EXECUTIVE SUMMARY

Residents’ error disclosure skills have improved over time, largely due to informal learning experiences, found a recent study. Researchers learned that residents:

• turned to each other for peer support and mentoring;

• feel responsible for disclosing errors;

• want to be a part of conversations surrounding error disclosure.


Residents’ error disclosure skills have improved over time, found a recent study.1 Researchers compared residents’ skills in 2012 and 2013 with the skills they had in 2005, and found significant improvement.

“This was surprising and a relatively novel finding, in that no prior studies had been able to demonstrate such improvement,” says Brian M. Wong, MD, FRCPC, associate professor in the department of medicine at University of Toronto.

The researchers were curious to know whether the training that they’d provided to residents over the years was the reason for the improvement. “Of course, we hoped we would find residents who had received this training would have better disclosure skills,” says Wong. However, this wasn’t the case.

“In some ways, though, this was more disappointing than surprising,” says Wong. “It really should not surprise us that a single half-day workshop might not have a major impact on error disclosure skills.”

This raised the question as to what — if not the training — had improved the residents’ error disclosure skills. “To further explore this, we interviewed nine residents from three different training programs: internal medicine, pediatrics, and orthopedic surgery,” says Wong.

The researchers asked the residents about their experiences learning how to disclose errors. The residents felt that faculty role-modeling and debriefings were helpful. Residents also turned to one another for peer support and mentoring.

“It turned out that while formal training was acknowledged as having some role, the more important learning experiences were the informal ones,” says Wong.

Some residents reported that they felt personally responsible for disclosing errors, and wanted to be a part of the conversation with the patient or family. “For us, this was perhaps the most surprising finding,” says Wong. “The residents saw disclosing errors as an important professional responsibility that they wanted to be directly involved with.”

Some even revealed that they’d disclosed errors independently without faculty present. This raises the ethical question of whether it’s ever permissible for residents to disclose errors on their own.

“When residents want to take ownership of the error disclosure process, it is our job as faculty members to ensure that they are prepared to disclose, and negotiate with them when they are ready to communicate effectively without direct supervision,” notes Lynfa Stroud, MD, MEd, another of the study’s authors. Stroud is associate professor in the Department of Medicine at the University of Toronto and a general internist at Sunnybrook Health Sciences Centre.

Timely and candid communication with a patient or family after a medical error can help limit harm, and is a professional and organizational ethical imperative, says Jonathan D. Stewart, JD, director of risk management and patient safety at Alamo, CA-based Beta Healthcare Group.

“Silence by organizations and physicians following medical injury compounds the harm experienced by patients and families. But clumsy ‘disclosure’ of an actual or apparent error can be even worse than silence,” says Stewart.

Ideally, clinicians have some preparation before disclosing an error to a patient or family. This might take the form of formal pre-event training with an opportunity to practice. “At a minimum, the clinician should have just-in-time training, with the benefit of a team huddle to prepare,” says Stewart.

The team should review the known facts and identify questions that still must be answered. “Avoiding engaging in confusing and potentially counterproductive speculation in front of the patient or family is very important from an organizational risk management perspective,” says Stewart.

Ideally, initial communication with a patient or family about a serious harm event happens within an hour.2 Organizations should identify individuals to support clinicians in preparing for these often difficult initial and follow-up conversations, says Stewart: “Medical ethicists may be well-suited for these roles.”

Ethicists may bring valuable skills to the pre-conversation meeting, in which the team agrees on the goals of the communication, attunes their message to the patient’s or family’s level of sophistication, and possibly rehearses the conversation.

“When an organization makes — and internally communicates — its commitment to timely and transparent communication after harm, it becomes possible to prepare for a swift and consistent response to such events,” says Stewart.

REFERENCES

1. Wong BM, Coffey M, Nousiainen 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. Agency for Healthcare Research and Quality. Disclosure Checklist: AHRQ Communication and Optimal Resolution Toolkit. Available at: http://bit.ly/2C6nyLd. Accessed Dec. 14, 2017.

SOURCES

• Jonathan D. Stewart, JD, Director, Risk Management and Patient Safety, Beta Healthcare Group, Alamo, CA. Phone: (925) 314-7618. Email: jonathan.stewart@betahg.com.

• Lynfa Stroud, Department of Medicine, University of Toronto. Email: Lynfa.Stroud@sunnybrook.ca.

• Brian M. Wong, MD, FRCPC, Department of Medicine, University of Toronto. Email: BrianM.Wong@sunnybrook.ca.