EXECUTIVE SUMMARY

Role-modeling, a strong patient safety culture, and simulation training provided to interdisciplinary groups facilitate error disclosure, found several recent studies. Ethicists can be aware of the following:

• Be alert for instances where care teams have not shared all available information with the patient and family.

• Be familiar with research showing patients want transparency on adverse events.

• Help to develop emotional support systems for healthcare workers involved in errors.


Nursing, medical, pharmacy, and dental students at Seattle-based UW Medical Center learn about error disclosure as a group.

“They can appreciate the need for effective teamwork in the planning phase, before initiating error disclosure,” says Andrew A. White, MD, an associate professor in UW’s department of medicine.

Feedback from students indicates that they learned not only about disclosing medical errors, but also about other professionals’ roles and perspectives, found a recent study.1

“Part of our premise is that we typically make mistakes as a team, and should disclose and accept accountability together. That happens best if all of the students are training together,” says White, one of the study’s authors.

Simulation with standardized patients allows residents to comprehend the dynamics of these difficult conversations in a risk-free setting. “We want the students to wrestle with some real-life emotions, without being traumatized by the simulation,” explains White.

To effectively prepare healthcare professionals for effective and ethical medical error disclosure, says White, “educational leaders should introduce the topic early, utilize simulation, apply current theory about how adults learn, and make the training interprofessional.”

Previous research has shown that medical, nursing, and pharmacy students witness errors and adverse events early in their clinical training.2 “Healthcare professional schools should provide robust training in the preclinical years, to anticipate the need for guidance,” advises White.

Patients Want Transparency

Case-based teaching pushes learners at all stages to contemplate how they and their institution should uphold multiple ethical principles during disclosure, says White. “Patients expect us to be transparent and truthful with the facts, and to be accountable for the harm we have caused,” he adds. This means acknowledging their distress, and providing an appropriate apology and emotional support.

However, trainees grapple with competing desires. They want to meet the patients’ needs, but worry about their own self-preservation, fearing consequences from their supervisors in addition to the patients.

“Educational leaders can minimize the ethical dilemma for trainees by upholding a just culture, and an emotionally supportive due process after trainees are involved in errors,” says White. He suggests ethicists facilitate ethical error disclosure in the following ways:

• Be alert for instances where care teams have not shared all available information with the patient and family.

“Those are times to probe the team’s assumptions and motivations,” says White.

• Be familiar with research showing that patients want transparency about adverse events.

This can help ethicists to refute groundless assertions that being truthful about errors will needlessly upset patients, says White.

• Encourage the robust development of emotional support systems for healthcare workers involved in errors.

“Virtually all healthcare workers intend to provide safe care, and are emotionally devastated when they make harmful mistakes,” says White.

Effective error reporting and disclosure programs go hand-in-hand with ethical responses toward the healthcare workers involved. “It can be frustrating to train students and residents on the ideal ethical handling of mistakes, knowing that they may enter healthcare systems that do not support those behaviors,” notes White.

A recent study’s findings underscore this difficulty. Researchers assessed 49 residents’ error disclosure skills using structured role play with a standardized patient in 2012-2013.3 Residents identified these two factors as key facilitators for disclosure:

• role modeling;

• a strong local patient safety culture.

“Significant further change should occur in the systems and culture of healthcare institutions, in order for graduating trainees to find that their skills match the reality of their practice environment,” concludes White.

REFERENCES

1. Wong BM, Coffey M, Nousianien MT, et al. Learning through experience: influence of formal and informal training on medical error disclosure skills in residents. J Grad Med Educ 2017; 9(1):66-72.

2. White AA, Gallagher TH, Krauss MJ. The attitudes and experiences of trainees regarding disclosing medical errors to patients. Acad Med 2008; 83(3):250-256.

3. McDonough KA, White AA, Odegard PS, et al. Interprofessional error disclosure training for medical, nursing, pharmacy, dental, and physician assistant students. MedEdPORTAL 2017;13:10606.

SOURCE

• Andrew A. White, MD: Associate Professor, Department of Medicine, University of Washington School of Medicine, Seattle. Phone: (206) 616-1447. Email: andwhite@u.washington.edu.