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Curiously, for the healing professions, this aspect ofdisclosure is frequently overlooked in the obsession withliability. But the evidence is clear that a serious preventa-ble injury causes severe emotional trauma. The patientwas wounded by those he or she trusted for care.

Unfortunately, on the surface, in the absence of otherinformation, for the patient the accident may appear tohave resulted from lack of caring, from not being careful.

The incident damages the patient’s trust—in thephysician and in the institution. If it is not openly andhonestly dealt with, trust is irrevocably destroyed and thepatient will be psychologically scarred for life.

The doctor-patient relationship also suffers, for it isbased on trust. Trust is based on truth. If there is silence, ordissembling, or incomplete information (partial “truths”),trust crumbles, both in the physician and in the institution.

The only treatment, the only way trust can be restoredand the patient begin to heal, is for the caregiver toacknowledge the error, take responsibility—and apologize.

Apology vs disclosure

The case for apology is very different from that fordisclosure. Apology is not an ethical right, but a thera-peutic necessity. Apology makes it possible for thepatient to recognize our humanity, our fallibility, ourremorse at having caused harm. It “levels the playingfield.” It makes it possible for the patient to forgive us.

Apology is necessary for healing, for “getting over it.”It doesn’t always work. Sometimes the patient’s anger istoo great for forgiveness. But healing cannot occur without it. To be effective, it must be a true apology, in which the caregiver takes responsibility for the eventand shows remorse and a desire to make amends.

One of the groundbreaking trends set in motionby the famous Institute of Medicine reports of 2000and 20011,2 and promoted by a growing number ofpatient advocacy groups is increasing transparencyin all aspects of health care.

Perhaps the most important manifestation is the callfor full disclosure following an adverse event. While boththe Joint Commission on Accreditation of HealthcareOrganizations and the American Medical Association callfor informing the patient when complications occur, whattakes place in practice is often less than “full” disclosure.Why is this, and what do hospitals need to do?

What hospitals need to do is develop and implementpolicies that ensure that all patients who are harmed bytheir treatment receive timely, open, complete informa-tion on the causes and circumstances that led to theirinjury, delivered in a compassionate manner by theresponsible caregiver. When the injury results from anerror or system breakdown, the response should includean apology and restitution.

The arguments for such an approach are both theo-retical and practical. The theoretical argument has twopillars: ethical and therapeutic.

The ethical case is straightforward and rarely challenged:the patient has a right to know what happened. Conversely,hospitals and physicians or nurses have no right, morally orlegally, to withhold information from patients.

Just as patients are entitled to know all the results oflaboratory tests, opinions from consultants, risks of treat-ment and alternative therapeutic options, they are entitled toknow what the causes of the breakdown are when thingsgo wrong. It is also what each of us would want for our-selves. We want to know what went wrong, why, and whatwill be done to prevent it from happening again.

Full disclosure is the right thing to do. It is not anoption; it is an ethical imperative.

The therapeutic argument is also simple and straight-forward: full disclosure is essential for healing.

Full Disclosure and Apology—An IdeaWhose Time has ComeBy Lucian L. Leape, MD

Examine some persuasive arguments that support fulldisclosure and apologies for medical errors and learnthe key steps hospitals need to take.

Special Report: Patient Trust and Safety

IN THIS ARTICLE…

THE PHYSICIANEXECUTIVE MARCH • APRIL 2006 17

“I’m sorry this happened toyou,” is no substitute, for it lacksresponsibility and remorse. Makingamends should include reimburse-ment for expenses as well compen-sation for long-term disability.

Apologizing is also necessaryfor healing of the doctor or nursewho made the error. They, too, areemotionally traumatized. They arethe “second victims,” devastated byhaving been the unwitting instru-ment that seriously harmed another.They feel shame and guilt thatsometimes can be overwhelming.

Apologizing, expressing theirremorse and desire to makeamends, can lead to forgivenessand healing for them as well. Soapology is a balm for both thepatient and the caregiver. It healstheir psychological wounds.

Can we afford it?

The practical arguments foropen and complete communication,with apology and restitution, arethat it is effective treatment forpatient and doctor and that it is lesscostly for all parties.

For decades, lawyers and riskmanagers have claimed that admit-ting responsibility and apologizingwill increase the likelihood of thepatient filing a malpractice suit andbe used against the doctor in courtif they do sue.

However, this assertion, whichon the surface seems reasonable,has no basis in fact. There is to myknowledge not a shred of evidenceto support it. It is a myth.

The reality, in fact, appears tobe just the reverse. Patients aremuch more likely to sue when theyfeel you have not been honest withthem. There now are several exper-iments under way—the VeteransAdministration, University ofMichigan, COPIC in Colorado—where full disclosure and smallearly settlements have resulted indramatic reductions in suits and in

payouts. These need to be expand-ed and replicated in other locations.

