Error Disclosure Research Articles

Teaching interprofessional health science students medical error disclosure

with facial deformity (t = ) 2.82, P < 0.01), epilepsy (t = ) 3.86, P < 0.001), schizophrenia (t = ) 2.68, P < 0.01) or depression (t = ) 3.52, P < 0.001). Furthermore, the course was effective in decreasing students views of facial deformity as a superficial condition that does not require correction (t = 3.48, P < 0.001) and of schizophrenia patients as violent (t = 7.17, P < 0.001). An end-of-course evaluation using a 5-point Likerttype scale (1 = strongly disagree, 5 = strongly agree) demonstrated an average satisfaction score of 4.3. Self-assessment scores averaged 4.3 in increased knowledge, 4.4 in enhanced empathy and 4.5 in reflection on the stigma. Thematic analyses of the students final papers on a stigmatised disease of their choice suggested that the majority of students perceived an increase in their own advocacy skills by the end of the course.

Clinical risk management and the ethics of open disclosure: Part I. Benefits and risks to patient safety

Summary Patient safety experts and other authorities have strongly postulated the open disclosure of errors and adverse events to patients as an essential component of effective clinical risk management in health care. Commentators also contend that ‘when things go wrong', openly disclosing such events to the patient and his or her nominated support person is simply ‘the right thing to do'. Despite the obvious importance of the issue of open disclosure and its possible implications for the nursing profession, it has not been comprehensively addressed in the nursing literature. A key aim of this article (the first of a two-part discussion) is to contribute to the positive project of redressing this oversight by providing a brief overview of what open disclosure is and what its intended purpose, aims, and rationale are. Consideration is also given to the risks and benefits of open disclosure as a public policy and whether it will succeed in achieving the anticipated outcomes envisaged. In a second article (to be presented as Part II), the ethics of open disclosure and its possible implications for the nursing profession are explored.

Clinical risk management and the ethics of open disclosure: Part 2. Implications for the nursing profession

Summary Patient safety experts and other authorities have strongly postulated the open disclosure of errors and adverse events to patients and their nominated support persons as an essential component of effective clinical risk management in health care. Commentators also contend that ‘when things go wrong', openly disclosing such events to the patient is simply ‘the right thing to do'. Important questions about the ethics of open disclosure remain, however. Is openly disclosing errors and adverse events to patients necessarily ‘the right thing to do'? Do hospital authorities and health care professionals always have an overriding duty to openly communicate with patients and their families when thing go wrong? If patients do not suffer any material harm when a mistake is made, should they or their nominated support persons still be told? Are there overriding moral considerations that might justify non-disclosure in certain circumstances? Despite the obvious importance of these issues and their possible implications for the nursing profession, they have not been comprehensively explored in the nursing literature. An important aim of this article (the second of a two-part discussion) is to contribute to the positive project of redressing this oversight.

The Attitudes and Experiences of Trainees Regarding Disclosing Medical Errors to Patients

To measure trainees' attitudes and experiences regarding medical error and error disclosure. In 2003, the authors carried out a cross-sectional survey of 629 medical students (320 in their second year, 309 in their fourth year), 226 interns (159 in medicine, 67 in surgery), and 283 residents (211 in medicine, 72 in surgery), a total 1,138 trainees at two U.S. academic health centers. The response rate was 78% (889/1,138). Most trainees (74%; 652/881) agreed that medical error is among the most serious health care problems. Nearly all (99%; 875/884) agreed serious errors should be disclosed to patients, but 87% (774/889) acknowledged at least one possible barrier, including thinking that the patient would not understand the disclosure (59%; 525/889), the patient would not want to know about the error (42%; 376/889), and the patient might sue (33%; 297/889). Personal involvement with medical errors was common among the fourth-year students (78%; 164/209) and the residents (98%; 182/185). Among residents, 45% (83/185) reported involvement in a serious error, 34% (62/183) reported experience disclosing a serious error, and 63% (115/183) had disclosed a minor error. Whereas only 33% (289/880) of trainees had received training in error disclosure, 92% (808/881) expressed interest in such training, particularly at the time of disclosure. Although many trainees had disclosed errors to patients, only a minority had been formally prepared to do so. Formal disclosure curricula, coupled with supervised practice, are necessary to prepare trainees to independently disclose errors to patients by the end of their training.

