Idaho Hospital Transparent, Apologetic After Child’s Death Due To Medication Errors

STLAccording to media reports, seven-month old August Dean Elliott died at St. Luke’s Magic Valley Medical Center due to a medication error.  The hospital held a press conference about the death, is investigating the event with the family and their attorney, and has apologized.  It looks like the hospital is handling the situation in an empathetic and intelligent manner.

Though this a tragic situation, it is good to see the hospital acting in this manner….in the not-so-recent past this behavior would have been unthinkable for a hospital.  The trick now is how to do we get every event (big or small, apparent or not-so-apparent) in every healthcare and insurance organization to be handled in this manner every time.  That day will come when every hospital and insurer has a disclosure program.

At Sorry Works! we are committed to helping organizations develop and sustain successful disclosure programs.  We recently launched the Sorry Works! Tool Kit to show organizations how to make disclosure work on a consistent and ethical basis  by developing successful and sustainable disclosure programs.  We are holding a November 12th webinar to teach from our new Tool Kit, and every participant will receive a copy of the Tool Kit.  To register for the November 12th webinar, click on this link.

Click on this link and this link to see media reports about the death of August Dean Elliott.

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Disclosure Documentary: Informed Consent Trailer & Pricing

dan hallThe Disclosure Documentary produced by Newport Classic Films and Dr. Steve Kraman and marketed through Sorry Works! is generating A LOT of interest. It’s a terrific movie that really gets people thinking about all of the issues surrounding medical errors and disclosure. And at 47 minutes in length, the documentary is perfect for Grand Rounds and other staff meetings.

Many experts from around the country provided interviews for the movie, including Dr. Dan Hall from the University of Pittsburgh Medical Center. A surgeon and ordained priest in the Episcopal Church, Dr. Hall offered an in-depth interview on informed consent. To see the trailer from Dr. Hall’s interview click here. To see Dr. Hall’s biography, click here.

INFORMATION ON PRICING FOR MOVIE: We are charging $500 for the movie for one hospital, practice, or nursing home. Organizations with multiple facilities (a chain of hospital or nursing homes, for example) or an insurer or association with many members should call 618-559-8168 or e-mail for a quote. To order the documentary, click on this link.

To see a trailer for the movie, click on this link.

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Sorry Works! Webinar: Starting and Sustaining Your Disclosure Program – Nov 12th, 1pm ET

We all want clinicians to say “sorry” after something goes wrong, and most of us know that webinar“running to the problem” is the best approach ethically and economically. But how do you actually start a disclosure program so that every adverse event is handled in an ethical and expedited fashion? And how do you sustain your disclosure program….how do you keep it from becoming the flavor of the month?

Sorry Works! recently released the Sorry Works! Tool Kit to teach healthcare organizations how to start and sustain a successful disclosure program. Sorry Works! Founder Doug Wojcieszak will be teaching from the Tool Kit in this exciting and interactive webinar. Wojcieszak will walk you through how to build your disclosure program including the development of your disclosure policy, how to teach disclosure to your front-line staff as well as claims, legal, etc, and then discuss cases and answer your questions. The registration fee includes a copy of the Sorry Works! Tool Kit.

When? Thursday, November 12th at 1pm ET/10am PT

Who Should Attend?

  • Risk managers
  • Claims managers
  • General counsel and defense lawyers
  • C-suite personnel
  • Chief Medical Officers
  • Physicians, nurses, and other front-line staff

To Register, Click on this Link.

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Hospital Admits Failings, Apologizes for Baby’s Death

ROBelow is an article that recently appeared in a British newspaper. The story pretty much speaks for itself. A baby died unexpectedly, the hospital’s review shows errors and mistakes, and then the hospital admitted their failings and apologized. The hospital appears to be extremely candid in their remarks — very powerful example of transparency.

Now, this event happened in a NHS hospital and, according to the news report, the family is pursuing a civil action against the hospital’s trust. Obviously, British healthcare is a little different than American healthcare…not sure how the British handle claims. If this event had happened in an American hospital, the hospital or their insurer could negotiate and settle with the family without going through civil litigation. After all, if you’ve determined fault and apologized, what is the point of a lawsuit? Just have some conversations, figure out what people need (financially and emotionally), and come to a reasonable agreement without the fighting. Perhaps the British can learn from how we are starting to handle claims with disclosure.

