How to disclose a missed diagnosis to a patient?

How to Disclose a Missed Diagnosis to a Patient

Disclose the missed diagnosis promptly in a private setting using clear, direct language that acknowledges the error, takes responsibility, expresses genuine regret, and outlines specific next steps for the patient's care and institutional prevention measures. 1, 2

Preparation and Setting

• Ensure the timing and setting are as appropriate and private as possible, avoiding rushed or public environments. 1
• Have both the patient and their support person/family member present when appropriate, as this provides emotional support and ensures accurate information transmission. 1, 3
• Plan this as the first of multiple conversations, recognizing that disclosure is a process, not a single event. 1, 3

The Disclosure Conversation Structure

Opening: Assess Understanding First

• Begin by asking the patient what they currently understand about their condition and care to establish a baseline. 1
• This allows you to tailor your explanation to their level of knowledge and identify any existing misconceptions. 1

Deliver the Information Clearly

• Give the information clearly and succinctly in plain, nontechnical language (e.g., "When we initially evaluated you, we missed the diagnosis of your appendicitis"). 1
• Provide transparent facts about what happened, who was involved, why the error occurred, and what the consequences are for the patient. 2, 4
• Express solidarity with statements like "I wish I had better news" or "I am deeply sorry this happened." 1
• Take responsibility explicitly—avoid minimizing language or deflecting blame to systems alone, as patients need to see individual accountability. 2, 5

Pause and Respond to Emotion

• Pause after delivering the information for the patient to absorb what has been said (supportive silence). 1
• Wait for the patient to respond before saying anything more; if they remain silent, ask "What's going through your mind?" 1
• Respond empathically to patient emotion using reflective statements that acknowledge their feelings (e.g., "I can see this is overwhelming"). 1
• Avoid trying to reduce patient distress by minimizing the error or changing the subject—this undermines trust. 1

Provide Information in Manageable Chunks

• Titrate the amount of information to the patient's emotional state—do not overwhelm them with excessive detail when they are in acute distress. 1
• Provide information in small discrete units and check regularly for understanding by asking them to explain back what they heard. 1
• Use multiple formats (verbal explanation, written summary, diagrams if relevant). 1

Essential Components of the Disclosure

Express Appropriate Moral Emotions

• Express genuine regret, remorse, and when appropriate, apologize—these moral emotions demonstrate that you are taking the mistake seriously and help patients move forward. 2, 5
• Acknowledge that the symptoms are real and the harm is significant; take the problem seriously. 1

Explain Next Steps for the Patient

• Discuss the meaning of the findings and specific next steps before ending the conversation, including what diagnostic tests or treatments are now needed. 1
• Clarify the goals of any new treatment (cure vs. prolongation of survival vs. improved quality of life) so the patient understands likely outcomes. 1
• Provide a clear follow-up plan with specific timeframes for reassessment. 6

Explain Prevention Measures

• Describe what will be done to prevent this error from happening to other patients in the future—this demonstrates institutional accountability and commitment to improvement. 2, 4
• This may include quality improvement projects, changes in protocols, or additional training. 4

Affirm Ongoing Commitment

• Affirm your commitment to supporting the patient with statements like "It's my job to help you get the best care possible" or "I'll continue to take care of you whatever happens." 1
• Emphasize nonabandonment—reassure them you will remain involved in their care. 1
• Help the patient identify additional sources of support (family, friends, support groups, social worker, patient advocate). 1

Encourage Questions and Create Space

• Encourage patients to ask questions by saying "What questions do you have?" rather than "Do you have any questions?" 1
• Use silence strategically to create space for patients to express their concerns. 1
• Schedule a follow-up appointment soon to address emerging questions and provide continued emotional support. 3

Provide Written Documentation

• Provide written summaries of what was discussed, including the nature of the error, the current diagnosis, and the treatment plan. 3
• Include contact information for follow-up questions and resources. 3

Common Pitfalls to Avoid

• Do not delay disclosure due to fear of litigation, shame, or concern about reputation—poor communication and lack of transparency are the primary drivers of lawsuits, not the error itself. 2, 4
• Do not minimize the error or use defensive language that shifts blame entirely to systems—patients need individual accountability. 1, 5
• Do not provide excessive technical detail during the initial disclosure when the patient is emotionally overwhelmed. 1
• Do not abandon the patient after disclosure—maintain continuity of care and schedule close follow-up. 1
• Do not have this conversation in a rushed or public setting where privacy cannot be maintained. 1

The Therapeutic Value of Honest Disclosure

• Honest, transparent communication about errors demonstrates respect, compassion, and commitment while maintaining trust through ongoing dialogue. 2
• The explanation itself may have therapeutic value by reducing uncertainty and allowing the patient to understand what happened. 1
• Research shows that proper error disclosure, while difficult, does not typically cause lasting psychological harm when done compassionately with adequate support. 3