“The Other Side of the Fence”: A Geriatric Surgical Case Study of Error Disclosure

This is an unfortunate story of care that went wrong for an elderly patient, her daughter, and her surgeon. The daughter, in spite of a close relationship with the attending surgeon, was left questioning whether the health care team had been on “the other side of the fence.” As the story unfolded, all experienced great pain in one way or another. In the aftermath, the daughter resolved to share her mother's story as a learning device with the aim of preventing similar future occurrences. The story is not unique because of its rarity, as most health care professionals can attest. In all likelihood it is not the “worst case we've ever encountered.” Neither does it stand apart because it so perfectly illustrates a single point. It is special simply because it is available for our examination, not having been lost to the vagaries of the legal system or conveniently concealed as an embarrassment or threat. In telling the story, the daughter and attending surgeon display great personal and professional courage, openness, and humanity as models for all of us to emulate when things go wrong. For this we are indebted to them. The issues involved were multiple and complex. We are invited to take the lessons, directly or by analogy, to our own clinical settings and apply them through the prism of the “curing” and “caring” roles that we all strive to fulfill in our quest to be complete professionals in a complete and caring health care delivery system. Open, timely, and empathetic communication is the foundation on which trusting, therapeutic relationships are based and on which the safety and quality of care depend. Our opportunity is to continuously improve the safety and quality of care for our patients by respecting their values and beliefs, and in this way to provide them, to the best of our ability, with the knowledge and confidence that their health care team is on their side. Illusion The greatest problem with communication is the illusion that it has been accomplished. — George Bernard Shaw, 1856–1950, Irish poet and playwright, 1925 Nobel Laureate in Literature

Patient race/ethnicity, age, gender and education are not related to preference for or response to disclosure

Objective:The purpose of this study was to (a) characterise patients’ preferences for disclosure of medical errors and reporting, (b) assess patients’ responses to disclosure of error and (c) determine how...

A novel interactive program for medical error management and disclosure

A novel interactive program for medical error management and disclosure

Perceptions of preventable medical errors in Alberta, Canada

(i) To compare public perceptions of the frequency, responsibility, causes and solutions for preventable medical errors for persons who report and do not report having experienced a preventable medical error while receiving healthcare services in Alberta, Canada. (ii) To describe public opinion about confidentiality and disclosure of preventable medical error. (iii) To examine the relationship between reporting preventable medical error and perceived quality of the healthcare system. Population-based telephone survey. Households selected by random digit dialing and individual in household selected by most recent birthday. Province of Alberta, Canada. Representative sample of adult Albertans (N = 1500). Public perceptions of the frequency, responsibility, causes and solutions for preventable medical error; opinions about confidentiality and disclosure; perceived quality of the healthcare system. Five hundred and fifty-nine (37.3%; 95% CI 34.8-39.8%) of 1500 respondents reported that they or a family member had ever experienced a preventable medical error while receiving health care in Alberta, Canada. Respondents who reported a preventable medical error were more likely to believe that preventable medical errors occur with greater frequency, were less likely to think that their doctor would tell them if a preventable medical error was made in their care, and tended to rate the quality of the healthcare system less favourably. This paper provides healthcare managers and policymakers with insight into the public's perceptions of preventable medical error and may facilitate the development of strategies to improve patient safety, public confidence and public satisfaction with the healthcare system.

Criminalization of medical errors: When is a mistake more than just a mistake¿

This article will review widely publicized cases involving healthcare providers against whom criminal charges have been brought, just at the moment that the idea of medical error disclosure is getting traction. This article will attempt to find similarities or patterns and propose that some level of control can be exercised over these matters. This article will address approaches to the issue that risk managers can take to prepare for possible cases, and ways that cases can be managed once charges have been filed. The author concludes that errors should be treated as what they are--errors, not criminal acts.

