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Special Communication  |   May 2012
Efficacy of a Physician's Words of Empathy: An Overview of State Apology Laws
Author Notes
  • From the Department of Legal Studies at Temple University in Philadelphia, Pennsylvania 
  •    This article is based on the following previously published articles by Ms Saitta and Mr Hodge: Saitta NM, Hodge SD. Is it unrealistic to expect a doctor to apologize for an unforeseen medical complication?—a primer on apologies laws. Pennsylvania Bar Association Quarterly. July 2011:93-110 and Saitta N, Hodge SD. Physician apologies. Practical Lawyer. Fall 2011:35-43.
     
  • Address correspondence to Samuel D. Hodge, Jr, JD, Chair, Department of Legal Studies, 464 Alter Hall, 1801 Liacouras Walk (006-03), Philadelphia, PA 19122-6083. E-mail: temple885@aol.com  
  •    Editor's Note: The authors are not providing legal advice concerning apology laws and recommend that physicians carefully scrutinize the laws of any particular jurisdiction and consult with an attorney from that state to see which statements are and are not covered.
     
Article Information
Professional Issues
Special Communication   |   May 2012
Efficacy of a Physician's Words of Empathy: An Overview of State Apology Laws
The Journal of the American Osteopathic Association, May 2012, Vol. 112, 302-306. doi:10.7556/jaoa.2012.112.5.302
The Journal of the American Osteopathic Association, May 2012, Vol. 112, 302-306. doi:10.7556/jaoa.2012.112.5.302
Abstract

Apology laws are gaining traction in the United States, prompting health care professionals to offer words of condolence for adverse medical outcomes without the fear of being sued for malpractice. Although these laws vary by jurisdiction, they have been shown to reduce the financial consequences of a medical malpractice lawsuit. The authors provide an overview of the laws regarding this issue and discuss apologies as a means to reduce medical malpractice claims.

Despite your best efforts, a patient dies after an unexpected medical complication. You wish to apologize to the patient's family members for their tragic loss, but you say nothing, sensing that your words could be misconstrued as an admission of fault. What should a physician do when torn between empathetic sensibilities and the innate need for self-preservation? Welcome to the practice of medicine in the 21st century. 
Children are taught to say “I'm sorry” when they cause harm to one another. An apology is a fairly routine expression and is valuable because of its ability to diffuse a difficult situation. Similarly, individuals are encouraged to “own up” to mistakes and accept responsibility for their actions.1 This dynamic is equally applicable in the medical arena. A physician who is emotionally invested in a patient often feels compelled to express condolences after a poor medical outcome. In addition, a physician's integrity and honesty serve as compelling reasons for apologizing. Lawyers, however, usually advise health care professionals to remain silent in these situations because of the potential adverse consequences in offering condolences, such as a malpractice lawsuit.2 This dichotomy places the physician in a moral dilemma—wanting to soothe the feelings of the patient or family while simultaneously wishing to avoid having an apology used against him or her in court. A number of states have passed apology laws that prohibit the use of a physician's apology as an admission of fault in court. With these laws, an apology now has the ability to mitigate the results of an unanticipated or poor medical outcome.1,2 
Medical Community's Stance on Apologies
The value of honest communication, including apologies, is nothing new in the medical community; in fact, a number of medical organizations have stressed the importance of honesty between patient and physician. The American Osteopathic Association's Code of Ethics, section 2, states, “The physician shall give a candid account of the patient's condition to the patient or to those responsible for the patient's care.”3 Similarly, the American Medical Association's Code of Medical Ethics provides, “It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. … Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient.”4 This code suggests that “in the wake of a medical error, patients have a right to know what happened.”5 The American College of Physicians espouses a similar position, and the National Patient Safety Foundation's Board of Directors approved a statement of principle with regard to explanations of errors.4 Even the Joint Commission requires institutions to have a process in place to inform patients and their families of unanticipated medical outcomes.2,5 
Benefits of an Apology
Psychological, emotional, and financial benefits clearly flow between the parties to an apology.2 Monetarily, an apology decreases the financial consequences that result from litigating a medical malpractice claim. For instance, 1 study6 determined that an apology gave the patient a sense of satisfaction and closure, which led to faster settlements and less demand for damages. In addition, the study found that accepting responsibility was more effective than expressing sympathy.6 When apologies contain admissions of fault, individuals report that they have a greater respect for their counterparts, which reduces the amount of money demanded and increases the willingness to settle.6 
Some hospitals in Pennsylvania7 and Kentucky8 have found that effective apology and disclosure programs reduce malpractice payments.1 In addition, the University of Michigan Health System reported faster settlement times and decreased payments by 47% per case with the advent of its apology and disclosure agreement.9 In fact, Cornell University and the University of Houston analyzed health care facilities in those states that have adopted apology laws and found that statements of regret facilitated faster settlement times and a decrease in malpractice claims.10 In essence, this study shows that apology laws work by reducing monetary damages for cases that go to court as well as lowering settlements and costs for those physicians who apologize.10 
The correlation between apologies and lower payouts in malpractice cases was confirmed by a 6-year study at the Lexington Veterans Affairs Medical Center in Kentucky.8 Steve Kraman, MD, manager of this program, found that if a bad outcome was followed by the appropriate reaction by the health care provider, such as disclosure of the facts, apology, and remuneration, the media reports focused on the reaction rather than the bad behaviors.11 This study also showed that the medical center, after implementing an apology program, paid less per claim than those hospitals without apology policies.11 However, Wei12 criticizes these findings, stating that there are major differences to be considered when comparing Veterans Affairs hospitals to nongovernment hospitals. 