Hospital bosses admit that baby died after ‘failings in care’ at Royal Oldham Hospital

By Beth Abbit, Greater Manchester News, September 23, 2015

Baby Spencer Butler may have survived if doctors had carried out a Cesarian section at an earlier stage, an inquest has heard.

Medical and midwifery neglect was a ‘major factor’ in the death of a newborn baby who was delivered tragically late, an inquest has heard.

Baby Spencer Butler may have survived if doctors at Royal Oldham Hospital had carried out a Caesarian section at an earlier stage, coroner Lisa Hashmi said.

She found a causal link between errors and omissions made and the ‘unprecedented level of activity’ on the maternity unit when Natasha Butler was in labour.

Pennine Acute Hospitals NHS Trust has since revised its Induction of Labour Guidelines and apologised to the family for the failings in care.

Heywood Coroners’ Court heard there was a ‘gross failure’ in care and a ‘catalogue of errors’ and missed opportunities had contributed to Spencer’s death.

She said leadership on the unit was ‘almost nonexistent’ and added: “Apathy prevailed when it came to practical thinking.”

Mrs Butler was admitted to the maternity unit on May 14 for induction of labour and was induced four times over three days. When her baby became unwell she was transferred to the labour ward for an emergency Caesarean.

Spencer died of acute intrauterine asphyxia just 33 minutes after his birth on May 17, 2014.

Speaking after the inquest, Mrs Butler and husband Sean, from Oldham, said: “To come home without Spencer was heartbreaking and the hardest thing is knowing that his death could have been avoided. There was nothing wrong with him, he was a healthy baby and there isn’t a day goes by that we don’t get upset about that and wish he was still here.

“Nothing will ever bring Spencer back and we can’t help but be angry about everything the hospital has put us through.

“We put our precious baby in the hands of the professionals, but looking back we don’t feel that he ever stood a chance.”

Pennine Acute Hospitals NHS Trust said an external review into a small number of maternity cases at the trust’s hospitals was commissioned last year and the findings shared with the family.

Chief nurse Gill Harris said: “This is a terribly tragic case. Without question The Pennine Acute Hospitals NHS Trust let down Spencer and his parents, Natasha and Sean Butler, in aspects of the care provided. For this, we are truly sorry.

“We have apologised to Natasha and Sean for the failings in the care afforded to them and we wish to reiterate that apology today. Our staff will continue to support the family at this difficult time.

“It is important we ensure that we learn from their experiences and use this feedback and learning to help us achieve the highest standards of maternity care. As part of our maternity improvement plan across our two maternity units, we have learnt significant lessons from the detailed internal investigation we carried out.”

Following Spencer’s death his family has raised more than £5,000 in his name for the Make A Wish Foundation.

Jenny Urwin, a clinical negligence specialist at law firm Slater and Gordon, is representing the family in a civil action against Pennine Acute Hospitals NHS Trust.

She said: “The facts of this case are truly harrowing. The Trust failed in its duty and an otherwise healthy baby’s life was lost.

“This family is devastated, but determined that lessons are learned so that no one else suffers the same tragedy.”

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Burned Vagina, Apology, and 50 Bucks?

Fifty dollarsAccording to recent media reports, a routine smear test for a New Zealand woman went horribly wrong after the pharmacy apparently failed to dilute the acetic acid, causing painful burns that took months to heal. The resolution: An apology and $50 bucks. The pharmacy is also apparently investigating what went wrong so it won’t happen again, but, this appears to be a prime example of a hollow apology. The victim feels insulted. Links for media reports are below.

I am not writing this column to shame the pharmacy. The media reports have already accomplished that task. My reason for this essay is to send a message to risk, claims, insurance, and legal professionals who work on these cases.   The compensation piece is still a struggle for disclosure cases.  Folks are OK saying sorry, but not OK paying money, or a fair amount of money.  Yes, this is an extreme example but it’s a great lesson too: For an apology to be real, it needs to meet the financial and emotional needs of the patient or family. Saying “sorry” is usually not enough. Words alone don’t make the apology real for the victim…you need to do something! Moreover, for resolution to be truly complete, the emotional needs of the caregivers must be addressed too; I’m sure the pharmacy technician who failed to dilute the acid must feel horrible.

