Hawai'i-Pacific Chapter
A quarterly e-newsletter for the Hawai'i Pacific Chapter of ACHE Vol. 2
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2017 ACHE National Congress
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Original Articles By ACHE Members
Apologies in Medical Practice and Malpractice: Communicative Implications of Who, When, and How
Leadership: The Road Less Traveled
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Jen Chahanovich, FACHE

Nick Hughey, FACHE

Micah Ewing

Chuck Tanner, FACHE

Suzie So-Miyahira

Nancy Hana


Josh Carpenter | Education

Emiline LaWall | Communications

Bobbie Ornellas, FACHE | Diversity

Tamara Pappas | Membership

Gidget Ruscetta, FACHE | Director

Angel Vargas, FACHE | Director

Denise Della

Art Gladstone, FACHE


Original Articles By ACHE Members
Apologies in Medical Practice and Malpractice: Communicative Implications of Who, When, and How
Amy Ebesu Hubbard, Ph.D.

     Offering an apology is a key factor in gaining interpersonal forgiveness, or reducing a person’s tendency to think, feel, and behave negatively and destructively and increasing that person’s tendency to think, feel, and behave positively and constructively toward another (Fehr, Gelfand, & Nag, 2010; Riek & Mania, 2011).  But, not all apologies are created equal.  Some apologies are simple with people expressing remorse through brief words, such as “I’m sorry” and “I apologize”.  Other apologies are more elaborate with people saying that they are sorry, showing remorse for their behavior and its effects, demonstrating understanding of the harm that was caused, taking responsibility for the harm, and explaining how the harm will be repaired or mitigated (if possible) and prevented in the future. 

 “Never ruin a good apology with an excuse” -Benjamin Franklin

     The use of apologies in the healthcare field, especially as it pertains to medical errors, is a complex and controversial topic.  Healthcare leaders are wise to consider potentially important implications for patients and their families, medical staff, the organization, and reputational standing in the community. Analyses of the pros and cons of apologizing revolve around whether apologies are an ethical requirement and a moral obligation to others that were harmed, whether apologies or certain components of apologies admit fault and then exposes healthcare organizations and personnel to malpractice lawsuits and other liability claims and costs (and what might lessen these vulnerabilities), and whether apologies serve to restore a ruptured relationship between the medical personnel (e.g., physician, nurse, or healthcare organization) and patient or family of the patient (Berlin, 2006; Carmack, 2014; Lazare, 2006). 

There is ample evidence that apologies can be useful in the medical field (Prothero & Morse, 2017), but questions still remain regarding the conditions under which apologies will be most effective.  Thus, if healthcare executives choose to allow and even encourage physicians and other medical personnel or representatives to apologize to patients who experienced a medical mistake or error, there are some important aspects of apologies to consider, garnered from the fields of communication and psychology, that go beyond examination of what constitutes an apology itself:  The when, how, and who.

1.     WHEN:  Timing of the apology

      One aspect to consider is the timing of the apology.  When should an apology be delivered?  Was the apology offered in a timely fashion?  What is considered an appropriate time and to whom?  Are victims or those harmed by a medical error ready to hear an apology?  Will they be receptive?  Will they be able to listen and retain the apology or will it be immediately dismissed or not recalled?  Should the apology happen immediately or later in a conversation?  The few studies that have examined the timing of apologies suggest that offering apologies later in a conversation can sometimes be more effective than earlier apologies because during a conversation the person who was wronged has had an opportunity to air their grievances and voice their feelings (Ebesu Hubbard, Hendrickson, Fehrenbach, & Sur, 2013; Frantz & Benningson, 2005).  Victims sometimes feel more understood when the apology happens later. 

     In an experimental study in which the timing of apologies was manipulated, many romantic partners who told their partners earlier in a conflict conversation that they were sorry did not recall hearing the apology.  The implication is that apologies might need to be repeated or stated both earlier and later during conversations.  It may not be sufficient to apologize a single time or unwarranted to think, “Well, I said I was sorry already”.  However, one also needs to be careful regarding another function of apologies.  Sometimes apologies are used to stop conversations from progressing further.  That is, people can interpret “I’m sorry” as a way to end a discussion topic and move on.  Thus, consideration of when to apologize reveals that it may be useful to apologize multiple times, making sure to at least apologize later in a conversation, and, if apologies are offered earlier, it may be useful to emphasize willingness to listen and discuss the conversational topic further.