Despite this criticism, several other health care facilities and insurance providers have implemented apology and disclosure programs. In the past 5 years, “Catholic Healthcare West persuaded several insurance companies covering their independent contractor physicians to participate in successful full-disclosure programs.”13 
One of the better known programs, the Early Resolution Program at the COPIC Insurance Company, a liability insurer directed by physicians in Colorado, has reported success since the implementation of its program known as “Recognize, Respond and Resolve.”14 The program is “‘no fault’ in that it does not tie compensation to evidence of fault on the provider's part.”14 After implementing this measure, the company paid substantially less for claims that it closed, both those that closed with indemnity payment and those that closed without indemnity payment.14 With data and studies that prove the efficacy of an apology policy, it is not surprising that the implementation of such programs has gained traction. In fact, the founder of the Sorry Works! Coalition, Douglas Wojcieszak, estimates that between 5% and 10% of hospitals have now adopted apology programs.1,11 
Aside from the purported positive financial consequences of an apology, this expression carries emotional and psychological benefits for all parties. An apology is “an important ritual, a way of showing respect and empathy for the wronged person.”15 An apology can undo the negative effects of an action and defuse an individual's anger, even if it cannot undo the harmful action itself.15 And, because an individual no longer perceives the offender as a personal threat, emotional healing occurs.15 Apologizing also helps rid an individual of guilt or self-reproach while simultaneously reducing arrogance and promoting self-respect.15 
Research shows that malpractice lawsuits often stem from anger,10 and “numerous case studies suggest that anger is a main motivator for litigation and can overcome the patient's aversion to the legal arena.” On the other hand, apologies by physicians reduce a patient's anger, encourage communication, and thus reduce the need to file a lawsuit.10 Therefore, it is not surprising that honest and open disclosures with patients may decrease the filing of a lawsuit. In fact, juries have been shown to be favorably impressed with these types of caring gestures.1,16 
In 2001 and 2002, trial consulting firm DecisionQuest conducted a mock trial in which a group of potential jurors was not told about a physician's expressions of sympathy or disclosure of an adverse medical outcome while a different group of jurors was informed that the physician disclosed the medical error.1 The unpublished research found that, although both juries found the physician liable for malpractice, the damages awarded by the jurors who were told that the physician had disclosed the problem were lower than those awarded by the uninformed jurors. The mock juries based their decisions on the physician's honesty, which made it appear that the physician had “done the right thing,” while the nondisclosure physician was perceived as participating in a cover-up. Furthermore, the second group disregarded the subjective element of an apology that does not necessarily indicate a breach of the appropriate standard of care. This group of jurors who were not told of the disclosure was motivated by wanting vindication for the patient, so it did not determine a causal link between monetary recovery and the true circumstances of the adverse medical outcome. 
