Table 4

Recommendations for reconciliation conversations emerging from key informant interviews

Eliciting patients' and family members’ needs
  • Explicitly ask what patients'/families’ needs are. Do not make assumptions—even that apology is desired.

  • Recognise that although most patients want an explanation, apology, compensation and learning, for many patients, simply being heard is most important and must occur early in the disclosure process.

Conducting reconciliation conversations with emotional intelligence
  • Time the conversation(s) appropriately.

    • Although early contact (within 48 hours of the incident) is important, some patients need time to process the incident, necessitating multiple conversations.

    • The onus is on institutions to follow-up with patients/families who need time to process the incident.

    • In arranging follow-up communications, elicit what timing works best for patients/families.

  • Offer apologies in a manner that maximises their effectiveness in promoting reconciliation:

    • Offered in person by the clinician(s) involved in the incident.

    • Offered after the provider has listened carefully to the patient and elicited his/her needs. This may involve not including an apology or offering a culturally appropriate apology or an apology which seeks forgiveness.

    • Timed according to the patient's needs, but generally not postponed until late in the process.

    • Includes more than ‘I'm sorry’; explicitly acknowledges the harm and the impact on the patient/family.

    • Not offered as a substitute for other forms of remediation such as compensation and proof of learning.

    • Executed skilfully and without coercion.

  • Respect cultural differences.

    • Reflect upon whether the process is culturally sensitive; ask questions as needed.

    • Ask what a meaningful apology includes in the patient's cultural or religious tradition, if appropriate.

  • Avoid insensitive word choices.

    • Contemplate wording ahead of the conversation, recognising that it is important to patients and can help or harm the reconciliation process.

    • Refer to ‘patient safety incidents’ instead of ‘errors’.

    • Replace ‘resolution’ with ‘reconciliation’.

    • Be open to patients’ differing interpretations of what constitutes ‘harm’ and ‘severity’.

Convening the right people to participate in reconciliation discussions
  • Ask patients who they want involved.

  • Include the clinician(s) involved in the harm event, unless the patient indicates this is undesirable.

  • Include support people such as lawyers and patient relations staff and notify patients of their right to consult a lawyer.

Responding to patients and family members who are particularly concerned with preventing recurrences
  • In disclosure conversations, share any patient safety lessons learned and actions taken. If the incident is still under investigation, assure patients/families that a review is being done.

  • If learning takes place over a longer time frame, be proactive about recontacting patients/families to share the patient safety steps taken.

Improving reconciliation guidelines
  • Strict protocols undermine the objective of tailoring institutional responses to individual patients’/families’ needs.

  • Use flexible guidelines that distil best-practice principles, ensuring that steps are not missed while not prescribing a ‘one size fits all’ communication approach.

  • Where necessary, amend guidelines to reflect the above best practice principles. Add (or, if it is already present, emphasise) the ‘being heard’ element of the disclosure process.

  • Move the being heard element to the first step in the initial and formal disclosure discussions.

  • Add a step that requires asking patients open questions such as ‘how can we help you?’