An apology is a statement given by one who has injured another that includes recognition of the error that has occurred, admits fault and takes responsibility, and communicates a sincere sense of regret or remorse for having caused harm [53]. At their most complete, apologies may also include promises to refrain from engaging in similar conduct in the future and compensation for the harm that has been done [47]. The messages contained in an apology can have powerful effects for both the person offering it and the recipient. In particular, apologies influence the ways in which people make judgments of responsibility—decreasing the blame that is attributed to another and decreasing the likelihood that the cause of the injury is viewed as something that is internal to and controllable by the other person [47, 51]. Similarly, apologies influence estimates of the likelihood that the injury-producing scenario will recur; the apology is interpreted as a signal that steps will be taken to avoid similar consequences in the future [16, 44, 46]. Apologies also have positive effects on expectations and intentions for a future relationship between the parties [38, 39, 44, 46], play a role in restoring trust [38, 39], reduce negative emotional reactions such as anger [16, 44, 46, 51], induce favorable physiological responses in both parties [59], and reduce antagonistic responses [16, 42, 44, 46].

Focus groups with patients have indicated similar preferences. Gallagher and colleagues [13] found patients desire and expect to be informed promptly about a medical error; to be given information about what occurred, why and how it occurred, how their health will be affected, and what steps will be taken to prevent future harm; and to receive an apology that signals a sense of regret and a desire to do better going forward. Indeed, they found “[m]any patients said they would be less upset if the physician disclosed the error honestly and compassionately and apologized…[and]…that explanations of the error that were incomplete or evasive would increase their distress” [13]. Patients also prefer that such communication occur without a need for prompting on their part [13].

Consistent with what patients say they would expect after a medical error, studies of patients who file suit find litigants are motivated to find out what happened and to prevent future injury, motivations that implicate apologies. For example, Vincent and colleagues [54] surveyed medical malpractice claimants about the reasons they filed suit. Over 90% of respondents indicated they wanted to prevent the same thing from happening to someone else, to receive an explanation for what had happened, or for the doctors to realize what they had done. Of the respondents who thought something could have been done to prevent the lawsuit, approximately 40% reported that if they had received an explanation and apology, they would not have felt the need to file suit [54]. Similarly, among the reasons that claimants interviewed by Hickson and colleagues [18] gave as motivating their lawsuits were the belief that “the courtroom was the only forum in which they could find out what happened from the physicians who provided care” (20%), the belief “that physicians had failed to be completely honest with them about what happened, allowed them to believe things that were not true, or intentionally misled them” (24%), and a desire to “deter subsequent malpractice by the physician and/or to seek revenge” (19%) [18]. Other studies have similarly found failure to provide explanations and poor communication generally are associated with litigation [1, 19, 21, 34, 35, 48].

Many physicians express the desire to apologize to patients when an error has occurred [13]. However, there is a disconnect between patients and physicians in their expectations and attitudes about the communication they will have after a medical error. In contrast to the desires and expectations of patients for disclosure and apology, there is evidence many physicians tend to provide minimal information about what happened, what led to the error, or what might be done differently in the future; to choose their words carefully so as to avoid being explicit about the error; and to believe patients who want more information will ask for it to be provided [13]. Similarly, there is evidence that providers are reluctant to make any offers of compensation for medical errors unless and until a lawsuit is filed [2, 15, 23, 43].

Despite the potential benefits of apologizing, apologies are not frequently given and there is wide variation in physicians’ tendencies to offer apologies in the wake of medical error. For example, in one survey, only one-third of both physician and nonphysician respondents who had experienced a medical error in their family reported they had received an explanation or an apology for what had happened [3]. Another survey of patients who brought suit found 40% reported not receiving an explanation; in only 13% of cases did patients report responsibility for what had happened was accepted either in part or in full and in only 15% of cases did patients report receiving an apology [54].

