Thursday, May 14, 2009

It Wasn't Personal...

“It wasn’t personal… Nobody intended to harm you… It was a systems error…”

These are the phrases that are often said to patients and family members following a medical error. The reasons behind them are good ones—very rarely are adverse events caused by willful acts of harm from an individual. The vast majority of errors can be traced to problems with the systems of health care, and the “tradition” of assigning blame and punishing individuals does nothing to address the real problems.

But sometimes this line of thinking is taken too far and leads to the discounting of the patient and family experience:

“It wasn’t personal… Physically you are healed, so why can’t you get over it… Nobody intended to harm you, so you shouldn’t feel so betrayed… Don’t take it so personally…”
But for patients and families who are victims of medical errors, it is personal. It is incredibly personal. The damage to the patient’s body is personal. The damage to the patient’s ability to trust is personal. The physical and emotional trauma is personal.

We don’t want to blame the individuals, but how do patients get the acknowledgement and support they need from a “system”? Where is the balance between these two seemingly conflicting ideas? It lies in the recognition that there is a difference between “taking blame” and “taking responsibility”.

There is a popular word used in business—“BLAMEstorming”. When something goes wrong, everyone involved gets together to supposedly brainstorm a solution. But the discussion quickly devolves into figuring out who is to blame, usually the person lowest in the hierarchy (and not present to defend themselves.) That person is punished and everything then continues as before with no changes made to identify or correct what really caused the problem. This activity is about as counter-productive in business as it is in health care.

“Taking responsibility” is completely different. It is the ability to say, “I recognize that there is a problem, and I will make sure it is addressed appropriately, whether or not it was my fault.” It requires a willingness to make it personal—a willingness to connect on a personal level with someone who has been harmed. So, why is this important? After all, it was a systems error, it wasn’t personal.

When patients decide to have a medical procedure, they don’t approach an empty hospital building and say, “That building looks trustworthy; I will have my procedure there.” Patients generally meet with a clinician and decide to trust that person. The trust is personal, so when something goes wrong the feeling of betrayal is also personal. In order for the patient to heal emotionally, the betrayal of trust needs to be addressed on a personal level.

What do patients and family members need to heal? It is specific to that individual but some general needs are: An apology for the harm caused; investigation of the error; disclosure about what happened to cause the error; corrective steps to prevent the error in the future; and support for the patients and family members harmed by the error. The person who takes responsibility for providing these also needs guidance on what these actions entail and how to provide them, or there is a risk they will become checkboxes on a form:

Apology – “The hospital is sorry you think there was an error.”

Investigation – “What makes you think an error occurred? Who did you talk to? Why didn’t you do this…?”

Disclosure – “Nobody remembers what happened, so we can’t tell you anything about it.”

Corrective Action – “Next time you should make sure your history is properly documented in your chart.”

Support – “You can’t seem to get over this; you should go see a psychiatrist.” It is no surprise that the patient or family member feels worse after this exchange and the person assigned by the institution comes to the conclusion that “Disclosure and Apology” doesn’t work.

Again, it comes back to the personal connection. The conversation may be awkward. The patient or family may be angry. They may need to have several discussions over what seems like a long period of time, even years. They may be better one day, and worse the next. This is the nature of trauma response; it doesn’t follow an order or timeline. If the person taking responsibility can think about what they would want if they were harmed, and approach the situation with compassion, the healing process can start even without them knowing all the information or the perfect words to say.

The person taking responsibility should also not be expected to provide all the assistance the patient or family may need, as it may include professional emotional or physical treatment. The goal is for the affected person to feel supported—not abandoned—by the system that caused the harm. By working together for healing, patients, families and clinicians can get away from the adversarial tradition of blame and punishment, keep their personal connection, and even together help repair the “systems” that contribute to adverse events and medical errors.

Megan McIntyre


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