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What to Tell Patients When Things Go Wrong (Part 1 of 2)

Posted on by CDC's Safe Healthcare Blog
Couple reading a letter

Author – Abbigail Tumpey, MPH CHES
Associate Director for Communications Science
CDC, Division of Healthcare Quality Promotion

Imagine this – the phone rings, you hear a voice on the other end, “Hi, Mrs. Tumpey….I’m calling from Dr. Smith’s office.  You had medical care at our facility a couple of months ago.  We are calling to inform you that during the procedure an unacceptable practice may have occurred that could have put you at risk for hepatitis or HIV infection.  Although the risk is low, we want to ask you a series of questions and request that you come in to our offices to be tested.”

What are you feeling at that moment?  Most likely, you are not really listening to what the caller is saying.  Immediately, you are thinking, “How could this happen to me?”  You are probably overwhelmed with a mix of emotions – fear, anger, sadness, and anxiety.  This is similar to the type of phone call or letter that tens of thousands of patients have received in the past decade.  Last year alone, nearly 14,000 patients were notified that they may be at risk for fungal meningitis or another fungal infection after contaminated medication was sent from an individual compounding pharmacy to 23 states.  Recently, several thousand patients were notified in Oklahoma after unsafe practices occurred for many decades in a dental facility.

Telling a patient that they may be at risk for an infection after receiving medical care from a trusted source is never easy.  In the past, patient notifications may not have taken patients’ feelings into account or fully maximized risk communication principles.  In 2009, a group of us at CDC, including communications experts and medical staff, set out on a quest to improve these patient notifications.  Although the circumstances surrounding individual incidents may vary, the communication needs that follow are consistent and predictable.

Realizing the growing need for guidance on the notification process, we conducted a series of focus groups to assess public perceptions and preferences surrounding patient notifications. We also conducted a series of stakeholder meetings with infection control experts, public health officials, and patient advocates to elicit best practices in patient notifications. We then compiled the results of this formative research and stakeholder engagement into a Patient Notification Toolkit. This toolkit includes the key steps a healthcare facility or public health department should take to initiate a patient notification and provides sample notification letters, press releases, and fact sheets that can serve as models and prove extremely useful – and time saving — during a notification event.

In my next blog, I will talk about some important risk communication principles that healthcare facilities and health departments should follow when notifying a patient of a medical error.  In the meantime, please check out our toolkit and give me your opinion of how we could improve patient notifications.

Posted on by CDC's Safe Healthcare Blog

2 comments on “What to Tell Patients When Things Go Wrong (Part 1 of 2)”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    Patients need respect and empathy when they find themselves in a situation where their health was jeopardized through unsafe medical procedures. Thank you so much for recognizing those needs and helping healthcare professionals respond to those needs!

    Healthcare-associated infections force healthcare organizations and government to do two things that are difficult even in better circumstances: admit a mistake and apologize. But those responses are what the public wants to hear most.

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