Improving reconciliation following medical injury: a qualitative study of responses to patient safety incidents in New Zealand

Abstract

BackgroundDespite the investment in exploring patient-centred alternatives to medical malpractice in New Zealand (NZ), the UK and the USA, patients' experiences with these processes are not well understood. We sought to explore factors that facilitate and impede reconciliation following patient safety incidents and identify recommendations for strengthening institution-led alternatives to malpractice litigation.MethodsWe conducted semistructured interviews with 62 patients injured by healthcare in NZ, administrators of 12 public hospitals, 5 lawyers specialising in Accident Compensation Corporation (ACC) claims and 3 ACC staff. NZ was chosen as the research site because it has replaced medical malpractice litigation with a no-fault scheme. Thematic analysis was used to identify key themes from interview transcripts.ResultsInterview responses converged on five elements of the reconciliation process that were important: (1) ask, rather than assume, what patients and families need from the process and recognise that, for many patients, being heard is important and should occur early in the reconciliation process; (2) support timely, sincere, culturally appropriate and meaningful apologies, avoiding forced or tokenistic quasi-apologies; (3) choose words that promote reconciliation; (4) include the people who patients want involved in the reconciliation discussion, including practitioners involved in the harm event; and (5) engage the support of lawyers and patient relations staff as appropriate.DiscussionPolicymakers and healthcare institutions are keenly interested in non-litigation approaches to resolving malpractice incidents. Interviewing participants involved in patient safety incident reconciliation processes suggests that healthcare institutions should not view apology as a substitute for other remedial actions; use flexible guidelines that distil best-practice principles, ensuring that steps are not missed, while not prescribing a ‘one size fits all’ communication approach.

Disclosing Adverse Events in Clinical Practice: The Delicate Act of Being Open

“…However, when the apology is inadequate it could lead to a distance and the relationship may deteriorate. The disclosure may be performed by meeting the patients' needs and focus on reconciliation in order to heal relationships, instead of (only) reaching a (financial) resolution (Hannawa, 2011(Hannawa, , 2019Hannawa et al, 2016;Moore & Mello, 2017). Moreover, when the disclosure is effective and patients perceive the error as understandable, they will experience it as enhancing the relationship (Hannawa & Frankel, 2018;Mazor et al, 2009).…”

“…> Face to face > Acknowledgment > 'Bad apology' can do harm (Hannawa, 2019;Moore & Mello, 2017) > Share pain (Iedema et al, 2009) Apology with admission and explanation (Hannawa, (Jones et al, 2019;Mazor et al, 2013) Action should be congruent with words of apology and caring (Mazor et al, 2013) Expect follow-up and tangible support (Iedema et al, 2008, Iedema et al, 2011 Expect relational recognition, maintaining relationship and reparation as priority (Hannawa, 2017) Patient expected input when time was ripe for closure (Iedema et al, 2011) Respond when patients or family members are concerned with preventing recurrences (Mazor et al, 2013;Moore & Mello, 2017) Action and information of clinician learning and improvement process (Iedema et al, 2011;Mazor et al, 2013) Reassurance that competent care of patient is top priority (Mazor et al, 2009) Healthcare professionals: challenges Which information should be recorded in patient clinical history Whether disclosure should be made on incidents without damage Moral distress when not included in disclosure discussions (nurse) Disclose promptly, as soon as possible, and not too informal (Hannawa, 2017;Iedema et al, 2008; Nurses are more fearful of punitive action (Harrison et al, 2017) Clear responsibility of the AE: physician communicated more patient-centered, emotional and attentive…”

Evaluation of a simulation-based Risk Management and Communication Masterclass to reduce the risk of complaints, medicolegal and dentolegal claims

“…Where patients are, for example, undergoing surgery, most want to be offered choices and asked their opinion when making decisions involving surgery 9 10. Furthermore, patients who have experienced suboptimal care are less likely to complain if their healthcare professional has communicated clearly and provided them with enough information, a satisfactory explanation11 and a timely, sincere, culturally appropriate and meaningful apology 12…”

The personal and the organisational perspective on iatrogenic harm: bridging the gap through reconciliation processes

“…Numerous healthcare systems now have published policies around disclosure. However, as Moore and Mello document in their paper in this issue of BMJ Quality and Safety ,1 details about how, what and when to disclose are scant, and based on minimal evidence about what works for patients, families, clinicians and organisations. Moore and Mello provide important insights from New Zealand, where a mandatory system for compensation following treatment injuries has been in place for over 40 years, on how to achieve reconciliation that satisfies the concerns of aggrieved patients and carers while being acceptable to clinicians and organisations.…”

“…Much of it may fall well outside the frame of reference of a biomedical or organisational understanding of the consequences of the incident. To give one example: an incident involving a participant’s hearing was, for the doctor, an unfortunate but ultimately moderate accident; for the participant, a musician, it was a major, life-altering event 1. As a recent UK government-sponsored review noted, organisationally defined thresholds of harm may serve a helpful analytical purpose, but ‘terms such as ‘low’ or ‘moderate’ harm (can be) unhelpful as a way of structuring a conversation with a patient or their carer.’11 …”