Explaining a Medical Error – OSCE Guide

Learning to explain a medical error is a valuable skill in clinical practice. Given the nature of the healthcare environment, you may encounter these situations in placements or when you start work. It may also appear in OSCEs. 

For this guide, we will use the SPIKES framework as an example of how to explain a medical error to a patient or relative. The SPIKES framework was developed for breaking bad news. However, it can be applied to a variety of clinical situations, including explaining mistakes and errors.

This guide provides a step-by-step approach to explaining a medical error using the SPIKES framework, with included video demonstration of explaining a prescribing error. 

You should also read our overview of how to effectively communicate information to patients.

Medical errors

A medical error is a mistake made in the context of healthcare and may include several situations:

• Where direct patient harm has occurred (e.g. prescribing and administering a medication a patient has a known allergy to)
• Where harm may occur in the future as a result of an error (e.g. an incident leading to foetal ischaemia, where problems due to hypoxic injury may not become apparent for years)
• Where harm may have occurred but was prevented (e.g. a patient being prescribed a medication they have a known allergy to, but it is not administered as staff noticed the error)

When an error occurs, the patient should receive an apology, be told what the error was, and any actions that will be taken to prevent the same scenario from occurring again.

Why is this important?

Medical errors are common. The NHS National Reporting and Learning System (NRLS) received over 2 million patient safety incident reports from April 2021 to March 2022, and while the majority of cases reported no harm, around 30% resulted in some form of harm to patients.²

Medical providers all have a duty of candour to be open and honest during a patient’s care. In the context of a medical error, we have a duty to report it and inform the patient. 

The duty of candour can be split into two types – statutory (currently only in England and Scotland) and professional. The professional duty of candour is regulated by specific bodies such as the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC). The statutory duty of candour is regulated by the Care Quality Commission (CQC) in England and the Care Inspectorate in Scotland.³

Both are very similar, but the statutory duty also includes additional requirements for “notifiable safety incidents” – these must be specifically reported. One of the major drivers for introducing the statutory duty of candour was the 2013 Francis inquiry, which found serious failings in transparency at the Mid Staffordshire NHS Foundation Trust.³

Clinical communication: general tips

Prepare for the consultation by choosing an appropriate environment (see the ‘setting’ section below) and performing sufficient background reading to ensure you have a good understanding of the patient’s situation.

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself including your full name and role.

Check you have the correct patient and confirm they are happy to be called by their name (e.g. Harry or Mr Miles).

Explain the purpose of the interview (e.g. “I have been asked to speak to you about the recent blood transfusion you had after your operation.”).

If you are seeing the patient instead of their usual doctor – apologise for the change and explain that you are stepping in for whatever reason.

Gain consent to discuss the topic with the patient and explain that the discussion will be confidential.

Active listening

Display active listening skills throughout the consultation:

• Maintain an appropriate level of eye contact throughout
• Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair)
• Nod to acknowledge what the patient is saying where appropriate
• Avoid interrupting the patient throughout the consultation

Establish rapport

Try to establish a rapport with your patient:

• Ask how they are, offer them a seat and a glass of water
• Empathise with any emotion they display/verbalise and acknowledge the difficulty/stress of situations they could be experiencing (watch them carefully)
• Listen and respond to the things the patient says

Structuring the consultation 

SPIKES is an effective way to structure your consultation when explaining a medical error. 

Setting

It’s important to explain the error in an appropriate setting:

• The discussion should occur in a comfortable, quiet, and private room. Although this is not always possible, make sure you have at least some privacy and that the patient and family have somewhere to sit. Bad news should never be broken standing in a corridor!
• Make sure to have some tissues available
• Ensure both you and the patient/relative are sitting down
• Arrange the chairs if necessary (e.g. at approximately 45-degree angles to each other), avoiding physical barriers between you and the patient (e.g. a desk)
• Ensure you have uninterrupted time during the meeting (turn off beepers and phones)

Perception

Begin by discussing the sequence of events leading up to this point and how the patient is feeling generally.

