Harvard Public Health Review Winter 2007
Review home
next story
Previous story- The America Next Door
HSPH home page

Leaders worth folowing: HSPH celebrates distinguished faculty and alumni
apologyANYONE WHO’S EVER GIVEN or received an apology knows the words “I’m sorry” can have a healing effect. For a patient harmed by a medical error, an apology from caregivers can ease profound feelings of shock, grief, anxiety, hurt, and anger. An apology can shore up the foundation of any doctor-patient relationship: trust. Yet too often, doctors and their institutions don’t express regret, or even explain what went wrong.

Lucian Leape, adjunct Professor of Health Policy at the Harvard School of Public Health (HSPH), is working to change that. This former pediatric surgeon, widely regarded as the leader of the patient safety movement, aims to make apology part of full-disclosure policies at hospitals nationwide—a critical step in reducing errors that kill an estimated 98,000 patients a year and injure far more. For Leape, apology in the face of a problem that could have been prevented is not only the right thing to do, it’s a “therapeutic necessity.”

Leape says patients need apologies before they can forgive and heal from the “emotional wound” inflicted by their new and unexpected injury. “Apologizing doesn’t always work; sometimes the anger is too great,” Leape says. “But healing can’t begin without it.”

A Champion for Patient Safety

Lucian LeapeHSPH’s Lucian Leape set the wheels for medical-errors disclosure and apology in motion in 1991 with a major study examining the root causes of medical malpractice cases in New York state hospitals. Based on the data, the Institute of Medicine (IOM) estimated that up to 98,000 Americans were dying annually from unanticipated “adverse events,” including preventable errors—a missed diagnosis, for example, or the wrong medication.

In December 1994, Leape published a pivotal paper in the Journal of the American Medical Association (JAMA) titled “Error in Medicine,” calling for medicine to apply the industrial model of systems redesign to prevent errors. Following reports that Boston Globe reporter Betsy Lehman had died tragically at the Harvard-affiliated Dana-Farber Cancer Institute from a chemotherapy overdose, Leape came into the spotlight that winter—and launched the patient safety movement. Unless errors were discussed openly and health systems were repaired, Leape argued, patients would continue to die needlessly.

In 1999, responding to his work, the IOM issued a landmark report on how hospitals evaluate the quality of their care. “To Err is Human: Building a Safer Health System” laid the groundwork for a drive toward full transparency and disclosure of medical errors. In 2001, the hospital accrediting organization known today as the Joint Commission set disclosure standards for adverse events. The nonprofit National Quality Forum, tasked with improving health-care-quality measurement and reporting, followed suit in 2006.

Through it all, Leape has served as a passionate spokesman for patients’ safety and “right to know.” Like adverse-event disclosure, he says, apology is “an idea whose time has come.”

This fall, 16 Harvard-affiliated teaching hospitals will start rolling out disclosure-and-apology training workshops for doctors, nurses, administrators, and insurance experts with funding from CRICO/RMF, the hospitals’ joint malpractice insurer. The workshops will help the hospitals put into action work by a group of clinicians, patients, lawyers, and insurance company risk managers convened by Leape in 2004, whose recommendations resulted in When Things Go Wrong, a 42-page set of principles for crafting disclosure and apology policies.

Unanimously supported by the 16 hospitals, this slender document underscores health care providers’ “ethical obligation” to report the whole truth, and nothing but—and to support victims of mishaps, as well as distraught caregivers. Since March 2006, when When Things Go Wrong was published online, each hospital has drawn up a disclosure-and-apology policy that reflects its unique culture. The guide has been “downloaded thousands of times and translated into several languages”—evidence, Leape notes, of an accelerating trend toward transparency in medicine. (For copies, visit www.macoalition.org.)

The Malpractice Factor
Why is it so hard for physicians to apologize? Fear of lawsuits is a major factor. Lawyers and insurance companies have long warned against apologizing to avoid litigation, even though 34 states now prohibit a doctor’s expressions of remorse, fault, or causality from being used in court as evidence of their guilt. Although errors attributed to individuals are “always a health systems problem,” Leape says, patients “understandably blame the person who made the mistake, not the systems failure behind it.”

No one knows what impact errors disclosure will have on malpractice litigation. To assuage insurers’ concerns, Leape points to research linking poor communication with patients’ decisions to sue, as well as success stories in three states for hospitals that practice open disclosure and also provide compensation to patients for costs related to their injuries. In Colorado, there has been no change in lawsuit rates at COPIC, the state’s largest insurer, which reimburses injured patients for lost time and expenses; nor has a veteran’s hospital in Kentucky seen malpractice lawsuits increase. In Michigan, one health care system has seen a large decline over four years in both the incidence and the costs of litigation (see sidebar).

In talks around the country, Leape stresses that the patients most likely to sue are those who lose trust in their caregivers. “What we’re trying to say to our brethren—physicians primarily, but also nurses, even insurance companies-is that how you handle these situations during the acute phase is absolutely crucial to how patients will handle them,” he says.

“The first step is to say, ‘You’ve had this happen, and we’re sorry it did,” Leape says. “Next is, ‘Here’s everything we know now, and what the future holds.’ The third step is, ‘We don’t know how it happened, but we’re going to conduct a full investigation and we’ll keep you informed.’ A formal apology follows if the investigation reveals an error or systems failure.”