Similarly, in a study of error disclosure by surgeons to standardized patients, the researchers found wide variation in disclosure practices [5]. Some surgeons (57%) explicitly referred to the error as an “error” or a “mistake”; others either described the event as a “complication” or “problem” (27%) or did not indicate the outcome was preventable (16%). Many, but not all, surgeons (65%) took responsibility for the error; some independently, but others only after pressed by the patient. Fewer than half of the surgeons (47%) offered some expression of apology or regret to the patient; these expressions ranged from explicit apologies for the error to much less direct statements of regret (“I’m sorry to have to tell you this…”). Very few, only 8%, assured the patient the error would be examined with an eye toward preventing harm in the future [5].

Another study examined both medical and surgical physicians’ self-reported responses to error scenarios and found physicians reported wide variation in whether they would apologize after a medical error; almost two-thirds (61%) indicated they would express regret for the adverse outcome, one-third (33%) reported they would apologize in a way that explicitly acknowledged the error, and a few (6%) would offer no apology at all [11]. The inclination to offer an apology was even smaller when the error was one that would be less apparent to the patient. Surgical specialists were considerably less likely than medical specialists to apologize [11].

Moreover, it is not at all clear that apologies pose the litigation risk that is often feared. First, as a general matter, empirical research has demonstrated both that most injured patients do not file lawsuits [23, 43] and that physicians tend to substantially overestimate the risk of being sued [31]. Second, as noted previously, there is evidence that apologies tend to diminish blame and make injured patients less likely to sue and more willing to settle when they do. Third, although there has been little empirical examination of how apologies play out at trial [4], imagine the consequences of an apology for cases that still result in a trial: “The long painful, shameful spectacle of the plaintiff lawyer trying to prove in public that the physician is negligent, a bad person, will not take place. The court’s role will be limited to establishing just compensation. What is a jury likely to do with a physician who has been honest and also apologized? Judgments will most likely be far less costly” [33].

Nonetheless, in part because physicians and other potential defendants fear their apologies might be interpreted as evidence tending to prove legal liability, over two-thirds of the states have enacted evidentiary rules that make some apologies inadmissible in court as evidence of liability. Many of these statutes are limited in their application to cases of medical error, whereas other versions more broadly encompass all civil cases (which would include cases involving medical error). These statutes vary in the scope of their coverage. Some statutes make inadmissible statements that express sympathy for the others’ injuries while allowing the admission of statements that admit responsibility. Other statutes protect a wider range of statements, specifically making inadmissible statements that express “fault,” “error,” or “mistake” in addition to an expression of sympathy. A final category of statute protects “apologies” without further description [44, 46]. Because there has been little empirical examination of such statutes, it is not clear whether or in what ways these provisions will affect the apologizing for medical error.

Beyond the threat of litigation, then, there are a variety of barriers to disclosure and apology after medical errors. Gallagher and colleagues [14] suggest “the norms, values, and practices that constitute the culture of medicine” may play a greater role in encouraging or inhibiting disclosure and apologies than does the risk of liability. In particular, a desire for and history of self-regulation and an expectation (by self, peers, and patients) of perfection may make it difficult to apologize for errors [55].

More generally, to admit that an error has occurred and to apologize for it is embarrassing and injurious to one’s pride and requires one to come to grips with a threat to one’s self-esteem. Acknowledging an error conflicts with a striving for perfection and can result in a sense of vulnerability [26, 32]. Simply put, it is difficult to apologize. As Frenkel and Liebman [9] have noted, “Apologies have a potential for healing that is matched only by the difficulty most people have in offering them.” Indeed, physicians are reluctant to conclude that iatrogenic injury has occurred [56] and three-fourths of physicians agree that disclosing a serious medical error would be difficult to do [14].

