For example, a discussion about a medication error, among the most common type of error in behavioral healthcare settings, might begin with the following (adapted from advice from the Massachusetts Coalition for the Prevention of Medical Errors (6)):

Let me tell you what happened. We gave you a [insert type of drug or

dosage] instead of the [insert] you were supposed to receive. I want

to discuss with you what this means for your health, but first I'd

like to apologize. I'm sorry. This shouldn't have happened.

The conversation can progress to explain that "we are going to do everything we can to make sure this doesn't happen again" and a promise to talk about the findings once they are available. The dialogue then should turn to a discussion of health consequences and a full explanation of any adverse effects and necessary follow-up treatment or monitoring.

Conclusion

The current healthcare environment, including behavioral healthcare, does not always support the concept of apology and disclosure. Communication among behavioral healthcare professionals, organizations, consumers, and their families must be at the center of all safety efforts. By meeting the human need to know, organizations are doing the right thing and fundamentally changing behavioral healthcare to better meet the desired goals of quality and safety.

Dr. Cesare-Murphy has served as a Joint Commission consultant surveyor for psychiatric facilities, as well as having served as a faculty member for surveyor training and field education. Before joining The Joint Commission, Dr. Cesare-Murphy was an assistant professor of psychology at Saint Xavier University and a national consultant on organizational development and performance improvement. She has extensive experience in community mental health and developmental disabilities services.

References

1. Leape LL. Understanding the power of apology: How saying 'I'm sorry' helps heal patients and caregivers. Focus on Patient Safety 2005;8(4): 1-3. http://npsf.org/paf/npsfp/fo/pdf/Focus2005Vol8No4.pdf.

2. Leape LL. Full disclosure and apology--an idea whose time has come. Physician Executive 2006;March-April:16-18.

3. Woods MS. Healing Words: The Power of Apology in Medicine. Joint Commission Resources; 2007.

4. The National Medical Error Disclosure and Compensation (MEDiC) Act of 2005. Proposed by Sens. Hillary Rodham Clinton and Barack Obama. September 28, 2005.

5. Crafting an effective apology: What clinicians need to know. Joint Commission Perspectives on Patient Safety 2005;5(4):7-8.

6. Massachusetts Coalition for the Prevention of Medical Errors. When Things Go Wrong: Responding to Adverse Events. Boston: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

BY MARY CESARE-MURPHY, PHD

ABOUT THE AUTHOR

Mary Cesare-Murphy, PhD, is the Executive Director of the Behavioral Health Care Accreditation Program at the Joint Commission.

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