A closer look at the role of apology in error disclosure: a simulation study.

Background: The importance of open communication following harmful medical errors is widely accepted including the role of authentic apology. Yet, disclosure conversations remain difficult for clinicians and offering an authentic apology is challenging. Purpose: To better understand how clinicians can improve disclosures and apologies by using simulation to observe the approach clinicians use in the initial disclosure, where and when apologies occur within these conversations, what content apologies are linked with, who apologizes, and how apologies differ by their timing within the overall disclosure conversation. Methods: Forty-nine simulations of physician-nurse teams from the U.S. and Canada were videotaped planning and disclosing either a medical or surgical error to a patient-actress. Data from the disclosure portions were coded and analyzed using Atlas-Ti to describe the communication approach clinicians use when disclosing errors and the occurrence and timing of apologies within those disclosures. Results: Ninety-eight clinicians participated: 38 MD-RN teams from the U.S. and 11 from Canada. Of the 49 total simulated error disclosures, 30 involved medical teams disclosing an insulin overdose; 19 were surgical teams disclosing a lost specimen. The average length of the error disclosure conversations was 9.8 minutes (range = 6.1-14.2 min) and tended to follow a similar roadmap. On average, teams offered 2-3 apologies per disclosure (range = 0-9). These apologies occurred at all points during the disclosures and were offered by both physician and nurse participants. Discussion: Clinicians approached the initial disclosure conversations by addressing nine topics in a relatively consistent order. Apologies occurred throughout the disclosures. With opening comments, clinicians apologized to foreshadow bad news; with closing comments, they linked their remorse to broader professional and organizational goals around patient safety and transparency. Within the disclosure, clinicians sometimes linked the apology to their own emotional experience. More frequently, they linked apologies to the patient's emotional response, which may be more effective to ensure that patients hear that the clinicians' remorse is linked to patient suffering rather than clinician discomfort. To improve these difficult discussions, training materials and guidelines for communicating with patients after harm should reflect the complex role that apologies play.