When Something Goes Wrong

Honesty after harm is the hardest conversation in medicine. It’s also now a system-level imperative.

Every clinician I’ve ever met remembers their mistakes more vividly than their saves.
We carry them. The dose, the missed finding, the delay, the moments where, despite everything, we harmed the person we were trying to help. And in the immediate aftermath of one of those moments, every instinct in your body, and a fair amount of well-meaning institutional advice, tells you the same thing: say as little as possible.

That instinct is human. It is also, I’ve come to believe, one of the most damaging reflexes in all of healthcare, for the patient, for the clinician, and for the institution. Because what families remember after something goes wrong is almost never just the error. It’s whether anyone had the courage to be honest with them about it.

I want to talk about the conversation we are most tempted to avoid, and why avoiding it has quietly become impossible.

What I’m seeing

When harm happens, two scripts compete inside a hospital.

The first is the old one: deny and defend. Limit information. Route everything through legal. Protect the institution. It feels safe. It is, in fact, the riskiest thing we can do and I’ll show you why with the data in a moment.

The second is harder and rarer: tell the patient and family what happened, honestly and compassionately, take responsibility, and stay in the relationship. Not a scripted non-apology. Not “mistakes were made.” A real, human conversation.

What I see is that most clinicians want to have the second conversation and have no idea how. They’ve never been taught. They’re terrified of saying the wrong thing, of legal exposure, of their own shame. So they freeze, or they go cold and clinical, or they disappear and the family, who can sense evasion instantly, fills the silence with the worst possible interpretation. The thing that turns a tragedy into a lawsuit is very often not the error. It’s the wall that goes up afterward.

Why this is no longer optional

For years, error disclosure was treated as a matter of individual conscience and local culture. That era is ending.

CMS now expects structured adverse-event disclosure as part of its Patient Safety Structural Measure, meaning the ability to disclose harm honestly and well is no longer just an ethical aspiration or a bedside skill. It is becoming an organizational requirement, something hospitals are expected to demonstrate they actually do. [1]

Sit with what that means. The conversation that most clinicians were never trained for, and that most institutions instinctively suppress, is now something the system is being held accountable for. The gap between “what we’re expected to do” and “what we’ve actually trained anyone to do” has rarely been wider. And it spans the whole organization, the attending physician at the bedside, the risk manager navigating the legal and organizational dimensions, and the administrators responsible for the culture and the process. This isn’t one doctor’s hard conversation anymore. It’s a system capability.

The data that should change your mind

Here’s where the old “deny and defend” instinct collapses under its own evidence.

Communication failure is already implicated in roughly 30% of malpractice claims, cases tied, in one analysis of more than 23,000, to 1,744 deaths and $1.7 billion in cost. [2] How we handle the conversation around harm isn’t adjacent to liability. It’s central to it.

And we know what happens when institutions choose honesty instead. When the University of Michigan Health System moved from “deny and defend” to a model of open, prompt disclosure, telling patients what happened, apologizing, and where appropriate making things right, the results weren’t just ethically better. They were better on every dimension leadership cares about. Malpractice claims dropped year over year, the cost per case fell substantially, and the time to resolve claims was cut by more than half. [3]

Read that against your instincts. The approach that feels dangerous, honesty, reduced lawsuits. The approach that feels safe….silence….is the one entangled in a third of the claims. Transparency isn’t only the right thing. It’s the lower-risk thing. We’ve just been afraid of it because no one taught us how to do it well.

Why the usual fixes don’t work

When hospitals do try to address disclosure, they tend to reach for policy and paperwork, a disclosure form, a flowchart, a line in the risk-management manual.

But a policy doesn’t help the physician standing in front of a devastated family, throat tight, trying to find the first sentence. The hard part of disclosure was never the decision to disclose. It’s the execution, saying it in a way that is honest without being self-protective, compassionate without being evasive, and clear without hiding behind the passive voice. That is a communication skill, and like every communication skill in this series, it cannot be absorbed from a document. It has to be practiced.

The other trap is the script. A scripted apology is worse than no apology, families hear the lawyer in it immediately, and it confirms their fear that the institution cares more about itself than about them.

What actually works

The organizations that get this right do three things.

They train the actual conversation, not just the policy. People practice disclosure out loud, in realistic scenarios, with coaching — ideally with professional actors playing the patient and family, until they can stay present and honest under the emotional weight of the real thing.

They train the whole team, not just the physician. Because effective disclosure is a coordinated effort. When done well, it requires alignment between the attending physician, risk manager, and administrator. These are the individuals who must work together in real time, and training them together is what enables success when it matters most.

Everyone involved needs to understand not only the human side of the conversation, but also the organizational and legal dimensions that surround it. This level of preparedness is best achieved through a combination of role-play with professional actors and interactive e-learning modules, ensuring that the entire staff is equipped and ready when something goes wrong.

They build it to meet the standard. With CMS now expecting structured disclosure, the training has to be real and demonstrable, aligned with the requirements, not a one-time talk that fades. [1]

Where my team fits

This is exactly what the Mastering Medical Error Disclosure program was built for: helping clinicians, risk managers, and administrators have the honest, compassionate conversation that harm demands and helping organizations meet CMS’s disclosure expectations with skill rather than scramble. Like everything we do, it moves people past theory into practiced, confident capability through live role-play with professional actors. You can see how it’s structured here.

The conversation after harm will always be hard. But “hard” is not the same as “unteachable”, and the cost of leaving it to instinct is now measured in both human trust and institutional risk.

If you take one thing from this

After something goes wrong, the family is watching one thing above all: whether you’ll tell them the truth like a human being.

Honesty after harm isn’t a legal liability to be managed. It’s a skill to be trained and the evidence says it’s the safest path there is.

Next in the series: the conversations behind the curtain, the conflict, feedback, and staff dynamics that shape the patient experience long before anyone reaches the bedside.

Dr. Anthony Orsini is a practicing neonatologist and the founder of The Orsini Way. More on the team’s work and research at theorsiniway.com.

Sources

[1] CMS Patient Safety Structural Measure / structured adverse-event disclosure expectations; The Orsini Way program launch. https://theorsiniway.com/mastering-medical-error-disclosures/

[2] CRICO Strategies / Harvard Risk Management Foundation; AJMC summary (communication in ~30% of malpractice claims; 23,000+ cases; 1,744 deaths; $1.7B). https://www.ajmc.com/view/30-of-malpractice-complaints-involved-communication-failure

[3] University of Michigan Health System open-disclosure (”CANDOR” / communication-and-resolution) outcomes: reduced claims, lower cost per case, faster resolution. https://www.patientsafetysolutions.com/docs/June_2016_Disclosure_and_Apology_The_CANDOR_Toolkit.htm