EXECUTIVE SUMMARY

There are certain things nurses and physicians should never say to a patient or family member because they can lead to an increased risk of liability and dissatisfaction. Risk managers should educate clinicians about these comments to avoid.

  • Some remarks involve promising too much or making a guarantee.
  • Staff also should not let people hear them complaining about internal issues, such as staffing shortages.
  • Risk managers should work closely with the communications department to ensure printed and digital materials do not contain these messages.

Healthcare and risk management are full of things one should say and do, including the best practices that improve outcomes and lower liability risk. But there also are plenty of things a risk manager never wants to hear uttered by a healthcare employee.

These are the things that one should never say to patients or family members because they could lead to a lawsuit or complicate a lawsuit defense. Many forbidden comments involve promising too much to the patient, says Erin O’Leary, producer with the Graham Company in Philadelphia.

O’Leary and Bette McNee, RN, NHA, clinical risk management consultant at Graham Company, offer this list of things never to say in healthcare:

1. Never make a promise. It can be tempting to make promises when reassuring anxious patients or describing the likely course of events during treatment, but O’Leary says risk managers should train staff to never promise anything. Nothing is guaranteed in healthcare, and a promise can be taken literally by the patient and family members, she says.

It will not help for the healthcare provider to explain that he or she did not mean the comment as a literal promise for a specific outcome, she says. Once the party hears “I promise…” the damage is done, she says.

2. Do not offer a guarantee. A statement like “We guarantee your satisfaction” can be even worse than a promise because it can be interpreted, accurately or not, as a legally binding statement, O’Leary says.

3. Do not overstate qualifications or what is possible. This can be problematic in marketing materials, which may offer “constant supervision” or “the best possible care.”

“Those are the kinds of statements that plaintiffs’ attorneys are turning around and using on organizations, directors and officers, or practitioners to say that they are not providing the care they stated they would provide,” O’Leary says.

4. Never offer personal opinions. Nurses can find themselves in awkward positions when they get to know patients and family members, and those people look to the nurse as a trusted source of information. Nurses may be asked for their “real, honest” opinions about a colleague, or their own opinion on another clinician’s judgment. Risk managers should remind nurses that they must deflect this sort of inquiry.

“When you are at work, you are an agent of that organization, but a lot of patients and families will try to get personal opinions from staff, without realizing that when you are at work you can’t really speak your mind in a personal way,” McNee says. “It is very important for people to understand that they can’t give a personal opinion when someone asks them what they think of a doctor’s qualifications, for instance. As much as you want to be helpful and friendly, you are still an employee of the hospital or health system.”

5. Do not let patients and visitors hear staff griping. Everyone complains about their workplaces, but it is unprofessional to allow nonemployees to hear nurses or physicians griping about housekeeping, food services, other clinicians, or any other aspect of the organization, McNee says.

Such comments may be relatively minor venting for the nurse or physician but they can undermine confidence in the patient’s care and encourage a sense that that organization is not well run, she says.

6. Avoid topics in the news that are related to a patient’s care. Even if the subject comes up in an abstract way, like a patient asking the nurse’s opinion on a nursing staff ratio bill that is in the news, the topic should be off limits, O’Leary says.

“It’s like how you don’t talk about religion or politics at dinner. You have to have a policy that you don’t talk about these in-house problems or debates, even if someone asks you directly for your opinion, or if you want to use it as an explanation for why you’re not at fault in a given situation,” O’Leary says. “If you express concern about nursing staff ratios, what are you saying to that patient about his or her care? You may say you’re not talking about this institution, but when you’re in those scrubs, you are an agent of that hospital and have to avoid that kind of discussion.”

Do Not Say Care Is Insufficient

7. Never tell a patient that care is substandard. That would seem like a no-brainer, but it happens all the time because staff do not realize they are saying exactly that, McNee says. They think they are rightly defending themselves from a patient’s complaint.

In response to an unhappy patient or family member, healthcare providers may talk about institutional problems such as short staffing, scheduling difficulties, supply problems, or similar issues. This can be difficult for nurses who are genuinely frustrated and want to explain to an unsatisfied patient why they cannot fix the problem. But O’Leary says they must avoid the temptation to say “We’re short staffed” or “Administration won’t give us the help we need.”

That can sound like an admission of guilt, a direct statement that the clinical team is providing inadequate care, McNee says. Such a statement can be used against someone in litigation, she says.