A great way to begin making an apology “real” is with a simple question: “How do we make this situation right by you? We are very sorry for our mistake. What do we need to do to meet your needs?” Then, shut up and listen. Let the patient talk, share their feelings, and what they might need. This is an honest and disarming question. Most victims are girding for a fight, so, when an organization makes this approach it literally lets the air (and anger) out of the room. In fact, most victims will have no idea how to respond…so you will have to be ready to offer suggestions, but make it fair! Just assume any settlement offer will be end up on social media or in traditional media, like this vagina story. Don’t be offering 50 bucks for something you know to be worth much, much more.

As to this case, a fair resolution would have paid all medical bills, missed work (or used vacation/sick days), any other bills or financial burden experienced by the family because of the mistake, and provided reasonable consideration for pain & suffering. Moreover, the pharmacy would have shown the woman how their procedures have been fixed so the mistake will never happen again. And, finally, the apology would have been given in person by the pharmacy director and — if possible — the technician and staff involved in the mistake.

Hey, to help you design and develop a disclosure program that covers all the bases including fair compensation after a legitimate medical error, be sure to join Sorry Works! on Thursday, November 12th at 1pm ET/10am PT for a webinar on developing your disclosure program. Sorry Works! Founder Doug Wojcieszak will be teaching from the new Sorry Works! Tool Kit…and all attendees will receive a copy of the Tool Kit. Click here to register.

Links for media reports on the burned vagina story can be found here and here.

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See the Trailer for Disclosure Documentary

flyerWe proudly announced on Tuesday that Sorry Works! is promoting the Disclosure Documentary produced by Lawrence and Steve Kraman. A lot of buzz was created with the launch of our relationship, and we want to keep the momentum going.

Click on this link to see a trailer of the documentary.  The film provides an in-depth look at disclosure from every angle — including skeptics — and will get your  people thinking about this important issue.  This is a must see for everyone.

After viewing the trailer, you will want to see the entire film. To purchase the documentary, please call Sorry Works! at 618-559-8168 or e-mail

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Disclosure Documentary to be Promoted Through Sorry Works!

Steve Kraman, Newport Classic Films, and Sorry Works! Join Forces to Market Disclosure Documentary

Public Showings to be Planned Across the Country


SEPTEMBER 22, 2015


Dr. Steve Kraman, who is credited with starting the disclosure movement with his flyergroundbreaking work at the Lexington, Kentucky VA Hospital, and his brother, film director Lawrence Kraman, recently developed and produced a comprehensive documentary that explores the disclosure movement from all angles. Eighteen months in the making,“Full Disclosure: The Search for Medical Error Transparency” includes the voices of leading physicians, healthcare and insurance executives, and attorneys as well as skeptics and detractors. This balanced, well-developed documentary provides all stakeholders in the med-mal debate with a comprehensive and compelling view of the potential for disclosure in acute and long-term healthcare settings. A link for the trailer from the movie is below.

Now the Kraman brothers are partnering with Sorry Works! to market and distribute their documentary.

“As a filmmaker, I know the best films you can do are about subjects with which you are familiar. My own brother, Dr. Steve Kraman, had established and publicly reported the results of the first medical error disclosure program in a major hospital – an extraordinary achievement. Steve’s story and the story of the disclosure movement that followed needed to be told in a compelling manner,” said Newport Classic Films’ Lawrence Kraman. “Upon the film’s completion Steve and I were searching for an existing organization that we could partner with to market and distribute the film and sponsor public screenings. While we did have discussions with larger organizations we eventually realized that working with Sorry Works! would be a better fit for us. Doug has put together an organization that is compact, responsive, and is widely recognized by healthcare, insurance, and legal organizations around the United States. We are excited about the potential of this partnership.”