Explore the patient’s ideas about the situation and what they already know. In the video demonstration, the patient required a blood transfusion following knee surgery. In this example, the doctor asks things like: “Do you understand why you had the bleed?” and “Has anyone spoken to you about why you had the bleed?”. These can also serve as a warning shot to the patient. 

Invitation

Check if the patient wants to discuss the issue with you today – in an OSCE setting the answer will always be yes, however, on the wards, be aware that some patients may want to wait until family are present.

Explore if they have any specific concerns before delivering the news, but be aware this may invite questions or worry from them. In this case, you should provide reassurance where appropriate: “Just to reassure you there isn’t another diagnosis and you are recovering well, but I’m going to explain a bit more about what happened and why we think you had the bleed”.

Knowledge

Ensure you deliver the information in sizeable chunks, and regularly check the patient’s understanding.

Explain the error using simple language: “One of the drugs you were prescribed, the anticoagulant, which is the blood thinner, was mistakenly prescribed at a higher dose than you needed. And that might have caused or contributed to your bleed”.

Allow a large pause if necessary, so the patient can digest what you have told them.

After explaining the error, it is important to apologise for what went wrong: “I’m really sorry that this happened”. It is wise to wait for the patient to re-initiate the conversation. Make sure your tone is respectful, at a slow pace, and clear.

You can offer to provide more details about the mistake when the patient is ready: “Do you want me to explain what might have happened?”.

Explain the circumstances of the mistake slowly and clearly. Use the correct language. There should not be any ambiguity, and avoid using euphemisms or medical jargon. Deliver information in chunks, pausing between each piece of information.

“This drug should have been prescribed as a low dose for you to prevent blood clots from happening because you’re less mobile after surgery. We also use the drug at a higher dose to treat blood clots, and you were mistakenly prescribed the higher dose”.

Emotions and empathy

Recognise and respond to emotions with acceptance, empathy and concern. Demonstrate an empathic approach throughout the consultation.

It is natural for a patient to have an emotional reaction and they may become angry. It is important to recognise this, and you may note some of the following behaviours when a patient is angry:

• Loud speech or shouting
• Swearing/verbal abuse
• Aggressive posturing
• Standing up and not wanting to sit down
• Pacing up and down
• Shaking/fist-clenching
• Change in eye contact

If you recognise that the patient is angry then you can adjust your communication style to try and defuse as much of the anger as possible or to try and prevent the situation from escalating.

You can read the full guide on dealing with angry patients and relatives, but some general tips are:

• Provide the patient with time to process the information and express their feelings
• Try to keep a calm tone
• Speak slowly and clearly
• Adopt a professional yet relaxed posture
• Acknowledge the patient’s anger and concerns
• Try to understand why they are angry
• Respond with empathy

Strategy and summary

Explain the next steps to the patient clearly and reassure the patient that the situation has been, or will be reviewed and is being taken seriously.

“So you’ll continue your rehab, I’ve personally double-checked your medications to make sure all of your prescriptions are correct. We’ve discussed this as a team because we want to prevent this from happening again, and I’ve submitted a formal incident report as well”.

Provide the patient with details of how to make a formal complaint: “I understand, I’ll get you a form so you can make a formal complaint to the liaison service”.

Allow them to ask any questions they may have. They may feel that they need time to process the information given, and it may be appropriate to offer to come back and speak to them again later in case they think of questions in the meantime.

After the consultation

Dispose of PPE appropriately and wash your hands.

Be aware that explaining a medical error can be emotionally challenging for you as a healthcare professional, particularly if it was a mistake that you made or the patient became very angry.

Think through your own thoughts, and reflect on how you’re feeling. Take time out if needed.

References

1. MDU Notes. Learning from Medical Errors. Available from: [LINK]
2. NHS England. NRLS national patient safety incident reports: commentary. October 2022. Available from: [LINK]
3. Care Quality Commission. The duty of candour: guidance for providers. Available from: [LINK]
4. The MDU. Breaking bad news. Available from: [LINK]