Apology in cases of medical error disclosure: Thoughts based on a preliminary study

RESEARCH ARTICLE Apology in cases of medical error disclosure: Thoughts based on a preliminary study Sonia Dahan1,2, Dominique Ducard3, Laurence Caeymaex1,3* 1 Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France, 2 Faculté de Médecine, Université Paris Est Créteil UPEC, Créteil, France, 3 Céditec EA 3119, Université Paris Est Créteil UPEC, Créteil, France * a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Dahan S, Ducard D, Caeymaex L (2017) Apology in cases of medical error disclosure: Thoughts based on a preliminary study. PLoS ONE 12(7): e0181854. https://doi.org/10.1371/journal. pone.0181854 Editor: Antony Bayer, Cardiff University, UNITED KINGDOM Received: November 17, 2016 Accepted: July 7, 2017 Abstract Background Disclosing medical errors is considered necessary by patients, ethicists, and health care professionals. Literature insists on the framing of this disclosure and describes the apology as appropriate and necessary. However, this policy seems difficult to put into practice. Few works have explored the function and meaning of the apology. Objective The aim of this study was to explore the role ascribed to apology in communication between healthcare professionals and patients when disclosing a medical error, and to discuss these findings using a linguistic and philosophical perspective. Methods Qualitative exploratory study, based on face-to-face semi-structured interviews, with seven physicians in a neonatal unit in France. Discourse analysis. Published: July 31, 2017 Copyright: © 2017 Dahan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The authors decided to limit access to the data for ethical reasons. Although anonymous, the data include examples of apologies in private situations which should be protected from public access. Despite these limitations, the data from the study will be made available for researchers who meet the criteria for access to confidential data, by contacting a nonauthor institutional contact representing the Ethics Committee of CHI Creteil Hospital, by email at . Results Four themes emerged. Difference between apology in everyday life and in the medical encounter; place of the apology in the process of disclosure together with explanations, regrets, empathy and ways to avoid repeating the error; effects of the apology were to allow the patient-physician relationship undermined by the error, to be maintained, responsibility to be accepted, the first steps towards forgiveness to be taken, and a less hierarchical doctor-patient relationship to be created; ways of expressing apology (“I am sorry”) reflected regrets and empathy more than an explicit apology. Conclusion This study highlights how the act of apology can be seen as a “language act” as described by philosophers Austin and Searle, and how it functions as a technique for making amends following a wrongdoing and as an action undertaken in order that neither party should lose face, thus echoing the sociologist Goffmann’s interaction theory. This interpretation also PLOS ONE | https://doi.org/10.1371/journal.pone.0181854 July 31, 2017 1 / 10 Apology in medicine Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. accords with the views of Lazare, for whom the function of apology is a restoration of dignity after the humiliation of the error. This approach to the apology illustrates how meaning and impact of real-life language acts can be clarified by philosophical and sociological ideas. Introduction Medical care exposes patients to the risk of errors [1]. A medical error (ME) has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (error of execution), the use of a wrong plan to achieve an aim (error of planning), or a deviation from the process of care that may or may not cause harm to the patient [2]. When an error causes damage to the patient, it is seen to be unacceptable and calls for redress. For over 20 years now, disclosing the error and the damage caused has been considered necessary by patients, ethicists, and healthcare professionals (HCP) [3–8]; in many countries, national guidelines have been published to encourage such disclosure [8–10]. However, this policy seems difficult to put into practice on a large scale for many reasons: the disinclination to disclose bad news, the fear of blame, or fear of a demand for compensation by the patient affected [8,11]. Medical literature insists on the close attention which must be paid to framing the disclosure of ME, since the way in which the ME is announced and information about the situation communicated is a decisive factor in the experience of both patients and HCP [4–6]. In this context, the act of apology has been described by patients, ethicists and HCP as appropriate and necessary [12,13]. In the medical field as elsewhere, apologies have been shown to help resolve conflict and avoid litigation [14], resulting in positive responses including fewer malpractice suits [15–18]. Depending on the words uttered, a distinction can be made between protective or partial apologies, and admissions or full apologies: protective apologies contain a manifestation of goodwill, such as regret, sympathy and benevolence, whereas apologies admitting error contain a self-critical expression [19]. Over the past twenty years, a growing number of states have adopted “apology laws”. Such laws are protective measures designed to mitigate risk and the fears of doctors that their admission of error might increase the probability of a malpractice suit and financial settlements [8,19–21]. They are intended to encourage those causing injury to apologize, thus expressly ensuring that at least some types of apology cannot be used against them and their institutions in litigation [17]. In practice, “apology laws” and the practices they foster vary between states and countries: all of them protect partial apologies, but some fail to protect full apologies, reading self-critical stances as partial admissions of liability. A phenomenological and linguistic examination of the notion of apology, as defined by its uses and forms of expression, shows that it contains three conditions: a state of affairs described as an anomaly or abnormality (a breach, shortcoming, deficiency, error, fault or difficulty), a negative assessment of the effects of this state of affairs (unfavourable, not preferable, not desirable, detrimental), and a way out (exoneration, mitigation of the fault, release) for the agent at the origin of (...truncated)