Factors Encouraging Silence
Why would a physician remain silent when research clearly shows that an honest and sympathetic discussion with the patient about a mistake or adverse outcome has numerous advantages?2 Quite simply, the physician may not be aware of the error because other causes for the patient's adverse outcome may be suspected, such as an inevitable consequence of a disease process.16 Also, physicians may not be comfortable with delivering bad news because of a lack of training in this area.16 In addition, some physicians may avoid a disclosure and apology because they believe that such statements import fault even when the physician has done nothing wrong.9 
In this regard, a study by the University of Michigan Health System found that barriers to disclosure include a “deny and defend” strategy by physicians as well as legal and cultural barriers.9 Physicians naturally worry that, by admitting fallibility, they will undermine the trust patients have in them, especially in the changing environment of medical services.12 A mask of infallibility has been placed over the medical world, and this perception is perpetuated by both physicians and patients.12 Thus, considering the high pedestal upon which physicians are placed, one can understand a physician's desire to avoid admittance of fallibility so as not to disappoint the patient.2 
Some physicians are also afraid of the legal ramifications that may result from innocent and honest disclosure that is taken as an admission of a breach of the appropriate standard of care.2 This fear was confirmed by a 2000 survey in which almost half of the physicians questioned expressed concern over being named in a lawsuit in the near future.17 Nevertheless, more current research suggests that physicians generally endorse disclosure of harmful mistakes to patients.18 These findings are often at odds with the advice of lawyers, insurers, and hospital executives who may serve as a barrier to an apology, for “hospital executives want ‘to do the right thing' but their lawyers or insurers are resisting.”19 
The legal considerations of a physician's actions have not always been at the forefront of a physician's mind while treating a patient, but the litigious nature of today's society has changed this dynamic. What has happened to force physicians into a role of practicing defensive medicine? As society has industrialized, a different relationship between physician and patient has emerged, one that does not freely promote the frank communication that exists between neighbors.1 
Studies20-22 also indicate that nonpecuniary motivations to the filing of medical malpractice suits include wanting to prevent a recurrence of a similar situation to someone else, wanting a proper explanation or apology, wishing to be returned to the status quo, and wanting sanctions for duress.23 While most patients who file lawsuits want to make sure the mistake does not happen to someone else, they also want an explanation and an admission of negligence12; they ultimately want a feeling that justice has been served.2 
Overview of Apology Laws
In response to the malpractice crisis and the proven benefits of a physician's apology, a majority of states have enacted laws to encourage expressions of sympathy without the statement of condolence being misconstrued as an admission of liability.1,2 For the full list of state statutes and URLs to each state's apology law, see the Table. Massachusetts was the first state to enact an apology law, in 19864; 34 other states along with the District of Columbia have enacted laws that prohibit a physician's apology as admissible evidence in a legal proceeding. Most apology laws apply to statements and gestures of benevolence made to either a patient or that patient's family in the wake of an unanticipated outcome.24 Although some states do not have apology laws in place, others, including Pennsylvania, currently have legislation pending.1 
Table.
Apology Laws by State1,2
State Code Web Site
Arizona Ariz Rev Stat §12-2605 http://www.azleg.gov/ars/12/02605.htm
California Cal Evid Code §1160 http://www.leginfo.ca.gov/cgi-bin/displaycode?section=evid&group=01001-02000&file=1150-1160
Colorado Colo Rev Stat Ann §13-25-135 http://www.state.co.us/gov_dir/leg_dir/olls/sl2003a/sl_126.htm
Connecticut Conn Gen Stat Ann §52-184d http://www.cga.ct.gov/2011/pub/chap899.htm#Sec52-184d.htm
Delaware Del Code Ann tit 10. §4318 http://delcode.delaware.gov/title10/c043/sc01/index.shtml
District of Columbia DC Code §16-2841 http://newsroom.dc.gov/file.aspx/release/13210/02%20DC%20Acts%20Part%201.pdf
Florida Fla Stat §90.4026 http://www.flsenate.gov/Laws/Statutes/2011/90.4026
Georgia Ga Code Ann §24-3-37.1 http://www1.legis.ga.gov/legis/2005_06/search/sb3.htm
Hawaii Haw Rev Stat §626-1, Rule 409.5 www2.hawaii.edu/~barkai/e/HRE.DOC
Idaho Idaho Code Ann §9-207 http://www.legislature.idaho.gov/idstat/Title9/T9CH2SECT9-207.htm