Again, the ethical argument isclear: patients should not have tobear expenses caused by our mis-takes. From a practical standpoint,the figures are encouraging.

In the 1990 Harvard MedicalPractice Study in New York state, itwas found that compensating allpatients with disabling injuries fortheir out-of-pocket expenses wouldcost less than liability insurance premiums paid by doctors and hospitals.3

A no-fault compensation systemwas recommended. While this hasyet to happen, the experience at theVA, Michigan, and COPIC providesfurther evidence of its feasibility.

Barriers to disclosure

Why does full disclosure sooften not occur? Why do so manypatients fail to receive a full andtruthful explanation of what wentwrong and hear their caregiveraccept responsibility and apologize?The reasons are many and complex,but several stand out.

Apology makes it possible for the patient to recognize our humanity,our fallibility, our remorse at having caused harm.

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First, apologizing is hard todo—for anyone. As we all know, itis difficult in non-medical situations,even when the “injury” is merely aslight or an insult. But a medicalapology is much more difficult.

The harm we have caused isphysical and may even be disablingor fatal. The more serious the injury,the more difficult it is to apologize.Showing sympathy (“I’m sorry youwere hurt.”) is much easier, but lacksthe essence of true apology, which isto take responsibility for the harmand express true remorse.

In fact, because it seems tospecifically communicate noresponsibility or remorse, somebelieve it can be, paradoxically,more harmful than no expression ofconcern.

Second, the injury was notintentional. The doctor or nursedidn’t harm the patient on purpose.It was an accident, due to an error,not a deliberate act. Even thoughthe caregiver may feel bad for thepatient, and chagrined, it was an“honest mistake.”

Third, many physicians lack theskills, which are considerable, topresent bad news well. We haven’tbeen trained to control our ownemotions while we try to handlepatients’ anger, frustration and dis-appointment.

But probably the most impor-tant reason caregivers don’t readilyadmit errors and apologize is shameand fear. Shame at failing to live upto our own and the patient’s expec-tations of perfection. Fear of theconsequences: loss of the patient’strust, loss of respect of colleagues,the risk of being sued.

These rational fears have beenfed and amplified by bad legaladvice that ignores the emotionalconsequences of injury for bothpatient and caregiver. Indeed, hos-pital lawyers and insurance compa-nies sometimes demand that doc-tors and nurses not admit responsi-bility or apologize following a pre-

ventable adverse event. Fortunately,that is changing.

Moving ahead

What should hospitals do? It istime to take our focus off self-pro-tection and put it on our mission,which is patient care.

Leaders have an obligation totheir patients and to their staff tohelp heal the emotional trauma thatfollows a serious adverse event. Thecore is to establish effective meth-ods for disclosure, apology andsupport. To do this, leaders have toset expectations, provide training,and provide support systems forpatients and personnel.

First, set expectations. Hospitalpolicy should be clear and unequivo-cal (and in writing): patients are entitled to a full and compassionateexplanation when things go wrong.Usually, this will be the responsibilityof the patient’s physician, althoughnurses, pharmacists and othersshould be involved when appropri-ate. The policy also should includeproviding apology when indicated.

Second, doctors and nurses, aswell as risk managers and other sup-port personnel, need training in com-municating with patients afteradverse events. They also need train-ing on how to support colleagueswhen they are “second victims.”

Third, support systems need tobe developed for all parties. Patientsneed help after an event, includingafter discharge from the hospital. Wealso need to provide support and“just-in-time training” to help thephysician communicate with thepatient following the event. And weneed to help these second victimsdeal with their emotional trauma.Professional and peer support sys-tems must be developed.

Finally—and this is the toughpart—after enlisting full support ofthe boards of trustees, hospital lead-ers need to insist that liability carri-ers provide early settlements for

injured patients. Making amends, financial or

otherwise, is intrinsic to a meaning-ful apology. No patient should haveto sue to receive a just settlement.The amounts required are often sur-prisingly small. But they should besufficient to meet the actual expens-es, and should be given freely, notgrudgingly, as true reparations.

The new world of transparencycan be daunting, requiring substan-tial changes in many of our prac-tices and ways of thinking. Thebenefits for our patients, and forourselves, can be tremendous.

Lucian L. Leape, MD, is aprofessor of health policyat Harvard University

and a long-time advocate of the non-punitive systems approach to the pre-vention of medical errors. He can bereached at leape@hsph.harvard.edu

References

1. Kohn KT, Corrigan JM, Donaldson MS,eds. To err is human: Building a saferhealth system. Washington, DC: NationalAcademy Press, 1999.

2. Institute of Medicine. Crossing the quali-ty chasm. Washington, DC: NationalAcademy Press 2001.

3. Johnson WG, Brennan TA, Newhouse JP,and others. The economic consequencesof medical injuries: Implications for ano-fault insurance plan. JAMA. 1992,267(18):2487-2492.