The “Full Disclosure” film is available as both a 47-minute “Grand Rounds” length video, and a longer 90-minute theatrical version. The movie will be available for purchase through Sorry Works! and the Sorry Works! website ( There will also be many hours of edited “raw” footage shot during the filming of the documentary that will be made available through Sorry Works! To promote the films and raw footage, the Kraman/Sorry Works! partnership will be hosting public showings of the movie in select cities in the United States over the following year, with the first public showing to be scheduled soon. If your organization is interested in hosting a viewing of the film, please contact Sorry Works! at 618-559-8168 or

“The goal of the partnership with Sorry Works! is to distribute this movie far and wide….we want as many people as possible to view it. Not only do we want healthcare professionals and healthcare students to see the movie, but also consumers and legislators. We anticipate having diverse crowds at the public showings, from hospital CEOs and med-mal defense attorneys to consumer advocates and plaintiff’s attorneys. We know there will be some frank discussions among these audiences, and hope this will lead to a grass-roots movement for disclosure with more hospitals and nursing homes adopting disclosure practices,” said Dr. Steve Kraman.

Doug Wojcieszak, Sorry Works! Founder, is excited about the new partnership with the Kraman brothers.

Sorry Works! is thrilled to be partnering with Steve and Lawrence. This documentary is such a unique and important product….there is nothing like it out there. This film is not simply an endorsement for disclosure at all costs but instead is a balanced look at this important issue that will make all stakeholders in the med-mal debate think and work to understand what disclosure means for them and their organizations,” said Doug Wojcieszak, Sorry Works! Founder.

“The movie gets people talking about disclosure, and we want everyone to see it, concluded Wojcieszak.

To learn more about the documentary, including a trailer, visit this link.

For information on ordering the documentary, please contact Sorry Works! at 618-559-8168 or e-mail







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Announcing Release of 2nd Edition of Little Book of Empathy….

Booklet2ndEdition_webOver the last three years we have literally sold thousands of copies of the Little Book of Empathy. Hospitals, insurers, long-term care organizations, associations, etc have purchased this inexpensive and practical booklet which is perfect for front-line staff, managers, directors, and c-suite. The booklet covers everything you need to know about staying connected with patients, residents, and families post-event without prematurely admitting fault. It’s a quick read for even the busiest doctor or nurse, yet priced right for any budget.

Well, we are proud to announce the release of the 2nd Edition of the Little Book of Empathy. This new version includes expanded and up-to-date information on post-event communication strategies. There are also new chapters covering 2nd victims of medical errors and starting a disclosure program. Finally, the 2nd Edition provides several cases to practice and study. Lots of new information, but we have kept the price the same low price. Click here for ordering information.

Bulk pricing is available for larger orders, and we can also customize the booklet for your organization with your logo on the cover, welcome message from CEO, contact phone numbers, etc. For more information on bulk prices or customizing, please call 618-559-8168 or e-mail

To order your copies of the 2nd Edition of the Little Book of Empathy, please click on this link.

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Injecting Humanity into the Claims Process – share with claims, legal, and insurers

EinsteinIn the disclosure movement, we spend a lot of time teaching docs and nurses how to say “sorry” after something goes wrong, and how to get c-suite, risk, and legal to be pro-active post-event and meet the emotional and financial needs of patients, residents, families, and clinicians. There is a lot to think about and do. Lots of logistics. Ultimately, however, what we are trying to do is inject humanity into the claims process.

Inject humanity into the claims process?

Yes…because for so long humanity along with emotions, feelings, etc have literally been stripped out of the med-mal claims process. Humanity and the emotional needs of consumers and clinicians have been pushed out of the way by an overriding concern with money. Both sides (defense and plaintiffs) stress over the bucks. For claims and defense, the fixation on money is why clinicians have historically been silenced post-event, and relationships with patients and families terminated. Hospitals and insurers have always tried to portray a tough image. Some plaintiff’s attorneys have confided that many zeros on a check can be a hollow victory for a family when the doctor/hospital refuses to apologize, provide details of the errors, and discuss how mistakes will be prevented in the future. Moreover, the 2nd victim movement is now a hot topic as clinicians are sharing stories of PTSD, ruined careers, divorce, and even suicide because emotional support (not legal support!) is lacking post-event. Humanity is in short supply.