Illinois Ill Comp Stat §5/8-1901 http://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=073500050K8-1901-
Indiana Ind Code §34-43.5-1-1 http://www.in.gov/legislative/ic/code/title34/ar43.5/ch1.html#IC34-43.5-
Iowa Iowa Code §622.31 http://coolice.legis.state.ia.us/cool-ice/default.asp?category=billinfo&service=iowacode&ga=83&input=622#62
Louisiana La Rev Stat Ann §13:3715.5 http://legis.la.gov/lss/lss.asp?doc=77558
Maine Me Rev Stat Ann tit. 24 §2907 http://www.mainelegislature.org/legis/statutes/24/title24sec2907.html
Maryland Md Code Ann, Cts & Jud Proc §10-920 mlis.state.md.us/2005rs/bills/hb/hb0114f.pdf
Massachusetts Mass Gen Laws Ann ch 233 23D http://www.malegislature.gov/Laws/GeneralLaws/PartIII/TitleII/Chapter233/Section23D
Missouri Mo Rev Stat §538.229 http://www.moga.mo.gov/statutes/C500-599/5380000229.HTM
Montana Mont Code Ann §26-1-814 http://data.opi.mt.gov/bills/mca/26/1/26-1-814.htm
Nebraska Neb Rev Stat §27-1201 http://nebraskalegislature.gov/laws/statutes.php?statute=27-1201
New Hampshire NH Rev Stat Ann §507-E:4 http://www.gencourt.state.nh.us/rsa/html/LII/507-E/507-E-4.htm
North Carolina NC Gen Stat §8C-1, Rule 413 http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter_8C/GS_8C-413.html
North Dakota ND Cent Code §31-04-12 http://www.legis.nd.gov/assembly/60-2007/session-laws/documents/JPROF.pdf#CHAPTER284
Ohio Ohio Rev Code Ann §2317.43 http://codes.ohio.gov/orc/2317.43
Oklahoma Okla Stat tit 63 §1-1708.1 H http://law.justia.com/codes/oklahoma/2006/os63.html
Oregon Or Rev Stat §677.082 http://www.oregonlaws.org/ors/677.082
South Carolina SC Code Ann §19-1-190 http://www.scstatehouse.gov/code/t19c001.php
South Dakota SD Codified Laws §19-12-14 http://legis.state.sd.us/statutes/DisplayStatute.aspx?Statute=19-12-14&Type=Statute
Tennessee Tenn Code Ann §409.1 http://www.tncourts.gov/rules/rules-evidence/4091
Texas Tex Rev Civ Prac & Rem Code Ann §18.061 http://www.statutes.legis.state.tx.us/SOTWDocs/CP/htm/CP.18.htm
Utah Utah Rules of Evidence, Rule 409 http://www.utcourts.gov/resources/rules/ure/0409.htm
Vermont Vt Stat Ann tit 12 §1912 http://www.leg.state.vt.us/statutes/fullsection.cfm?Title=12&Chapter=081&Section=01912
Virginia Va Code Ann §8.01-581.20:1 http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+8.01-581.20C1
Washington Wash Rev Code Ann §5.64.010 http://apps.leg.wa.gov/rcw/default.aspx?cite=5.64.010
West Virginia W Va Code §55-7-11a http://www.legis.state.wv.us/WVCODE/ChapterEntire.cfm?chap=55&art=7&section=11A#07
Wyoming Wyo Stat Ann §1-1-130 http://legisweb.state.wy.us/statutes/titles/Title1/T1CH1.htm
Table.
Apology Laws by State1,2
State Code Web Site
Arizona Ariz Rev Stat §12-2605 http://www.azleg.gov/ars/12/02605.htm
California Cal Evid Code §1160 http://www.leginfo.ca.gov/cgi-bin/displaycode?section=evid&group=01001-02000&file=1150-1160
Colorado Colo Rev Stat Ann §13-25-135 http://www.state.co.us/gov_dir/leg_dir/olls/sl2003a/sl_126.htm
Connecticut Conn Gen Stat Ann §52-184d http://www.cga.ct.gov/2011/pub/chap899.htm#Sec52-184d.htm
Delaware Del Code Ann tit 10. §4318 http://delcode.delaware.gov/title10/c043/sc01/index.shtml
District of Columbia DC Code §16-2841 http://newsroom.dc.gov/file.aspx/release/13210/02%20DC%20Acts%20Part%201.pdf
Florida Fla Stat §90.4026 http://www.flsenate.gov/Laws/Statutes/2011/90.4026
Georgia Ga Code Ann §24-3-37.1 http://www1.legis.ga.gov/legis/2005_06/search/sb3.htm
Hawaii Haw Rev Stat §626-1, Rule 409.5 www2.hawaii.edu/~barkai/e/HRE.DOC
Idaho Idaho Code Ann §9-207 http://www.legislature.idaho.gov/idstat/Title9/T9CH2SECT9-207.htm
Illinois Ill Comp Stat §5/8-1901 http://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=073500050K8-1901-
Indiana Ind Code §34-43.5-1-1 http://www.in.gov/legislative/ic/code/title34/ar43.5/ch1.html#IC34-43.5-
Iowa Iowa Code §622.31 http://coolice.legis.state.ia.us/cool-ice/default.asp?category=billinfo&service=iowacode&ga=83&input=622#62
Louisiana La Rev Stat Ann §13:3715.5 http://legis.la.gov/lss/lss.asp?doc=77558
Maine Me Rev Stat Ann tit. 24 §2907 http://www.mainelegislature.org/legis/statutes/24/title24sec2907.html
Maryland Md Code Ann, Cts & Jud Proc §10-920 mlis.state.md.us/2005rs/bills/hb/hb0114f.pdf
Massachusetts Mass Gen Laws Ann ch 233 23D http://www.malegislature.gov/Laws/GeneralLaws/PartIII/TitleII/Chapter233/Section23D
Missouri Mo Rev Stat §538.229 http://www.moga.mo.gov/statutes/C500-599/5380000229.HTM
Montana Mont Code Ann §26-1-814 http://data.opi.mt.gov/bills/mca/26/1/26-1-814.htm
Nebraska Neb Rev Stat §27-1201 http://nebraskalegislature.gov/laws/statutes.php?statute=27-1201
New Hampshire NH Rev Stat Ann §507-E:4 http://www.gencourt.state.nh.us/rsa/html/LII/507-E/507-E-4.htm
North Carolina NC Gen Stat §8C-1, Rule 413 http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter_8C/GS_8C-413.html
North Dakota ND Cent Code §31-04-12 http://www.legis.nd.gov/assembly/60-2007/session-laws/documents/JPROF.pdf#CHAPTER284
