Regretfully, things in the practice of dentistry do not always go to plan. What is expected of us when things go wrong, and is it ever wrong to apologise? Anita Kemp, Case Manager at Dental Protection, looks at the facts.
Open disclosure requires honesty, openness and timeliness when divulging an adverse event or outcome to our patient. The HSE outlined in its Open Disclosure1 policy document:
"3.12 Apology: When a failure or error in the delivery of care/treatment is identified the patient and/or relevant person must be provided with a sincere and meaningful apology in a timely manner which is personal to the patient and to the given situation. When things go wrong during a patient’s health care journey, for whatever reason, a genuine expression of regret delivered in a manner which is empathic is always appropriate."
When adverse events occur, and open disclosure and a subsequent apology is required, we can often feel extremely vulnerable. The progression of a procedure that did not go as planned or as expected can leave both our patients and us feeling anxious, upset and at times angry. In these circumstances our inherent fight or flight responses can be activated, and, in some instances, what was meant as an apology can come across as defensive and evasive in nature. During these times of distress and uncertainty, an understanding of the integral elements and the purpose of an apology can be invaluable.
Why should we apologise when something goes wrong?
Notwithstanding the requirements of our professional obligations, Leape (2012)2 identifies that patients expect an apology after being harmed by an error. He continues that apologies convey a sense of respect, mutual suffering, and responsibility.
Mutual suffering is an integral element of an apology worth consideration. As dental healthcare professionals (DHPs) we never suffer the outcome, pain or anxiety of treatment experienced by our patients. Nevertheless, as Robbennolt (2009)3 suggests, if we can demonstrate an understanding and empathy towards our patient, a reduction in anger and blame may be observed – leading to a positive increase in trust.
Trust is an important aspect of any therapeutic relationship. When a DHP works with honesty, openness, and the ability to acknowledge an adverse event or problem, patients are more likely to trust in the DHP’s ability to either remediate the problem themselves or provide a suitable pathway for specialist referral that will ensure the most favourable outcome. If trust is lost, the DHP may be more vulnerable to complaints or concerns arising from the treatment provided.
Research by psychologist Beverly Engel (2002)4 suggests that the art of apology is crucial to mental and physical health. Studies have found that the recipient of an apology experiences physiological changes including a decrease in blood pressure, slower heart rate and steadier breathing. These noticeable physical effects allow space for problem solving as opposed to a heightened reaction.
Similarly, regret, remorse and shame are feelings often felt when we inadvertently hurt another person. In the event of an adverse outcome, all these feelings have the potential to cause negative emotional and physical effects in the treating DHP. Engel continues that when an apology is given and responsibility for actions are taken, we can help rid ourselves of esteem-robbing self-reproach and guilt.
So, if we should apologise – why don’t we?
Innate fight or flight responses, coupled with vulnerability and fear, can all determine our reasoning and rationale to provide or not provide an apology. Hubris can play a part too, particularly when our self-image is founded in being caring and competent. Fear of loss of patient confidence, ridicule from colleagues and regulatory investigation can undermine our self-esteem and affect our ability to make emotive decisions.
If we do apologise, what should it look like?
Most importantly in these instances, we should ask “what does our apology look and feel like to our patients?” An apology must feel genuine, sincere, and heartfelt. It must refer to the specific incident or problem and must acknowledge each patient’s specific circumstance. Apologies should be delivered in the first person by the DHP responsible in a personalised manner. Use of language is pivotal, and the DHP should aim to soften the apology by using “sorry” rather than the formal “I apologise”.
According to Lazare (2005)5 the four key components of an effective apology comprise:
• Acknowledgement – acknowledge what has happened
• Remorse – offer empathy for the position the patient is in
• Explanation – give a clear and specific explanation of what happened
• Reparation – anything from remediation by you or by referral or monetary compensation.
An apology should include:
• assurance that the circumstances will be investigated and that the standards of the profession will be maintained
• an explanation of what has occurred. This should be provided to the patient’s level of satisfaction and should include opportunities for the patient to relate their experience and to ask questions. The DHP should also seek assurance from the patient that they understand and are comfortable with the content of their discussion
• the word “sorry”, which is not an admission of liability.
Furthermore, an apology needs to be personal in nature, not vague or imprecise, but clear and specific regarding the events that have occurred. The use of layman’s language as opposed to quasi-legal or technical jargon should be used in the description of the event and the likely outcome. The research broadly indicates patients want a meaningful apology along with an honest and open explanation. When this is not forthcoming, a patient is more likely to feel aggrieved and take the matter further.
In our experience at Dental Protection, DHPs are often needlessly concerned that an apology can be viewed as an indication or admission of fault or liability. If an adverse outcome or problem does occur, don’t be afraid to offer an apology. Fundamentally, this is what every patient in this situation wants to hear. Remember there is considerable evidence that supports the protective benefits of an apology and, when you do apologise, don’t be afraid to begin with three very powerful words, “I am sorry”.
1Health Service Executive (HSE), Open Disclosure
2Leape L, “Apology for Errors”, Frontiers of Health Service Management, 28 (3) pp. 3-12 (2012)
3Robbennolt JK, “Apologies and Medical Error”, Clinical Orthopaedics Related Research, Feb 467 (2) pp.376-82 (2009)
4Engel B, “The Power of the Apology”, Psychology Today. July 2002
5A Lazare (2005) Quoted in Riskwise 25, Jan 2012, p20