Apology is an important component of the disclosure process after patient safety incidents. In his book Healing Words: The Power of Apology in Medicine, Michael Woods depicts healthcare apology as consistent with the ‘common courtesy‘ that is generally offered for other forms of infringements. However, unlike the apology offered after mundane transgressions, apology following patient safety incidents is a structured process with recommendations guiding all its stages. Furthermore, apology after adverse events ‘can have profound healing effects’ for both the patient and the healthcare provider. As explained by Noni MacDonald and Amir Attaran in their paper titled Medical errors, apologies and apology laws, this is because apology can ‘facilitate forgiveness and provide the basis for reconciliation‘ for the patient, and it ‘can help diminish feelings of guilt and shame‘ for the physician.
An effective apology is only possible when the physician offering the apology fulfils some fundamental criteria. These, according to MacDonald and Attaran, and Richard Roberts, in his paper titled The art of apology: when and how to seek forgiveness, are:
- Acknowledgement of the event
- Acceptance of responsibility for the event
- The expression of regret or remorse
- Explanation of what happened
- The offer of reparation
Acceptance of responsibility for the adverse event is perhaps one of the most difficult stages of the apology process, and yet it is the most important. Indeed Richard Roberts, in his paper titled The art of apology: when and how to seek forgiveness, conceived of apology as constituting the remorseful acceptance of responsibility. Carol Liebman and Chris Hyman, in their paper titled A mediation skills model to manage disclosure of errors and adverse events to patients, referred to this type of apology as the ‘apology of responsibility‘, and they said this is symbolised by the phrase “I’m sorry we did this to you”, and they distinguished this from an ‘apology of sympathy‘ which is reflected by the phrase “I’m sorry this happened to you”. Liebman and Hyman therefore argued that accepting responsibility is essential for a full apology because only this satisfies the injured party.
Even when the major criteria of apology after an adverse event are fulfilled, the wrong timing of the apology may have a detrimental effect on the whole process. According to Roberts, the offer an apology for adverse events should not be made prematurely but only after establishing what happened, and that this resulted from an error. Roberts emphasised the dangers of a poorly timed apology when he said ‘if you do it too soon, you won’t know enough facts’, and ‘if you wait too long, you might be suspected of deception or disregard‘.
Besides the timing of the apology, where it is offered, and who are present at the time, also affect its effectiveness. Roberts, for example, advised that the apology should be offered in ‘a comfortable physical layout‘ with ‘adequate privacy‘ because these are essential for meaningful conversations. He also advised caution in deciding who should be present when the apology is made, noting that ‘having more people participate increases the chance that all relevant concerns will be aired, but it also increases the risk that the moment will be less personal and, perhaps, less effective‘.
Similarly, the technique used to communicate the apology may determine whether it is acceptable to the patient or not. In this regard, Roberts advised the physician to convey the apology in a sitting position and adopting ‘an open and receptive posture‘. He advocated speaking in a ‘professional and empathic manner’ whilst maintaining eye contact and listening attentively. He likewise encouraged the use of words that express remorse and that share the patient’s frustrations, and avoiding the use of jargon language, defensive statements, and angry rebuttals. He particularly urged the doctor to be careful not to send the wrong messages with facial expressions and body language.
There are several barriers to physicians offering apologies after adverse events. The major barrier noted by Marlynn Wei in her paper titled Doctors, apologies, and the law: an analysis and critique of apology laws, is the inherent difficulty physicians have with including apology into the disclosure process. Referring to this as apology hesitancy, Wei suggested that it may be associated with the fear health practitioners have that any apology will constitute an admission of guilt and therefore open the door for negligence claims against them. As a mitigating measure against this fear, Wei advocated the institution of no-fault apology laws which she said would exclude the admission of statements of sympathy as evidence in negligence lawsuits.
In the next post, we will look at compensation and forgiveness following patient safety incidents.