8. Do not tell a patient you are providing certain care because “That is what your insurance will pay for.” This happens more in therapy or specialty services than typical floor units, but McNee says a healthcare worker sometimes will comment that the patient’s plan of care was determined by what their insurance covers.

“That brings up huge red flags. If I’m lying in that bed, and they’re looking at my options for care and tell me we have to do this thing first because of insurance, it certainly doesn’t sit well,” McNee says. “It’s not just whether this procedure or test is covered. It’s telling patients that you think they should go on to option B, but you have to do option A first so that your insurance requires that. That makes me feel like you’re not giving me the care you know is best for me.”

9. Do not use insurance as a scapegoat for avoiding a better answer. Doctors and nurses often encounter patients and family members who think they know the best course of treatment because they read something online. It can be tempting to dismiss the discussion by saying “Your insurance won’t pay for that.” It is a quick way to get out of a discussion, and deflects any dissatisfaction to the insurance company rather than the clinician, McNee notes.

But that response can give the false impression that clinicians are basing clinical decisions on insurance coverage rather than what is appropriate for the patient, she says. Even if it takes longer, the better response is to tell the whole truth, which may be “At this point, you don’t have the signs and symptoms that would suggest that test is appropriate, so there’s no need to perform that test now. It’s not clinically indicated.”

It may be true that the insurance will not pay for that test, McNee explains, but the more complete explanation is better.

10. Do not speak too freely or defensively after an adverse event. The aftermath of an adverse event can be stressful on everyone involved, and as McNee jokingly says, they tend to only happen on nights and weekends when there is no specially trained supervisor or administrator to respond. Unfortunately, a lack of training and the high emotions can lead healthcare professionals to say the wrong thing, she says.

“When you have to call a family member to say that their mom fell while trying to get out of bed to the bathroom and reinjured the knee she just had surgery on, that initial communication is so important,” McNee says. “Thankfully, we don’t have to make those calls, or even worse calls, too often. But the bad thing is that when people have to make those calls, they forget the key things they have to convey, and what they are supposed to say and not supposed to say.”

Provide a Script

Many hospitals try to cover these situations in a customer service or professional education module, but McNee recommends providing a carefully worded script that is posted on care units for nurses to use when making such calls. The script should be direct but simple, providing what happened, the initial condition of the patient, what is being done for the patient, and that the incident is under investigation.

“Also, tell them that they will receive a call from a specific person you name, not just a nursing supervisor, by a certain time, and give them that person’s phone number and extension,” McNee says. “You give them very specific information that they will want to know. If they ask questions you can’t answer at that time, tell them that the right person will provide that information when it is available.”

It is important not to be defensive in this conversation, O’Leary notes. That can be difficult when the nurse is stressed from the experience and the family member is concerned about the patient, she says.

“You don’t want to be defensive about yourself, the other caregivers, or the organization. Rather, you want to focus on providing the other person the information that matters to the family,” O’Leary says. “Covering yourself can feel like the natural thing to do, but that’s not what the family is interested in. They want the information that will make them feel more confident in the care that is being provided. A defensive response can actually make them feel very doubtful about that.”

Make sure nurses do not sound too perfunctory or blasé about the incident, McNee says. They should express some concern, and speak as if they care about the patient.

“If family are hearing you make a call just because it’s on the to-do list after an incident, and you sound like you’re annoyed at even having to do it, you’re doing more harm than good at that point. You don’t want staff members saying, ‘I don’t really know what happened, but I’m just calling to let you know something happened, and now I have to get back to work,’” she explains. “That uncaring voice would be probably the worst thing at that point.”

Make sure all your media avoid these mistakes, O’Leary says. Healthcare organizations use so many methods of communication now, both digital and print, that it is easy to overlook some of these problems, she says. Risk managers should work closely with the communications department to educate them on what should not be said in official communications, like offering promises and guarantees, O’Leary says.

“It’s so important to set the proper expectations up front. We’re constantly seeing changes in case law and what kind of cases are being brought against healthcare facilities, so it is important to choose your verbiage carefully to protect yourself proactively,” she says. “This applies to all the information you’re providing to patients before and during their stay, and also all the information you’re sending their loved ones. Make sure your staff understands that what you’re saying in writing is what you’ll be held to.”

SOURCES

  • Bette McNee, RN, NHA, Clinical Risk Management Consultant, Graham Company, Philadelphia. Email: bmcnee@grahamco.com.
  • Erin O’Leary, Producer, Graham Company, Philadelphia. Email: eoleary@grahamco.com.