Sorry Works!

Sorry Works! Blog

Making Disclosure A Reality For Healthcare Organizations 

Question from the Road: Lose a Patient?

Yesterday I did a webinar for a large hospital system, and the following question was posed during Q&A: "I'm in charge of our system's ambulance service, and, well, every so often we lose a patient. What do we say to the family when we lose their loved one?"

Wow, what a question, but not that out of the ordinary when you think about it. Fact is things get lost, misplaced, filed incorrectly, etc all the time in health care, except in this instance it's an actual person that is "misplaced." Here was my response:

"Tell the truth, but only say what you know when you know it. Don't be in a hurry to blame the driver, or the person who arranged the transfer, etc, because you don't know for sure. Instead, simply, 'We are sorry we lost your husband. We were supposed to take him from Point A to Point B, but somehow he ended up at Point D. I know this is a scary situation, but your husband is secure and OK, and we are getting him to Point B in a quick and safe manner. We are very sorry this happened, and we are going to conduct a review to understand how and why it happened, take corrective measures so it doesn't happen again, and report back to you. Can we talk again at 2pm tomorrow afternoon so I can update you on our review?'"

We see similar situations in long-term care when items such as clothing, jewelry, etc get lost. Was it stolen? Maybe. If so, who stole employee, another resident, or family member? Or did the resident with memory problems misplace the item or mistakenly throw it in the trash? Possibly. Or did the caring grandson, knowing that grandma is having memory problems, take the treasured watch home for safe keeping and simply not tell anyone, yet? Could be. In this circumstance when confronted with an angry resident or family demanding to know where grandma's watch has gone, don't get defensive and simply say, "I am sorry the watch is lost. Let me help you find the watch. Let's try to see what happened to the watch."

Then, there is the scenario we role play in disclosure training seminars: A 40-year old woman had a Pap smear in August, then she goes back to her physician in February for another issue, but during that February visit the physician asks if the woman has seen the specialist about her Pap smear. The patient looks dumbfounded: "What specialist? I never heard anything about the Pap smear. Is there something wrong? Nobody told me." In such a situation, a physician might a) downplay or even cover up the episode, or B) blame her staff for misfiling the report and not calling the patient, or c) say the following: "OK, we had an irregular reading with your Pap smear that raised some concerns and we need you to see a specialist. Somehow, unfortunately, there has been a disconnect between our office and you...I need to understand what happened. I am sorry this happened. The most pressing issue, however, is that we get you to the specialist ASAP...we're six months behind at this point. I know the specialist and will call in a favor to get you seen soon, possibly today. Also, I will try to understand what happened with your August Pap smear, and report back to you. Can we talk at 2pm tomorrow afternoon? Do you have any other questions? How else can I help you right now? My staff and I are going to stay with you every step of the way." In this scenario the lab report may have been filed away incorrectly and no one called the patient, OR the office called three times and left messages, but the teenage son deleted all of them, and the husband threw away the letter that came in the mail. You don't only say what you know when you know it.

For information on Sorry Works! webinars and disclosure training seminars, call 618-559-8168 or e-mail

GeneralAdmin1 Comment