Ohio Ohio Rev Code Ann §2317.43 http://codes.ohio.gov/orc/2317.43
Oklahoma Okla Stat tit 63 §1-1708.1 H http://law.justia.com/codes/oklahoma/2006/os63.html
Oregon Or Rev Stat §677.082 http://www.oregonlaws.org/ors/677.082
South Carolina SC Code Ann §19-1-190 http://www.scstatehouse.gov/code/t19c001.php
South Dakota SD Codified Laws §19-12-14 http://legis.state.sd.us/statutes/DisplayStatute.aspx?Statute=19-12-14&Type=Statute
Tennessee Tenn Code Ann §409.1 http://www.tncourts.gov/rules/rules-evidence/4091
Texas Tex Rev Civ Prac & Rem Code Ann §18.061 http://www.statutes.legis.state.tx.us/SOTWDocs/CP/htm/CP.18.htm
Utah Utah Rules of Evidence, Rule 409 http://www.utcourts.gov/resources/rules/ure/0409.htm
Vermont Vt Stat Ann tit 12 §1912 http://www.leg.state.vt.us/statutes/fullsection.cfm?Title=12&Chapter=081&Section=01912
Virginia Va Code Ann §8.01-581.20:1 http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+8.01-581.20C1
Washington Wash Rev Code Ann §5.64.010 http://apps.leg.wa.gov/rcw/default.aspx?cite=5.64.010
West Virginia W Va Code §55-7-11a http://www.legis.state.wv.us/WVCODE/ChapterEntire.cfm?chap=55&art=7&section=11A#07
Wyoming Wyo Stat Ann §1-1-130 http://legisweb.state.wy.us/statutes/titles/Title1/T1CH1.htm
×
The laws of each state have their own nuances, so physicians must be mindful of the particular jurisdiction in which they practice. For example, North Dakota's and Utah's laws do not state that the expression must be related to the discomfort, pain, suffering, injury, or death of the patient. In addition, in some jurisdictions, apologies made orally or written are covered.24 Also, some state apology laws do not specifically mention to whom the apology may be given, which can leave the application of the law open for interpretation in a given situation.1,2 For example, states with apology laws that do not specifically mention the admissibility of expressions of sympathy to a family member, friend, or representative of the patient include Washington, Vermont, Maryland, South Dakota, Indiana, Hawaii, Oregon, and North Carolina. Maine's apology law specifically covers “a domestic partner relationship with an alleged victim.”1,2 The apology laws of Montana and Delaware apply to the patient, the patient's family, or a friend of the patient, while the apology laws of Connecticut, Vermont, and Ohio cover an apology made to any person who has a family-type relationship with the patient. 
Some legislatures place a time limit during which an apology is inadmissible. These time limits are intended to encourage swifter communication by the physician. For example, Washington and Vermont place a 30-day restriction on an admission, while Illinois allows a 72-hour window for the statement to be inadmissible. The general assemblies of both South Carolina and Georgia have voiced the opinion that expressions of sympathy should be encouraged to promote communication between a physician and the patient who experienced an unexpected outcome. Georgia's statute states, “General Assembly further finds that such conduct, statements, or activity should be particularly encouraged between health care providers and patients experiencing an unanticipated outcome resulting from their medical care.” South Carolina's statute contains nearly identical wording.1 
A very important distinction has arisen in some states between a statement of sympathy and an admission of fault.1,2 For instance, Maine and Louisiana make this particular distinction in their apology laws by stating that nothing in the statute prohibits the admissibility of a statement of fault. The laws of Nebraska, Virginia, Vermont, Louisiana, Maryland, South Dakota, Indiana, Hawaii, California, Florida, Tennessee, Illinois, Missouri, New Hampshire, Idaho, and the District of Columbia include similar language in their statutes. Vermont's wording is a little different, stating “liability protections … shall not be construed to limit access to information that is otherwise discoverable.” Although most apology laws are categorized under rules of evidence pertaining to a medical error, many states protect apologies regardless of whether the outcome results from medical malpractice.1,2,5 
Conclusion
A number of studies have demonstrated that apologies in the medical arena have reduced the cost of litigation. A simple apology allows physicians to remain true to their honesty and integrity while exhibiting their humanity and providing some much-needed closure to their patients and their patients' families. It is the amelioration of this anger that leads to less costly litigation. Therefore, we believe that if a physician's jurisdiction has the appropriate legislation, he or she should consider apologizing for an unexpected medical outcome. It may be the best medicine available to soothe the feelings of a patient or family and to avoid a malpractice lawsuit. 