Look, we can finger point all day about who pushed humanity out the door by fixating on money, and get nowhere. At Sorry Works! we’ve always believed that the fix to med-mal begins (and mostly ends) with the medical community and the risk, claims, and legal professionals who support clinicians post-event. These folks are – for lack of a better term – organized in units we call hospitals, medical practices, or insurers. Dealing with plaintiff’s attorneys and consumers is literally like trying to herd cats. So, working with hospitals and insurers is the key, yet there are still too many claims professionals and defense lawyers who have the “old-style” insurance mentality. Victory for these folks is how many dollars (or pennies) they can save the company. By fighting over money, they ignore humanity or just strip it out of the claims process altogether. In other words, they’re mean. Too often claims folks and defense lawyers are seen as “jerks” and “witches” by consumers, plaintiff’s counsel, and even doctors and nurses. Nobody likes jerks and witches. Anger increases and along with it the chances of protracted litigation and the associated expenses. Settlement figures typically go up because if all we are going to fight about is money, angry consumers will fight for every penny too! They want revenge. Learning from mistakes is negated, while clinicians suffer in silence. Opportunities to provide real closure for all sides in a med-mal case are lost.

Take the humanity out of the process and expenses go up, not down. Sure, you might get out of a few cases on the cheap, but, your overall expenses are higher when humanity is absent.

There is a reason that disclosure hospitals report lower overall expenses even though they typically have a higher number of claims (versus non-disclosure hospitals): They have injected humanity in the claims process. For a disclosure hospital or insurer, claims is not just about the bucks. It is a chance to address the emotional needs of consumers as well as clinicians, which often decreases anger and the desire for revenge. Doesn’t mean we aren’t going to meet our financial obligations, it’s just a much different conversation. The temperature is lower, anger diminished along with the desire for revenge, and the parties can have an adult conversation about what everyone truly needs. Opportunities for real closure are welcomed.

We honor our humanness by admitting mistakes and learning from them, which leads to fewer mistakes in the future…. and even more savings! We save more money by rescuing our clinicians (who represent a huge financial investment) from PTSD, ruined careers, divorce, and suicides. Even more savings are reaped by the good PR associated with disclosure. In summary, by injecting humanity in the claims process saves lots of money.

Again, please share this column with claims professionals, defense lawyers, and insurance professionals. Injecting humanity back in the claims process is all about seeing the bigger picture.


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Excerpt from Sorry Works! Tool Kit: Identifying Colleagues?

confused docIn the new Sorry Works! Tool Kit, we provide a comprehensive review of the most commonly asked questions and challenges you will receive when starting and sustaining a disclosure program. The Q&A section is extremely valuable for c-suite, risk, attorneys, disclosure team leaders, physicians and nursing leaders, etc. Below is one of the questions asked and answered in the Tool Kit — to see the rest be sure to order the new Sorry Works! Tool Kit today.

Situation: You may have had the following demands hurdled at you by angry family members:

“What were the names of the doctors and nurses involved in my son’s surgery?”

“What was the name of that doctor who visited me yesterday afternoon? You know, the tall one with the accent?”

What was the names of those two nurses last night? You know, the two idiots who could never answer my call button. I think they were goofing off all the time…”

The knee jerk reaction may be to withhold names, however, family members will get this information anyway through discovery. So, why prolong the inevitable and in so doing make family members even angrier and more suspicious? Moreover, sharing the names of people involved in an event or situation does NOT mean we are assigning blame or implying they are bad clinicians. Again, no speculating, editorializing, or jousting, even if you have a hunch a mistake did happen. Simply stick with what you know:

“Yes, the tall physician with the accent is Dr. Smith.”

“The nurses who cared for you last night were Ms. Jacobs and Mr. Jones. I am sorry you were frustrated. I suggest you speak with Jacobs and Jones this evening, and/or speak with the nursing manager.”

Now, some long-term care professionals have expressed concern about providing last names due to safety concerns (they don’t want an angry family member showing up at a colleague’s house). This is a valid concern, but you can certainly provide a first name — John, Mary, Sue, etc — and direct the family member to administration.

In disclosure we always say staying connected post-event is the best thing for patients, families, and caregivers. Sometimes, this means providing a name.

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