1. Mason, Diana J. PhD, RN, FAAN, AJN Editor-in-Chief

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"Patient-safety advocate Roxanne Goeltz tells a story," writes Nancy Berlinger in her new book, After Harm: Medical Error and the Ethics of Forgiveness, "about the hospital CEO who is asked how he finds out when a medical error has taken place at his institution. 'When we fire a nurse,' he replies."


No wonder nurses are often hesitant to disclose and apologize for errors they commit in their work: they've been scapegoats for medical error for a long time. They may agree to hide errors to protect themselves from punishment and because their employers' legal staffs argue that apologies may be admissible in a malpractice case. But more and more states are passing laws that rule as inadmissible expressions of sympathy for the patient after an error or admissions of fault (see And legal staffs often fail to consider that an institution's costs from errors can actually decrease if it embraces the disclosure of errors to patients and families. Such disclosure also provides the erring clinician with an opportunity to apologize, receive forgiveness, and avoid prolonged devastation from having caused harm to someone in her care.


In the November-December 2003 issue of the Hastings Center Report, Nancy Berlinger warns that blame-free cultures can lead to what she and theologian Dietrich Bonhoeffer call "cheap grace"-an apology (from an individual or institution) as an expression of sympathy rather than an admission of fault, with forgiveness expected, and without an opportunity for restitution. Both the clinician and institution should own up to the mistake-the clinician for whatever role she played in the error (such as giving a medication as prescribed without recognizing that it was an incorrect dose) and the institution for not putting in place systems with safeguards to reduce the chances of errors from human lapses.


Offer financial payment for harm done to a patient.

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What do you say to the patient when you've made a mistake in his care? Here are two suggestions offered by Berlinger:


* Tell the patient about the error and include a full description of how the error occurred.


* Apologize, sharing your regret with the patient; a sincere, remorseful apology can help both you and the patient find a way to forgive your error.



These steps can be framed in an institutional policy, along with the following:


* Adopt the principle that "withholding the truth violates patient autonomy and has a corrupting effect upon care providers" (Berlinger, p.32).


* Provide clinicians with the opportunity to discuss how an error happened without being punitive or humiliating; this should also include an analysis of the failure of the institution's systems to prevent the error and what could be done to prevent its repetition.


* Provide the opportunity for counseling to the patient or family and the provider.


* Invite the patient or family to participate in the institution's efforts to prevent a recurrence of an error. This could include serving on a task force to design better care processes.


* Ensure that the patient and family do not bear the cost of treatment that may arise.


* Offer financial payment for the harm done to the patient.



And when the system really is at fault, perhaps administrators should apologize not just to the patient but to the clinician who made the error.


Understaffed units and unsafe systems of care can lead to a nurse giving the wrong medication to a patient. In such a case, an apology from an administrator might be accompanied by a paid day off and free counseling to help the clinician deal with the devastation. To err is human; to forgive, divine. The challenge may be in the second part of that adage. But true forgiveness emanates from sincere regret and efforts to prevent an error from occurring again. It must be a shared responsibility.