   Financial Disclosures: None reported.
 
References
Saitta NM, Hodge SD. Is it unrealistic to expect a doctor to apologize for an unforeseen medical complication?—a primer on apologies laws. Pennsylvania Bar Association Quarterly. July 2011:93-110.
Saitta N, Hodge SD. Physician apologies. Practical Lawyer. Fall 2011:35-43.
AOA Code of Ethics. American Osteopathic Association Web site. http://www.osteopathic.org/inside-aoa/about/leadership/Pages/aoa-code-of-ethics.aspx. Accessed February 8, 2012.
AMA's Code of Medical Ethics. American Medical Association Web site. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page. Accessed February 8, 2012.
Ebert R. Attorneys, tell your clients to say they're sorry: apologies in the health care industry. Ind Health L Rev. 2008;5:337.
Robbennolt JK. Apologies and settlement. Court Review. 2009;45:90-97. http://aja.ncsc.dni.us/publications/courtrv/cr45-3/CR45-3Robbennolt.pdf. Accessed April 4, 2012.
Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Aff. 2004;23(4):22-32. http://content.healthaffairs.org/cgi/content/abstract/23/4/22. Accessed April 4, 2012.
Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131(12):963-967. http://www.annals.org/content/131/12/963.short. Accessed April 4, 2012.
University of Michigan Health Systems. Full disclosure of medical errors reduces malpractice claims and claim costs for health systems. Innovations Exchange. June 23 , 2010. http://www.innovations.ahrq.gov/popup.aspx?id=2673&type=1&isUpdated=False&isArchived=False&name=print. Accessed July 6, 2011.
Ho B, Liu E. Does sorry work? the impact of apology laws on medical malpractice. J Risk Uncert. 2001;43(2):141-167. doi:10.1007/s11166-011-9126-0. [CrossRef]
O'Reilly K. “I'm sorry”: why is that so hard for doctors to say? American Medical News. February 1 , 2010. http://www.ama-assn.org/amednews/2010/02/01/prsa0201.htm. Accessed July 7, 2011.
Wei M. Doctors, apologies, and the law: an analysis and critique of apology laws (Student Scholarship Papers, Paper 30). Yale Law School Legal Scholarship Repository Web site. http://digitalcommons.law.yale.edu/student_papers/30/. Accessed February 10, 2012.
Wojcieszak D, Banja J, Houk C. The Sorry Works! Coalition: making the case for full disclosure. Jt Comm J Qual Patient Saf. 2006;32(6):344-350. [PubMed]
Quinn R. COPIC's 3Rs Program: Recognize, Respond to and Resolve Patient Injury. Sorry Works! Coalition Web site. http://www.sorryworks.net/files/3rsaosreq.ppt. Accessed July 26, 2011.
Engel B. The power of apology. Psychology Today Web site. http://www.psychologytoday.com/articles/200208/the-power-apology. Published July 1 , 2002. Accessed July 6, 2011.
Federico F. Disclosure of medical error. Forum. 2003;23(2):1-18. http://www.rmf.harvard.edu/~/media/Files/_Global/KC/Forums/2003/ForumMay2003.pdf. Accessed April 2, 2012.
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000:155-201. [PubMed] [PubMed]
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Lamb R. Disclosure: a visiting journalist's perspective. Forum. 2003;23(2):13.
Bismark M, Dauer E, Paterson R, Studdert D. Accountability sought by patients following adverse events from medical care: the New Zealand experience. CMAJ. 2006;175(8):889-894. http://www.cmaj.ca/content/175/8/889.full.pdf+html. Accessed April 9, 2012.
Friele RD, Sluijs EM. Patient expectations of fair complaint handling in hospitals: empirical data. BMC Health Serv Res. 2006;6:106. http://www.biomedcentral.com/content/pdf/1472-6963-6-106.pdf. Accessed April 9, 2012.
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I'm sorry laws: summary of state laws. American Medical Association Advocacy Resource Center Web site. http://www.physicianspractice.com/all/p2files/images/publication/charts/11_2007_TheLaw_Chart1.pdf. Accessed July 6, 2011.
Table.
