DEAR IHI —
I’m the patient safety officer at my organization, and a medication error recently harmed a patient. Fortunately, the patient was not permanently harmed, but I’ve been losing sleep over it. The risk managers at my hospital have encouraged us not to communicate with the patient and family until they complete their investigation. I can’t help but feel that both the patient and the care team would feel more at ease if we could openly communicate about what happened. What should I do? — CONCERNED PSO
DEAR CONCERNED PSO —
I’m saddened to read about your situation, but I can’t say I’m surprised.
It's estimated that 1 in 10 patients are harmed by the care they receive. Communication following harm can be unclear, confusing, or even nonexistent. Patients and families are often left with unanswered questions and a feeling of disrespect, and they sometimes turn to legal action to find out what happened.
One of the biggest steps we have taken in the patient safety movement is the goal to be transparent especially after an adverse event. Many patient safety advocates believe miscommunication and silence following adverse events is disrespectful and is now considered as a harm to patients.
Initially, we referred to the process as “disclosure.” However, many believed that the term is legalistic and brought along with it a certain amount of baggage. Rick Boothman of the University of Michigan has shown that communicating with patients has reduced malpractice risk, but we wanted to base communication on the moral requirement of transparency, to show respect for patients and families. We also learned that communication was also good for the clinicians involved — and it sounds like you know that, too.
I can understand the risk manager’s hesitation to communicate with the family if you don’t have all the facts. However, that initial communication should not be delayed. The person speaking with the patient or family member can at the very least reassure the family that the event is being investigated and there will be updates as more information becomes available.
Fortunately, we now have one more resource to help you. The Agency for Healthcare Research and Quality (AHRQ) has just released a new toolkit, which suggests how an organization can set up a process to both communicate with patients after adverse events and learn from the events to prevent errors in the future, which is what many patients most want. The CANDOR Toolkit was tested and applied in 14 hospitals across three U.S. health systems as part of a $23 million grant. It’s an important milestone in the safety world.
My advice would be to examine the toolkit and determine the gaps you have in your organization. The toolkit offers an effective way to help you identify members of your organization who are effective at communicating with patients and families after adverse events.
Finally, a note of warning. Many patients are grateful when clinicians communicate with them honestly about what happened. But many are not. Communicating with patients after adverse events is always the right thing to do, but it may not feel that way in the moment. The patient may be angry with you. The AHRQ toolkit has some good material on how to care for the caregiver, and you should make sure you’re doing what you can to take care of yourself. Another great resource is Medically Induced Trauma Support Services, which offers support for patients and families and for clinicians.
Good luck, and thank you for your courage to do the right thing.
Frank Federico, Vice President, IHI
Here are a few more resources on communicating with patients after adverse events:
Editor's Note: "Dear IHI" is an advice column in which IHI experts answer questions from health care change agents in the field. Look for a new installment every other Thursday. Have a question for "Dear IHI"? Send it to email@example.com or on Twitter using the hashtag #DearIHI and @theihi.