Information Statement

Communicating Adverse Outcomes

This Information Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

The responsibility to inform a patient or his/her family of an adverse health care outcome is an inevitable part of the practice of medicine. Adverse events, or disappointing outcomes, do not necessarily occur as a result of an error or negligent care; these results occur for multiple reasons, including uncorrected “unreasonable” expectations, complicating biological factors and courses of treatment or surgery that don’t work out as anticipated.

When such an event happens, a patient often wants acknowledgement and understanding, an assurance that the physician will take steps so that the event will not occur again or risks of a similar occurrence will be minimized, an apology (if appropriate) and consideration of the financial impact on the patient.

Consistent with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards and the American Academy of Orthopaedic Surgeon’s (AAOS) Principles of Medical Ethics and Professionalism, the AAOS believes that an orthopaedic surgeon should put the interests of the patient first and communicate directly with a patient/family member in an honest, compassionate manner as soon as possible after an adverse event occurs.

As stated in the AAOS Advisory Statement on The Importance of Good Communication in the Physician-Patient Relationship, good communication with patients has always been essential in orthopaedic practice and is the cornerstone of the physician – patient relationship. Open, honest communication favorably affects patient behavior, health outcomes, patient satisfaction, and often reduces the incidence of malpractice actions.

After an adverse event occurs, it is the orthopaedic surgeon’s responsibility to assure the event is investigated immediately and all facts are collected. The patient’s health care needs should be addressed as soon as possible.

When an adverse outcome has occurred, the orthopaedic surgeon should communicate in an honest, empathic manner with the patient or his/her family as soon as feasible after the event. During the course of the discussion, the orthopaedic surgeon should refrain from commenting about reasons for the event until the medical investigation is concluded. Currently understood facts related to the patient’s condition should be discussed and follow up with the patient after the investigation is completed should occur. Blame should not be assigned and speculation about fault should be avoided. An honest disclosure of what happened to the patient will reduce anger and mistrust, as will an apology that avoids a suggestion of fault or conjecture, if appropriate. The orthopaedic surgeon should describe precautions that will be taken so that risk of the same event happening again will be minimized. The discussion should also include recommendations and steps for follow-up care and an offer to transfer the patient’s care to another physician, if appropriate. An administrator or patient liaison should be present, if possible, both to serve as a witness and to assist with the patient’s resulting needs and requests.

If an error is the cause of the adverse event, the orthopaedic surgeon should coordinate with the risk manager or legal counsel to determine the amount of detail that should be provided in any discussion. Some information, such as peer review matters, root cause analysis material, results of disciplinary actions and legal counsel communications are privileged and should not be a part of the discussion with the patient. Similarly, if the event could escalate to a claim, in certain states expressions of sympathy relating to the pain, suffering or death of a patient made to the patient/family member are not admissible in court as evidence of an admission of liability, whereas statements of fault are considered admissible evidence.

The physician-patient relationship is built upon trust and honesty. The AAOS Code of Medical Ethics and Professionalism reinforces these principles in section II.A. which states: “The orthopaedic surgeon should maintain a reputation for truth and honesty. In all professional conduct, the orthopaedic surgeon is expected to provide competent and compassionate patient care, exercise appropriate respect for other health care professionals, and maintain the patient’s best interests as paramount.” Consistent with these principles, the AAOS urges orthopaedic surgeons to behave in a manner consistent with these recommendations when communicating about adverse events with their patients and their family members.

© October 2004 American Academy of Orthopaedic Surgeons

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons^®.

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