Apology Laws by State1,2
State Code Web Site
Arizona Ariz Rev Stat §12-2605 http://www.azleg.gov/ars/12/02605.htm
California Cal Evid Code §1160 http://www.leginfo.ca.gov/cgi-bin/displaycode?section=evid&group=01001-02000&file=1150-1160
Colorado Colo Rev Stat Ann §13-25-135 http://www.state.co.us/gov_dir/leg_dir/olls/sl2003a/sl_126.htm
Connecticut Conn Gen Stat Ann §52-184d http://www.cga.ct.gov/2011/pub/chap899.htm#Sec52-184d.htm
Delaware Del Code Ann tit 10. §4318 http://delcode.delaware.gov/title10/c043/sc01/index.shtml
District of Columbia DC Code §16-2841 http://newsroom.dc.gov/file.aspx/release/13210/02%20DC%20Acts%20Part%201.pdf
Florida Fla Stat §90.4026 http://www.flsenate.gov/Laws/Statutes/2011/90.4026
Georgia Ga Code Ann §24-3-37.1 http://www1.legis.ga.gov/legis/2005_06/search/sb3.htm
Hawaii Haw Rev Stat §626-1, Rule 409.5 www2.hawaii.edu/~barkai/e/HRE.DOC
Idaho Idaho Code Ann §9-207 http://www.legislature.idaho.gov/idstat/Title9/T9CH2SECT9-207.htm
Illinois Ill Comp Stat §5/8-1901 http://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=073500050K8-1901-
Indiana Ind Code §34-43.5-1-1 http://www.in.gov/legislative/ic/code/title34/ar43.5/ch1.html#IC34-43.5-
Iowa Iowa Code §622.31 http://coolice.legis.state.ia.us/cool-ice/default.asp?category=billinfo&service=iowacode&ga=83&input=622#62
Louisiana La Rev Stat Ann §13:3715.5 http://legis.la.gov/lss/lss.asp?doc=77558
Maine Me Rev Stat Ann tit. 24 §2907 http://www.mainelegislature.org/legis/statutes/24/title24sec2907.html
Maryland Md Code Ann, Cts & Jud Proc §10-920 mlis.state.md.us/2005rs/bills/hb/hb0114f.pdf
Massachusetts Mass Gen Laws Ann ch 233 23D http://www.malegislature.gov/Laws/GeneralLaws/PartIII/TitleII/Chapter233/Section23D
Missouri Mo Rev Stat §538.229 http://www.moga.mo.gov/statutes/C500-599/5380000229.HTM
Montana Mont Code Ann §26-1-814 http://data.opi.mt.gov/bills/mca/26/1/26-1-814.htm
Nebraska Neb Rev Stat §27-1201 http://nebraskalegislature.gov/laws/statutes.php?statute=27-1201
New Hampshire NH Rev Stat Ann §507-E:4 http://www.gencourt.state.nh.us/rsa/html/LII/507-E/507-E-4.htm
North Carolina NC Gen Stat §8C-1, Rule 413 http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter_8C/GS_8C-413.html
North Dakota ND Cent Code §31-04-12 http://www.legis.nd.gov/assembly/60-2007/session-laws/documents/JPROF.pdf#CHAPTER284
Ohio Ohio Rev Code Ann §2317.43 http://codes.ohio.gov/orc/2317.43
Oklahoma Okla Stat tit 63 §1-1708.1 H http://law.justia.com/codes/oklahoma/2006/os63.html
Oregon Or Rev Stat §677.082 http://www.oregonlaws.org/ors/677.082
South Carolina SC Code Ann §19-1-190 http://www.scstatehouse.gov/code/t19c001.php
South Dakota SD Codified Laws §19-12-14 http://legis.state.sd.us/statutes/DisplayStatute.aspx?Statute=19-12-14&Type=Statute
Tennessee Tenn Code Ann §409.1 http://www.tncourts.gov/rules/rules-evidence/4091
Texas Tex Rev Civ Prac & Rem Code Ann §18.061 http://www.statutes.legis.state.tx.us/SOTWDocs/CP/htm/CP.18.htm
Utah Utah Rules of Evidence, Rule 409 http://www.utcourts.gov/resources/rules/ure/0409.htm
Vermont Vt Stat Ann tit 12 §1912 http://www.leg.state.vt.us/statutes/fullsection.cfm?Title=12&Chapter=081&Section=01912
Virginia Va Code Ann §8.01-581.20:1 http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+8.01-581.20C1
Washington Wash Rev Code Ann §5.64.010 http://apps.leg.wa.gov/rcw/default.aspx?cite=5.64.010
West Virginia W Va Code §55-7-11a http://www.legis.state.wv.us/WVCODE/ChapterEntire.cfm?chap=55&art=7&section=11A#07
Wyoming Wyo Stat Ann §1-1-130 http://legisweb.state.wy.us/statutes/titles/Title1/T1CH1.htm
Table.
