Toward a Culture of Safety: Part 4, AERD as Relationship Management

You can find POCA's Adverse Events Reporting Database here:

Let’s compare two possible telephone conversations (based on real events)* between a patient and their acupuncturist:

P: I don’t know what happened with my treatment yesterday, but my thumb feels really stiff and the palm of my hand feels tender, like it hurts when I pick things up.

A: Hmm. It looks like you might have a bruise where I needled Lung 10 for your sore throat. That happens sometimes, it’s nothing to be concerned about.

P: But my hand hurts. That’s not supposed to happen, is it?

A: Sometimes a needle can hit a capillary, you know how capillaries are too small to see? By the way, how’s your throat?

P: It’s maybe a little better, but if I’d known something like this was going to happen to my hand, I would’ve stayed home and just gargled with salt water, you know what I mean?

A: It’s really nothing to be concerned about. It should clear up in a few days.

P: Well I’m concerned, it’s my dominant hand, and it’s actually kind of painful to use it.

A: Look, this is really no big deal, sometimes bruises happen with acupuncture. You could put a warm compress on it. Or we carry some Chinese liniment in the clinic, maybe you could stop by and pick up a bottle…

P: I really don’t feel like spending any more money at your clinic right now, and did I not explain that it hurts to drive?

Possible outcomes at this point: patient hangs up the phone (and never comes back); conversation gets increasingly accusatory and maybe ruins both the patient’s and the practitioner’s day, practitioner resentfully offers patient a refund which patient resentfully accepts…etc. Patient leaves the interaction with negative feelings about acupuncture, and the acupuncturist leaves the interaction with negative feelings about patients. Everyone’s stress has increased.


P: I don’t know what happened with my treatment yesterday, but my thumb feels really stiff and the palm of my hand feels tender, like it hurts when I pick things up.

A: Oh, I’m sorry to hear that! Tell me more about what part of your hand hurts, exactly.

P: I think it’s mainly the fleshy part of my thumb…but it kind of radiates outward to my whole palm.

A: Hmm. I wonder if you might have a bruise where I needled Lung 10 for your sore throat. That can happen sometimes. Is there any discoloration you can see?

P: Yes, it’s kind of purplish, actually, on that part of my thumb…but my hand hurts even where it’s not purple. And it’s stiff. That’s not supposed to happen with acupuncture, is it?

A: Yeah, no — it’s like with any form of medical intervention, there are certain risks, and most of the time those risks don’t happen, but every so often they do. That’s what bruising with acupuncture is like — we really prefer when it doesn’t happen, but every once in a while, it does. Probably what happened is that a needle hit a capillary — they’re too small to see, so you can’t really prevent it, but if the needle connects with a capillary at just the right angle, you can get a pretty substantial bruise. Typically there’s not much to do at this point, other than be gentle with your hand and maybe put some warm compresses on to speed up the healing process? Just keep an eye on it.

P: So like how often does this kind of thing happen? I had two treatments before this and I never had a problem.

A: Yeah, your previous treatments were much more typical and much more in line with what we expect.  In fact I was going to ask you, if you don’t mind, we have a safety database where we try to track things like this and if you don’t have any objections, I’m going to file a report about your bruise. Because if it’s enough to make you uncomfortable, it’s enough that we want to track it, because we’re always trying to get a better idea of how often these things happen. Is that OK with you?

P: Yeah. OK. So there isn’t anything else I can do at this point?

A: You could try some liniment, or some arnica salve, or even just soak it in warm water. If you want to stop by so that I can take a look at your hand, I’d be happy to do that, but I’m pretty sure it’s a bruise and it’s just a matter of giving it time to clear up. If for some reason it seems like there’s anything else going on, please call back and let me know. You’ve got another appointment scheduled for later this week, right?

P: Yes, Friday.

A: OK, let’s check in then. And in the meantime I’ll file the report. I confess I’m kind of a geek about acupuncture safety data, but I’m sorry you had to be the one to make a contribution to our research project.

P: (laughs) OK — anything for science, I guess? I was just worried.

A: Yeah, of course! I totally understand. Bruises like that are something we definitely want to pay attention to and take good care of, but at this point I don’t think you have to worry any further. Just keep me posted, OK?

P: Yes. Thanks for your time.

Possible outcomes at this point: the patient’s stress is reduced; the acupuncturist has added one minor thing to their to-do list — filing an AERD report — but that takes 10 minutes and it’s not stressful; the patient’s relationship to the acupuncturist continues undisrupted, and maybe even gets stronger, because the acupuncturist heard the patient’s concerns and took appropriate action that showed that they care about the patient’s experience, and also about acupuncture safety.

Here’s the thing about adverse events and negative outcomes: it’s easy for us acupuncturists to feel criticized/attacked/misunderstood, and as a result, to make it all about us. But it’s not actually all about us — that’s good news — and patients are generally not coming to these interactions with a desire to criticize or attack. They are, however, understandably sensitive to feeling dismissed or not taken seriously. In general, patients who experience negative outcomes are worried or upset because of the adverse event’s impact on them, and the most important thing is to keep the focus of the conversation on them. Collecting information for a AERD report is one good way to hear someone out at the same time that you’re gathering data that can help the rest of the co-op.

I, for one, would very much like to know how often patients get upset about events that acupuncturists consider minor — because there might be important reasons that it’s not minor for the patient. And I REALLY want to know about events that we consider extremely rare or even impossible, like a patient who reports that a needle broke off and the fragments migrated to other parts of their body. Yes, according to the Clean Needle Technique manual, there’s virtually no chance of that actually happening with stainless steel needles! However, if there’s any chance that it DID happen, and there needs to be a needle recall, it would be ideal for the co-op to find out RIGHT AWAY.

So instead of dismissing patients’ concerns — especially dismissing them with the implication that they’re overreacting, lying, or deranged — a better alternative is to use the AERD and just collect the information. You don’t have to worry about whether the patient’s concerns are “accurate” or “objectively verifiable”. Accurate and objectively verifiable aren’t a lot of help when it comes to pain management. If we really believe that all pain is a product of the brain, and all pain is real pain, for everyone, all the time — shouldn’t that impact how we respond to patient complaints?

At WCA, I’m happy to report, we’ve used the AERD to navigate more than one negative outcome/adverse event with the result that the clinic didn’t lose a regular patient, and a patient didn’t lose access to pain management that was working for them. The AERD, as a symbol of curiosity and concern about safety, acted like a container for something that otherwise could have (probably would have) disrupted our relationships. The AERD is a tool to promote safety as a cooperative project — we hope lots of acupuncturists will use it that way.

* (Real event: after one of my first-ever acupuncture treatments at my acupuncture school's student clinic, circa 1991, my entire palm turned purple for about a week as a result of a bruise at Lung 10. I wasn't freaked out by it, but a lot of patients would have been! In hindsight this might have destined me to take an interest in acupuncture adverse events.)

Author: lisafer

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  1. Yes! I tried this tactic the other day with a patient who reported being unhappy with his last treatment because of residual soreness (i.e. offered up the AERD) and it REALLY worked to help him feel validated. (He didn’t want to or want me to file a report). My therapist is always telling me that all anyone wants is validation when they come to you with their concerns, and that’s what I’m reading here too: validate, validate, validate (and offer the AERD).