“As surveys and the great weight of anecdotal evidence tell us,” he says, “all these measures help lessen the patient’s anxiety.”

‘Level With Us’
Patient rights advocate Doug Wojcieszak seconds that. The founder of the Sorry Works! Coalition, a grassroots organization in Glen Carbon, Illinois, that champions errors disclosure and apology, Wojcieszak says most malpractice lawsuits are the product, not of greed, but of anger over a system that leaves patients and families feeling “abandoned.”

In 1998, Wojcieszak’s 39-year-old brother, Jim, died following a series of blunders after being hospitalized for cardiac distress. Doctors confused his chart with that of his father, whose own cardiac workup had been “perfect,” Doug says. Mistakenly treated for a bacterial infection, Jim suffered three heart attacks in four days, all of which went undiagnosed—until the autopsy.

“We tell doctors, ‘Look, we can live with mistakes as long as you level with us,’” Wojcieszak says. “We know from experience that it’s not errors that drive lawsuits, it’s lapses in ‘customer service’—nurses were rude, no one returned phone calls. It’s the sense that doctors are hiding that makes patients more likely to sue.”

Experimental Health Courts
Wojciezak and Leape say hospitals could eliminate most malpractice suits by reimbursing patients for costs incurred from their injuries, including lost time and out-of-pocket expenses. That approach is squarely at odds with current policy, however, at least in the United States. As it stands, patients’ only recourse is to sue hospitals and doctors. “This only serves to increase their anger and the amount of money they try to extract from the system,” Leape says. “We need to experiment with a new approach.”

He points to promising research by Michelle Mello, the C. Boyden Gray Associate Professor of Health Policy and Law at HSPH, and her collaborators, who have proposed that states test a system similar to one in New Zealand. The proposal calls for patients to file claims with special “health courts” staffed by trained judges and neutral paid medical consultants. To receive compensation, patients would be required to show, not that health care providers were negligent, but that the injury would have been avoided in an optimal system of care. The compensation process would be faster, more reliable, and less adversarial than the current, lawsuit-based system. (For details, see “Malpractice Roulette” from the Fall 2005 issue of the Review and an August 2007 podcast with Mello).

Workshop for ‘Coaches’
Another reason doctors have difficulty delivering bad news to patients? They’ve never been trained.

Most doctors are uncomfortable even explaining the circumstances surrounding complications that might have been avoided, says Charles MacFarlane, vice president for learning with Joint Commission Resources, an Illinois company that helps hospitals improve health care quality. “These are difficult conversations,” he says. “Sometimes apologizing is a skill that has to be learned.”

For caregivers overwhelmed by self-recrimination, discussing the problem can be hard. The workshops, sponsored by CRICO/RMF, aim “to help institutions respond effectively and compassionately to patients, families, and clinicians,” says David Browning, a clinical social worker involved in the effort. Browning is a senior scholar at the Institute for Professionalism and Ethical Practice (IPEP), a Children’s Hospital-based initiative that helps clinicians communicate with patients about subjects that include organ donation, wrenching end-of-life choices, and medical errors. He will be partnering with Robert Truog, who directs both IPEP and clinical ethics at Harvard Medical School.

Participants will act out scenarios in which professional actors play injured patients and family members. Each half-day workshop will engage up to 25 people, who will take turns in various roles while the rest observe. “A scenario might begin with a clinician being notified that an error has occurred,” Browning explains. “It will progress to the conversations he or she will have with the physicians and nurses involved, helping them to prepare for the disclosure, then finally to the disclosure and apology.” Participants will serve as coaches at their own hospitals, advising others during preventable, real-life “adverse events,” be they a drug overdose, wrong-site surgery, or equipment failure.

“Communicating errors is like anything in medicine,” says HSPH alumnus Ken Sands, MPH 1993, senior vice president for health care quality at Harvard affiliate Beth Israel Deaconess Medical Center (BIDMC). “Some situations require expert assistance, and trained coaches must be available to provide this at all times.” In the case of BIDMC, workshop participants will be drawn from a communications team created in 2006 to guide hospital clinicians in errors disclosure.

Setting the Standard
What will be the impact of this whole effort? Leape hopes more health systems will adopt full disclosure and apology policies. He and other safety advocates in Boston, including CRICO/RMF, will pay close attention to how patients respond. CRICO/RMF representatives will keep an eye on malpractice trends, but say lawsuits are so few and slow to resolve, involving factors so complex, that changes may not emerge for years.

Openness, humility, conceding medicine’s imperfections—these are “new concepts in health care,” Leape observes. For years, risk managers pointedly have argued against full, open communication, apology, and restitution when treatment turns injurious. Now, change is clearly happening, he says, and for good reason: “We’re saying, it’s time to do what we’ve always known was right.”

Charlie Schmidt has written about public health and environmental health for Environmental Health Perspectives, Science, National Geographic Online, Discover, the Washington Post, and other journals and media outlets.

Review home
next story
Previous story- The America Next Door
HSPH home page
top of page

This page is maintained by Development Communications in the Office of Resource Development.
To contact us with suggestions, comments, and questions, please e-mail: review@hsph.harvard.edu

Copyright 2007, President and Fellows of Harvard College