2.     HOW:  Sincerity of the apology

     A second aspect to consider is how an apology is communicated.  Much of our meaning comes from our nonverbal behavior.  The way in which an apology is stated can make a difference.  Is the manner in which the apology is delivered consistent with the emotional content of the message?  Does the physician’s voice sound authentic and not forced?  Does the medical social worker’s face look remorseful and earnest?  Is the nurse’s demeanor warm and not robotic?  These questions probe the sincerity of the apology and there is an abundance of research, in and outside of the medical field, which supports that sincerity of the apology can lead to positive outcomes, such as increased forgiveness and reduced negative feelings.  For example, Basford, Offermann, and Behrend (2014) asked people to recall a time when a supervisor did something that negatively affected the employee.  They found that sincerely delivered apologies were associated with more forgiveness of the supervisor and more trust in and commitment to the supervisor than insincere apologies.  Moreover, insincere apologies were associated with less satisfaction with how the supervisor did his/her job, and less dedication to the organization than when no apologies were given.  When Hannawa, Shigemoto, and Little (2016) asked outpatients from Wake Forest Baptist Medical Center in the United States to watch vignettes or read a transcript where a male or female actor who played the role of surgeon varied the delivery of a disclosure of a medical error to the patient, sincere apologies resulted in more empathy for the surgeon which resulted in more forgiveness.  Ebesu Hubbard et al. (2013) found that sincere apologies for a recurrent conflict was related to less anger and irritation with one’s relational partner. 

      Another consideration is skill level and capacity to be sincere.  Think of the child who is told by a parent to apologize to a sibling, when the child does not want to?  The apology is likely ineffective because the apology is delivered insincerely.  Think of a politician or celebrity who reads an apology statement.  Does the apology sound and look sincere in tone, voice, and face?  Someone who is mandated to apologize or who reads a written apology may have a difficult time communicating their conviction to another.  Thus, it is important to find ways to communicate the sincerity of the apology to those that were harmed.

3.     WHO:  Nature of the relationship between people

     A third aspect to consider is the nature of the relationship between the apologizer and the person who was harmed.  When someone is the victim of a medical error, people seek to explain why the event happened, often looking to place blame on who is responsible for the error.  But that blame can take several forms.  People might view this in more global terms where the cause applies to many situations or a single isolated event.  People might see the cause as something that is stable and will happen repeatedly over time or a temporary and transitory matter.  People might judge the source of the problem to reside with an individual person who is inherently bad, mean, incompetent, unprofessional, irresponsible, lazy, careless, and the like or they may think the source of the problem is external to the individual in that the circumstances caused the problem rather than the individual.  

     People may also assess whether the harm was intentionally or unintentionally and for selfish or unselfish reasons.  Manusov’s (1990) research in this area indicates that people in less satisfying relationships interpreted their partners' negative behaviors as something that happens repeatedly and done on purpose and interpreted their partners' positive behaviors as something that only happened this one specific time because of certain circumstances.  Further, people who made these sorts of attributions tended to engage in more negative behaviors and were less likely to experience positive outcomes. 

      The implication is that the quality of relationships with patients, prior to any (if at all) medical errors can affect how harmful events are interpreted and responded to.  If a medical error is disclosed, the attributions about the causes of those medical errors are likely to be colored by the nature of that relationship.  Patients are more likely to give the benefit of the doubt to healthcare practitioners who they have preexisting good and satisfying relationships with.  An apology, then, no matter how sincerely offered and timed appropriately, can be seen negatively when a negative relationship exists between the medical personnel and the person who was harmed.

     Apologizing in healthcare can be more powerful and effective when the when, how, and who are considered.  This increases the possibility that forgiveness will be granted.  When someone chooses to forgive, the motivation to retaliate and seek retribution is diminished and, perhaps, then the bonds between healthcare personnel and patient and families can be restored, and people can possibly heal, not just physically but relationally from the harm caused by a medical error.  Such actions send a strong message across the organization and the community it serves.


Basford, T. E., Offermann, L. R., & Behrend, T. S. (2014). Please accept my sincerest apologies: Examining follower reactions to leader apology. Journal of Business Ethics, 119(1), 99-117.

Berlin, L. (2006). Will saying “I'm sorry” prevent a malpractice lawsuit?. American Journal of Roentgenology, 187(1), 10-15.

Carmack, H. J. (2014). A cycle of redemption in a medical error disclosure and apology program. Qualitative Health Research, 24(6), 860-869.

Ebesu Hubbard, A. S., Hendrickson, B., Fehrenbach, K. S., & Sur, J. (2013). Effects of timing and sincerity of an apology on satisfaction and changes in negative feelings during conflicts. Western Journal of Communication, 77(3), 305-322.

Fehr, R., Gelfand, M. J., & Nag, M. (2010). The road to forgiveness: A meta-analytic synthesis of its situational and dispositional correlates. Psychological Bulletin, 136(5), 894-914.

Frantz, C. M., & Bennigson, C. (2005). Better late than early: The influence of timing on apology effectiveness. Journal of Experimental Social Psychology, 41, 201–207.

Hannawa, A. F., Shigemoto, Y., & Little, T. D. (2016). Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes. Social Science & Medicine, 156, 29-38.

Lazare, A. (2006). Apology in medical practice: An emerging clinical skill. Journal of the American Medical Association, 296(11), 1401-1404.

Manusov, V. (1990). An application of attribution principles to nonverbal behavior in romantic dyads. Communications Monographs, 57(2), 104-118.

Prothero, M. M., & Morse, J. M. (2017). Eliciting the functional processes of apologizing for errors in health care: Developing an explanatory model of apology. Global Qualitative Nursing Research, 4.

Riek, B. M., & Mania, E. W. (2012). The antecedents and consequences of interpersonal forgiveness: A meta‐analytic review. Personal Relationships, 19(2), 304-325.



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