Making a mistake that harms a patient can lead to uncomfortable feelings of cognitive dissonance; that is, it is hard to have confidence in one’s competence as a healer and to simultaneously accept that one has caused harm to another (or that the system of which one is a part has caused harm) [52]. Such feelings may be particularly difficult for physicians, because such “[d]issonance is bothersome under any circumstance, but it is most painful to people when an important element of their self-concept is threatened—typically when they do something that is inconsistent with their view of themselves” [52].

One of the central features of an apology—the feature that distinguishes it from other ways of accounting for harm done such as offering an excuse—is the acceptance of responsibility for having caused harm. Indeed, apologies that accept responsibility are more effective than similar expressions that simply express sympathy [44, 46]. Sincerely offered expressions of sympathy, however, can have many of the positive effects of apologies that accept responsibility, although not to the same degree [44, 46].

It is also the case that whether the apology is accompanied by an offer of compensation can influence its impact. The notion that appropriate compensation is relevant to apologies has been articulated by Bishop Desmond Tutu: “If you take my pen and say you are sorry, but don’t give me the pen back, nothing has happened” [2]. Adapting this notion to the medical context, Berlinger has argued, “If a physician apologizes to an injured patient, if a physician genuinely fells remorse for having injured the patient, if a physician acknowledges that the mistake was her fault, but there are no provisions for fairly compensating the patient for the cost of medical care and lost wages resulting from the injury and no provisions for helping this physician to avoid injuring other patients, nothing has happened” [2].

Two recent statements suggest a formal broadening of this receptivity. In 2006, the National Quality Forum put forward an evidence-based safe practice guideline regarding the disclosure of serious unanticipated outcomes [41]. In addition to recommending that disclosure include an explanation of what happened and the implications for the patient, a commitment to investigate, and feedback about such investigation, the guideline advises physicians to express regret to the patient when there is an adverse outcome and to apologize when there has been an error.

Similarly, the Full Disclosure Working Group of the Harvard Hospitals issued a consensus statement in 2006 that recommends caregivers “acknowledge the event, express regret, and explain what happened. If an obvious error has been made, the caregiver should admit it, take responsibility for it, apologize, and express a commitment to finding out why it occurred” [10].

For example, an apology that accepts responsibility for an error and the harm caused may be most appropriate when it is clear that an error has caused harm. This is true whether the outcome was completely or partially caused by the error and whether the error occurred at the individual or systemic level. When, however, it is clear the adverse outcome was not the result of an error, an explanation of the cause of the complication coupled with an expression of regret for the outcome and sympathy for the patient’s condition seems more appropriate.

Finally, when it is not clear what the source of the problem was, the caregiver should express regret and sympathy along with the assurance that an investigation will take place. Once that investigation has occurred, additional information should be provided to the patient along with an apology if error is discovered. Although an apology should be made relatively soon after the error occurs, an apology that is deferred until an investigation has been completed can be effective (particularly if coupled with appropriate communication along the way). Specifically, experimental studies have found apologies can be most satisfactory when the apologizer has taken the time to be able to articulate the nature of the error and its impact [8].

Of course, these distinctions may not always be completely clear. The source of an adverse outcome may be difficult to ascertain or the outcome may be multiply determined. However, in dealing with this complexity, physicians should recognize they tend to be disinclined to recognize error even when it occurs [56] and that there is a tendency to avoid directly apologizing even for clear errors [3, 5, 11], and consciously attempt to counter these tendencies. In any case, a patient who sustains an adverse outcome should be provided with full information about the nature of the complication, his or her injuries and prognosis, and any resulting necessary treatment.

A thorough empirical examination of the role of apologies in addressing medical error and other adverse events has only just begun. Although the existing studies, drawing on data from the field and from experimental studies, demonstrate the potential for apologies to facilitate dispute resolution in this context, there is still much we do not know. In particular, future research might examine physician decisions about whether and how to apologize; the effects of training about communication, disclosure, and apologies on physician apology and how such formal training interacts with the informal training physicians receive; and the effects of evidentiary rules on physician decisions to apologize.