13 Admitting Medical Errors

“An error doesn’t become a mistake until you refuse to correct it.”

– Orlando A. Battista

The liability (malpractice) arm of the insurance offered through the American Veterinary Medical Association is the Professional Liability Insurance Trust (AVMA-PLIT). In a review of 18 months of claims in 2006 and 2007, 60% were identified as having some component of miscommunication. Types of miscommunication most commonly identified were (1) failure to obtain owner consent for a procedure on a patient, (2) failure to inform the owner of the animal’s prognosis, (3) failure to inform client of costs associated with procedures or hospitalization, (4) failure to give complete written and verbal discharge instructions, and (5) failure to listen to the client’s concerns and be available for further consultation.

Clearly, communication is the key to ensuring client satisfaction, enhancing likelihood of positive clinical outcomes through increased adherence, and preventing malpractice claims. In human medicine, it is well documented that those physicians who never have been sued are also those who ask more questions, encourage patients to talk about their feelings, use appropriate humor, and educate patients about what to expect.^[1]

Sometimes, medical errors occur. Most are unintended. The British Veterinary Defense Society surveyed veterinarians in the United Kingdom and reported that 78% of new graduates admitted making a mistake that could have resulted in an adverse reaction.

When considering whether or not clients are likely to press a malpractice claim, Berry and Seltman consider people as detectives who are looking for specific clues.^[2] The clues they are looking for are:

• Functional clues = technical qualities of the care provided
• Mechanical clues = inanimate objects such as the sound and smell of the facility, and equipment, lighting, and other non-verbal indicators or quality
• Humanic clues = behavior and appearance of those providing health services

Functional clues are the “what” of the veterinary experience for that client. Mechanic and human clues are the “how” of the veterinary experience. Paying attention to all these kinds of clues heads to a more effective and positive experience for clients.

If a mistake is made, according to AVMA-PLIT, clients are looking for an explanation of what happened and why it happened, a description of what is likely to happen next for their animal, a plan for how this will be prevented from happening to other animals, and a sincere apology. This is a departure from veterinary education 20 years ago when it was taught that to apologize was to admit error. Now we know that a sincere apology lets the client know you truly are invested in doing the best for their animals, their family, and perhaps their business, and is a powerful way of maintaining rapport with clients in the face of disappointment.

One way to remember this is through the acronym TEAM:

T = truth – Give a full explanation of what occurred, including responsibility

E = empathy – Make sure the client knows that you understand why they are upset or angry

A = apology – Show true remorse

M = management – What will you do to prevent this happening to other animals? What is next for this animal? What reparations might be made?

You should also consider when to tell the client a mistake has occurred or when to apologize for that mistake. A 2004 study on timing of apologies found that it’s not always best to apologize immediately.^[3] The person who is to receive the apology needs to be ready to receive it for it to be effective and if they’re very angry or despondent, they’re not ready for the apology. An apology offered too early during a  conflict may pressure that person to pretend they’re okay with the situation when they’re really not okay – you need to let people know if a mistake has occurred but sometimes you need to hold off on the apology until their initial reactions have subsided.

When discussing risks and possible complications with clients, it is important to resist creating so much fear that clients will avoid procedures. Clients may wish for a guarantee. One author suggests the following – Never provide a guarantee of outcomes but instead guarantee that you will do your absolute best for that animal or population of animals.^[4]

Informed consent is a mechanism to try to ensure better communications. The elements of informed consent are (1) discussion of clinical issues, (2) discussion of options, including pros and cons, (3) discussion of uncertainties of the decision such as side-effects and care, (4) assessment of client understanding, and (5) exploration of client preferences.^[5] This clearly is a great description of the type of conversations we’ve been talking about having with clients, and their signature on a consent form provides written authorization to proceed. So why are veterinarians hesitant to use written informed consent in practice? Some cite time as a factor, worrying about lengthy conversations and paperwork. Some worry that telling a client too much may scare them away from necessary procedures or treatments. We all know that informed consent is the standard in human medicine and many believe this should be the standard in veterinary medicine as well. I find it hard to believe that you truly have a collaborative relationship with your clientele if you are not having these kinds of conversations.

If a client accuses you of malpractice, contact your insurer. Most often, your actions will be judged against the standard of care in your area. A breach of the standard of care is deemed to have occurred if a similarly trained provider with the same information available would have prevented harm to the animal.

A couple of words about the licensing board in your state – the licensing board is a function of state government. It has the legal authority to regulate practice and exists to protect the public. The board establishes qualifications for licensure (new and continuing) and investigates complaints from the public. In 2008, the MN state licensing board received 80 complaints (27 for every 1000 licenses), with 44% involving incompetence, 19% unprofessional conduct including poor communications and poor medical record keeping, 12% unlicensed practice, and the rest chemical dependency and sanitation issues. Most of these were dismissed after investigation. Other possible outcomes included additional investigation by the state Attorney General, corrective action agreements, and disciplinary stipulations. Dr. John King, the former head of the Board of Veterinary Medicine in Minnesota, repeatedly stresses that medical records are vital – if something was not documented, it did not happen.