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Guilt, fear loneliness afflict families and caregivers after medical error

BOSTON – Guilt, fear and loneliness often afflict both the caregiver and the family in the aftermath of a medical error, feelings that can be overcome if all parties try to build bridges and develop solutions that not only can prevent error but lead to forgiveness.

“Too Err is Human,” the famed 1999 Institute of Medicine report, focused on the need to prevent medical error. However, “Little attention has been paid to the second half of the adage – ‘to forgive is divine’,” write Tom Delbanco, MD, and Sigall K. Bell, MD, in a “Perspective” published in the Oct. 25 edition of The New England Journal of Medicine. “How can we characterize and address the human dimensions of medical error so that patients, families and clinicians may reach some degree of closure and move toward forgiveness"”

The answer starts with honest and direct communication. Rather than assign blame, patients, families and clinicians need to talk openly with one another to understand the situation, the impact the event has had on all concerned, and what will be done to prevent similar mistakes in the future.

“Though it has been well recognized that clinicians feel guilty after medical mistakes, family members often have similar or even stronger feelings of guilt,” the authors note. Patients and their families may also fear further harm, including retribution from health care providers, if they express their feelings.

Compounding that problem, clinicians may isolate patients when they are most in need. They may turn away from patients they have harmed, reflecting their own fears of loss of reputation or even medical license,

“Clinicians too, suffer alone after making mistakes, agonizing over the harm they have caused, the loss of trust, the loss of their colleagues respect, their diminished self-confidence, the potential effects of the errors on their careers,” the authors write. “Paralyzed by shame or lacking their own understanding of why the error occurred, physicians may find a bedside conversation too awkward.”

While approximately 30 states have adopted “I’m Sorry” laws that, to some degree, make a physician’s apology for an error inadmissible in court, the authors note there are still barriers to a potentially healing conversation among clinician, patient and family.

“Until such statutes become universal and accepted by health care institutions, frightened clinicians are left to struggle with conflicting personal moral principles, professional ethics, and institutional policies,” the authors note.

While apology and disclosure are necessary, they may not be enough to reach the stage of forgiveness, which requires “shared understanding, rekindled trust, acceptance and closure.”

To achieve that goal, the authors suggest, organized communication and emotional support is vital. Steps might include structured curricula for professionals addressing error prevention and response; removing the stigma from transparent reporting systems, and creating a system of expert “first responders” who guide patients and clinicians when an error occurs.

“Perhaps most important, building bridges to injured patients necessitates including them and other patients in the development of solutions. Patients and families will bring ideas to the table that expand the horizons of health care professionals. The yield from working in partnership could be enormous, both improving people’s experience with medical error and preventing harm from occurring in the future.”

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Delbanco is a professor of general medicine and primary care and Bell is an instructor of medicine at Beth Israel Deaconess Medical Center. Delbanco is a co-creator of “When Things Go Wrong: Voices of Patients and Families,” a documentary produced by CRICO/RMF, the patient safety and medical malpractice company owned by and serving the Harvard medical community.

The Risk Management Foundation of the Harvard Medical Institutions and the Drane Family Fund provided grant support for the project.

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and consistently ranks among the top four in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.harvard.edu.