Most physicians still don't disclose errors

More training needed to standardize this practice

Although nearly every physician surveyed in a recent study said they would disclose a hypothetical error, fewer than half have actually done so, says a new study from the University of Iowa.1

"Our goal was to learn more about clinicians' attitudes, but also what they actually have and have not done," says the study's lead author Lauris Kaldjian, MD, PhD, associate professor of internal medicine in the University of Iowa's college of medicine and director of the college's program in biomedical ethics and medical humanities. "We were interested in what factors or beliefs might be motivating physicians who are more likely to disclose errors to their patients."

The researchers reviewed survey responses from 538 faculty physicians, resident physicians, and medical students from academic medical centers in the Midwest, Mid-Atlantic and Northeast regions of the United States. Respondents were asked about their attitudes toward disclosing medical errors, whether they would disclose an error from a hypothetical medical situation, and whether they had ever disclosed a real-life medical error.

Ninety-seven percent of the faculty and resident physicians indicated that they would disclose the hypothetical medical error that resulted in minor medical harm (resulting in prolonged treatment or discomfort) to a patient, and 93% responded that they would disclose the error if it caused major harm (disability or death) to a patient.

However, only 41% of faculty and resident physicians reported actually having disclosed a minor medical error, and only 5% responded as having disclosed a major error. In addition, 19% reported having made a minor medical error and not disclosing it, and 4% reported having made a major error with no disclosure.

If you take the results at face value, this would imply that over half of the physicians had never made a medical error, which is highly unlikely, says Kaldjian.

The study's findings also reveal that malpractice fears are not the only reason physicians are reluctant to disclose errors. Physicians are also worried about negative patient reactions, professional discipline, loss of reputation, and blame from colleagues.

For more standardization of error disclosure, the researchers recommend the following:

  • Encourage physicians to communicate clearly with patients and families about errors.
  • Take deliberate steps to reduce the professional repercussions that may be associated with disclosure.
  • Include administrative support for professionals who may feel isolated and vulnerable as they attempt to navigate the psychological demands of the disclosure process and its aftermath.

More training is needed

Only 18% of 3,100 physicians in the United States and Canada had received education or training in disclosure of errors, while 86% expressed interest in such education or training, according to another study.1 Here are key findings:

  • About half of the physicians surveyed reported that involvement in medical errors increased their job-related stress.
  • One in three physicians involved only with near-misses also reported that their lives were negatively affected. This indicates that physician distress after errors is not limited to the occurrence of serious errors. However, the greater the severity of the error, the more likely it was that the physician would be affected.

Only 10% of physicians surveyed agreed that health care organizations adequately supported them in coping with error-related stress.

The researchers recommend that hospitals offer more types of error-related support to physicians, both during and after work hours.

"The fact that so few physicians have had formal training in disclosure has important implications, both for quality professionals and for the profession at large," says Thomas H. Gallagher, MD, one of the study's authors and associate professor of medicine at University of Washington.

Based on the study's findings, there is good reason to believe the issues of lack of disclosure and lack of training are linked. "Having the training to do disclosures well is likely to at least partially diminish the distress health care workers feel after errors," says Gallagher.

Move toward standardization

Recently, the National Quality Forum (NQF) added standards of disclosure of unanticipated outcomes to its list of safe practices. The standard calls for aggressive education of providers — basic background education as well as just-in-time coaching immediately prior to disclosure.

Basic education typically consists of one- or two-hour sessions that sensitize health care workers to the challenges related to disclosure, says Gallagher. Cases are used to emphasize how difficult it can be to decide how much information to share with patients following errors, describe the basic steps involved in disclosure, and discuss the importance of getting help from the appropriate institutional resources before carrying out a disclosure.

Just-in-time coaching is usually provided by a risk manager or medical director, and consists of training immediately before an error is disclosed. This covers what information will be disclosed, who will do the disclosure, anticipates likely questions from the patient and formulates responses, and often includes some rehearsal, says Gallagher.

"The standard also recognizes the importance of supporting health care workers following errors," says Gallagher.

The NQF standard is important, because it calls on hospitals to apply standard performance improvement tools to the disclosure process, says Gallagher. He recommends tracking the following data: the percentage of staff trained, the percentage of eligible events disclosed, the presence of institutional policies and procedures on disclosure, and patient and physician satisfaction with disclosures.

At Portland-based Oregon Health and Science University, health care providers are encouraged to disclose errors, and the importance of this communication is emphasized with residents and faculty, says Christine Samuelson Slusarenko, MS, RN, director of medical affairs/quality management/employee health.

"Every case that I recall that has been reviewed, whether in determining whether or not a root cause analysis will be done or in less formal case reviews, had errors disclosed at the time they happened," Slusarenko says. "Delays, if any, occur because of delays in recognition of the error or disputes as to whether any error in fact happened."

She credits this consistency to a disclosure policy that has been agreed upon by the medical staff, effective education about the policy, and a commitment to strive for a blame-free culture in error reporting.

Particular complexity in family communication, unusual difficulty in patient or family communication with a provider, a patient or family's clear misunderstanding of a medical process or procedure, or anticipation of a volatile encounter are all times when a physician might require assistance, says Slusarenko. "Our patient advocate and chief medical officer are highly skilled in assisting physicians in disclosure, should they request assistance," she says.

References

  1. Kaldjian LC, Jones EW, Wu BJ, et al. Disclosing medical errors to patients: attitudes and practices of physicians and trainees. J Gen Intern Med 2007. Available on-line at http://www.springerlink.com.
  2. Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007; 33(8):467-476.

[For more information, contact:

Thomas H. Gallagher, MD, Associate Professor of Medicine, University of Washington, School of Medicine, 4311 11th Avenue NE, Suite 230, Seattle, WA 98105-4608. E-mail: thomasg@u.washington.edu.

Lauris C. Kaldjian, MD, PhD, Director, Program in Biomedical Ethics & Medical Humanities, Associate Professor, Department of Internal Medicine, University of Iowa Carver College of Medicine, 1-106 MEB, 500 Newton Road, Iowa City, IA 52242. Phone: (319) 335-6706. Fax: (319) 335-8515. E-mail: lauris-kaldjian@uiowa.edu.

Christine Samuelson Slusarenko, MS, RN, Director, Medical Affairs/Quality Management/Employee Health, Oregon Health & Science University, 3181 SW Sam Jackson Park Road Mail Code MBS, Portland, OR 97239-3098. Phone: (503) 494-6459. Fax: (503) 494-8492. E-mail slusaren@ohsu.edu.]