Apology Laws by State1,2
State Code Web Site
Arizona Ariz Rev Stat §12-2605 http://www.azleg.gov/ars/12/02605.htm
California Cal Evid Code §1160 http://www.leginfo.ca.gov/cgi-bin/displaycode?section=evid&group=01001-02000&file=1150-1160
Colorado Colo Rev Stat Ann §13-25-135 http://www.state.co.us/gov_dir/leg_dir/olls/sl2003a/sl_126.htm
Connecticut Conn Gen Stat Ann §52-184d http://www.cga.ct.gov/2011/pub/chap899.htm#Sec52-184d.htm
Delaware Del Code Ann tit 10. §4318 http://delcode.delaware.gov/title10/c043/sc01/index.shtml
District of Columbia DC Code §16-2841 http://newsroom.dc.gov/file.aspx/release/13210/02%20DC%20Acts%20Part%201.pdf
Florida Fla Stat §90.4026 http://www.flsenate.gov/Laws/Statutes/2011/90.4026
Georgia Ga Code Ann §24-3-37.1 http://www1.legis.ga.gov/legis/2005_06/search/sb3.htm
Hawaii Haw Rev Stat §626-1, Rule 409.5 www2.hawaii.edu/~barkai/e/HRE.DOC
Idaho Idaho Code Ann §9-207 http://www.legislature.idaho.gov/idstat/Title9/T9CH2SECT9-207.htm
Illinois Ill Comp Stat §5/8-1901 http://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=073500050K8-1901-
Indiana Ind Code §34-43.5-1-1 http://www.in.gov/legislative/ic/code/title34/ar43.5/ch1.html#IC34-43.5-
Iowa Iowa Code §622.31 http://coolice.legis.state.ia.us/cool-ice/default.asp?category=billinfo&service=iowacode&ga=83&input=622#62
Louisiana La Rev Stat Ann §13:3715.5 http://legis.la.gov/lss/lss.asp?doc=77558
Maine Me Rev Stat Ann tit. 24 §2907 http://www.mainelegislature.org/legis/statutes/24/title24sec2907.html
Maryland Md Code Ann, Cts & Jud Proc §10-920 mlis.state.md.us/2005rs/bills/hb/hb0114f.pdf
Massachusetts Mass Gen Laws Ann ch 233 23D http://www.malegislature.gov/Laws/GeneralLaws/PartIII/TitleII/Chapter233/Section23D
Missouri Mo Rev Stat §538.229 http://www.moga.mo.gov/statutes/C500-599/5380000229.HTM
Montana Mont Code Ann §26-1-814 http://data.opi.mt.gov/bills/mca/26/1/26-1-814.htm
Nebraska Neb Rev Stat §27-1201 http://nebraskalegislature.gov/laws/statutes.php?statute=27-1201
New Hampshire NH Rev Stat Ann §507-E:4 http://www.gencourt.state.nh.us/rsa/html/LII/507-E/507-E-4.htm
North Carolina NC Gen Stat §8C-1, Rule 413 http://www.ncleg.net/EnactedLegislation/Statutes/HTML/BySection/Chapter_8C/GS_8C-413.html
North Dakota ND Cent Code §31-04-12 http://www.legis.nd.gov/assembly/60-2007/session-laws/documents/JPROF.pdf#CHAPTER284
Ohio Ohio Rev Code Ann §2317.43 http://codes.ohio.gov/orc/2317.43
Oklahoma Okla Stat tit 63 §1-1708.1 H http://law.justia.com/codes/oklahoma/2006/os63.html
Oregon Or Rev Stat §677.082 http://www.oregonlaws.org/ors/677.082
South Carolina SC Code Ann §19-1-190 http://www.scstatehouse.gov/code/t19c001.php
South Dakota SD Codified Laws §19-12-14 http://legis.state.sd.us/statutes/DisplayStatute.aspx?Statute=19-12-14&Type=Statute
Tennessee Tenn Code Ann §409.1 http://www.tncourts.gov/rules/rules-evidence/4091
Texas Tex Rev Civ Prac & Rem Code Ann §18.061 http://www.statutes.legis.state.tx.us/SOTWDocs/CP/htm/CP.18.htm
Utah Utah Rules of Evidence, Rule 409 http://www.utcourts.gov/resources/rules/ure/0409.htm
Vermont Vt Stat Ann tit 12 §1912 http://www.leg.state.vt.us/statutes/fullsection.cfm?Title=12&Chapter=081&Section=01912
Virginia Va Code Ann §8.01-581.20:1 http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+8.01-581.20C1
Washington Wash Rev Code Ann §5.64.010 http://apps.leg.wa.gov/rcw/default.aspx?cite=5.64.010
West Virginia W Va Code §55-7-11a http://www.legis.state.wv.us/WVCODE/ChapterEntire.cfm?chap=55&art=7&section=11A#07
Wyoming Wyo Stat Ann §1-1-130 http://legisweb.state.wy.us/statutes/titles/Title1/T1CH1.htm
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