In a previous post, we looked at how to think about making mistakes, and how to not let the fear of mistakes stop us from extending ourselves. But what do we do when what we fear has happened? When you’ve done something, or didn’t do something, and the outcome for your patient has not been good.
Luckily we have decades of research from both the medical and veterinary worlds to learn from. Some of the findings may run counter to our first instincts of damage control and self-preservation, but the recommendations about an ideal course of action are all pretty consistent. What follows is a step-by-step approach, based on the research, of what to do when things have gone wrong:
1. Take care of the patient.
Your first priority needs to be to implement a plan of action that will minimise the damage caused by the adverse event and takes care of the patient’s immediate needs.
2. Take care of yourself.
An undesired outcome to one of our patients is a stressful event that, for many of us, will be accompanied by a cocktail of unpleasant emotions: shame, feelings of inadequacy, lack of self-confidence, and a genuine concern about the practical implications to our career and finances. This is normal, but it’s not helpful, so try to address it as soon as you can.
Start by speaking to someone. Tell a trusted colleague who can look at the situation impartially and unemotionally. Someone who can help you look at the situation objectively: was it really something that you did, or was the complication out of your control? If you were at fault, how bad is it? A third party can help you put the event in perspective and assist in formulating a plan of action at a time when your emotional response may be hindering the clear-headed thinking that is needed.
Another useful exercise is to get clarity on what the real implications of the situation could be, and what you could do about it. Author Tim Ferris calls this exercise ‘fear setting’. Ask yourself: what is the worst possible outcome that can come from this? Could I really lose my job or my license to practice? If I do get taken to the vet board, or sued, do I have insurance that will protect me? Could I lose money? How much? What would the day-to-day practical implications of this be? What will this event look like to me 1 year from now? Will I be ok?
Then ask yourself: is there anything that I can do NOW to prevent this worst-case scenario? What first step can I take?
3. Speak to your insurer or local defence society.
They will be able to guide you through the process and tell you what you should and shouldn’t say, and equally as importantly – reassure you that if worse comes to worst that you have a fallback.
4. Find the facts.
It is critical that you are very clear on the events that lead to the undesired outcome. Many of these situations can be very complicated, but before you speak to the client you need as much clarity as possible. One research paper puts it nicely: “The clinician needs to draw a bright line through a grey situation”. Do everything you can to determine whether what has happened was a preventable situation that has occurred because of some error on the part of the team or just an unintended consequence that occurred despite everyone acting in a way that most vets would have.
If the facts are not clear at the start it is important that the client is assured that you are investigating the incident and that you will report the findings to them, and then be very sure that you keep this promise.
5. Speak to the client
Without a doubt, for most of us, it’s dealing with the client that is the hardest part of managing mistakes. However, research shows that the right approach can minimise the risk of litigation, reduce the chances that the client will leave your practice, reduce the amount of any potential financial ramifications, and, that it’s even possible to strengthen the trust and loyalty that the client has to the practice. So how do we achieve this?
Start by getting your head right. An attitude of genuine empathy towards the client is likely to deliver the best outcomes for both you and the client in question. Ask yourself: “ If I was in this client’s shoes, how would I feel? What would I have liked to happen in this situation?’
Prepare yourself by rehearsing what you are going to say to them with a colleague, and accept that the client’s initial responses may well be anger, resentment, and accusations. Resist the temptation to become defensive. An emotional client may not be ready for logical reasoning. Instead, try to acknowledge their feelings by using statements of empathy, like: “I can see that you are very upset with me, and I understand why.”
If it all possible, have the conversation in person. Make a point of apologising if it has to be done over the phone. Clearly, you’d have to phone them to arrange a meeting. Be upfront from the start: “I have some difficult news to share. I’m very sorry to say that we’ve had some complications with Rover’s treatment. Would you be able to come in so we can discuss this with you in detail and talk about how we are dealing with the situation?”
Now they’re in the room with you. What do you actually say to them? Do you tell the truth, or do you just discuss the basics, but leave out any incriminating facts, or do you go full Donald Trump mode?
Studies into what influenced decisions to take legal action show that litigation is most often associated with a perceived lack of care or collaboration. In other words – we are sued when our clients feel that we don’t care about them and about what they want. So how do we show that we care when we’ve made a mistake? What do our clients want in these situations?
Again, by collating the research we get some very clear guidelines on this. When people have been the victims of medical error they want their clinician to:
- Be very clear that a mistake has occurred. Don’t try to be vague about what has happened to try to minimise the fallout. Your clients will smell the bullshit, and subsequent discussions will be tainted with suspicion and mistrust.
- Give an explicit apology. Many of us were taught not to apologise when things go wrong at work, as this could be seen as an admission of guilt, but it has been shown that apologies can reduce client anger and show them that you are trustworthy. We can differentiate between two types of apology: — If something has gone wrong because of a treatment error or a breach of standards an apology of responsibility is most appropriate: “I’m sorry that we made this error and that it has had negative outcomes for your pet. – When an unexpected adverse outcome has occurred, but no errors have been made, a heartfelt apology of sympathy is still appropriate: “I’m very sorry that this has happened to your pet and that you have to go through all of this.”
- Explain the facts: What exactly has happened? How did it happen?
- Explain the medical ramifications to their animal: how will this affect the animal in the short term, and what will the longterm consequences be?
- Tell them how the care of the animal will be managed. Explain what are you doing about it right now, and what will need to be done in the longer term.
- Be clear about who’s going to pay for it. If a genuine error has been made then the expectation is that ongoing care will not be the financial responsibility of the client. Compensation over and above medical costs should also be discussed. This does not mean that money has to be offered immediately, but a statement that acknowledges that you are conscious of the fact that the client may have suffered because of what has happened will go a long way to stop an immediate escalation of the situation. Ask “Is there anything that we can do to help resolve this situation?” Actual compensation will then need to be worked out with the insurer, but the research shows that the dollar amount of any compensation eventually paid is often less if an offer of compensation is made early on.
- Tell them how a similar event will be prevented in the future. What practices are being changed or instituted to stop this from happening to another patient? Patients who have been affected by medical error indicated that simply knowing that ‘something good has come of this’ reduced their negative feelings about the event.
6. Learn from it.
When the dust has settled it is vital that the events leading up to an unwanted outcome are evaluated with honesty. Making mistakes is acceptable, but failing to learn from your mistakes is not.
Was the thinking that led to the decision-making process flawed? Or was it a failure in instituting the plan? What can you do about it? You’ve promised the client that you will make changes that will prevent this from happening again, so keep your promise. You owe it to your patients, and to yourself.
Mistakes will happen, but they don’t need to mean the end of the world. This proven approach based on empathy and honesty towards our clients and ourselves can take the sting out of these events, and even lead to some positive changes. Knowing that we have a solid backup plan for when things do go wrong should allow us to face our daily challenges with an attitude that comes from a genuine desire for the best, rather than from fear of the worst.