12. Disclosure of medical errors: A view through a global lens

There are ongoing efforts worldwide to minimize the occurrence of medical errors. However, the issue of honest disclosure of a medical error to the patient or their family has been relatively unattended. We have previously reported the Canadian provincial initiatives encouraging open disclosure of a critical event and have suggested its integration into a ‘no-fault’ model. In the absence of uniform policies directing appropriate disclosure of a medical error, substantial scope exists for breaching the patient’s trust if errors during the process of care are not disclosed. We reviewed the various medical error disclosure initiatives across the globe to analyze the progress made in this key area. In 2001, the United States (US) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated an open disclosure of any critical event during care to the patient or their families. This was deemed as an essential accreditation standard for the institution. In Australia, the Australian Council for Safety and Quality in Health Care integrates the disclosure process with a risk management analysis towards investigating the critical event. In New Zealand, the patients suffering a medical error are rehabilitated and compensated through a no-fault, state-funded compensation scheme. The National Health Services (NHS) of the United Kingdom directs the doctors and managers to inform a patient of an act of negligence or omission that causes harm. The NHS scheme offers a remedial package to the patient including an apology and financial compensation in return for the patients waiving their right to litigate. The Canadian provincial initiatives, though similar in content, remain isolated because of their non-mandatory nature and absence of federal or provincial laws on disclosure. In Conclusion, we suggest that a uniform national policy centered on addressing errors in a non-punitive manner and respecting the patient’s right to an honest disclosure be implemented. &#x0D; Kalra J, Massey KL, Mulla A. Disclosure of medical error: policies and practice. Journal of the Royal Society of Medicine 2005; 98(7): 307-09.&#x0D; Hebert PC, Levin AV, Robertson G. Bioethics for clinicians: 23. Disclosure of medical error. CMAJ 2001; 164(4):509-13.&#x0D; Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Arch Intern Med. 2004; 164(15):1690-7.

The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada

Being involved in medical errors can compound the job-related stress many physicians experience. The impact of errors on physicians was examined. A survey completed by 3,171 of the 4,990 eligible physicians in internal medicine, pediatrics, family medicine, and surgery (64% response rate) examined how errors affected five work and life domains. Physicians reported increased anxiety about future errors (61%), loss of confidence (44%), sleeping difficulties (42%), reduced job satisfaction (42%), and harm to their reputation (13%) following errors. Physicians' job-related stress increased when they had been involved with a serious error. However, one third of physicians only involved with near misses also reported increased stress. Physicians were more likely to be distressed after serious errors when they were dissatisfied with error disclosure to patients (odds ratio [OR] = 3.86, confidence interval [CI] = 1.66, 9.00), perceived a greater risk of being sued (OR = .28, CI = 1.50, 3.48), spent greater than 75% time in clinical practice (OR = 2.20, CI = 1.60, 3.01), or were female (OR = 1.91, CI = 1.21, 3.02). Only 10% agreed that health care organizations adequately supported them in coping with error-related stress. Many physicians experience significant emotional distress and job-related stress following serious errors and near misses. Organizational resources to support physicians after errors should be improved.

Simulation-Based Medical Error Disclosure Training for Pediatric Healthcare Professionals

Ethical and regulatory guidelines recommend disclosure of medical errors to patients and families. Yet few studies examine how to effectively train healthcare professionals to deliver communications about adverse events to family members of affected pediatric patients. This pilot study uses a preintervention-postintervention study design to investigate the effects of medical error disclosure training in a simulated setting for pediatric oncology nurses (N=16). The results of a paired t test showed statistically significant increases in nurses' communication self-efficacy to carry out medical disclosure (t = 6.68, p < .001). Ratings of setting "realism" and simulation effectiveness were high (21 out of 25 composite score). Findings provide preliminary support for further research on simulation-based disclosure training for healthcare professionals.

In reply

In reply

Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees

Disclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood. To survey physicians and trainees about their practices and attitudes regarding error disclosure to patients. Survey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States. Actual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors. Responses were received from 538 participants (response rate = 77%). Almost all faculty and residents responded that they would disclose a hypothetical error resulting in minor (97%) or major (93%) harm to a patient. However, only 41% of faculty and residents had disclosed an actual minor error (resulting in prolonged treatment or discomfort), and only 5% had disclosed an actual major error (resulting in disability or death). Moreover, 19% acknowledged not disclosing an actual minor error and 4% acknowledged not disclosing an actual major error. Experience with malpractice litigation was not associated with less actual or hypothetical error disclosure. Faculty were more likely than residents and students to disclose a hypothetical error and less concerned about possible negative consequences of disclosure. Several attitudes were associated with greater likelihood of hypothetical disclosure, including the belief that disclosure is right even if it comes at a significant personal cost. There appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation.

Confronting Medical Errors in Oncology and Disclosing Them to Cancer Patients

Medical errors are common, and physicians face increasing pressure to fully disclose unanticipated outcomes and medical errors to patients. From an ethical perspective, disclosure is the right thing to do and is wholly consistent with the fiduciary model of the asymmetric physician-patient relationship, in which the patient, vulnerable due to illness, places trust in the expertise and person of the physician. When medical errors occur, the physician-patient relationship is fundamentally tested, and when physicians fail to offer an apology or explanation, patients often perceive a violation not only of their safety, but also of their trust. The issue of which events merit disclosure is still under debate. The most widely disseminated disclosure standard, from the Joint Commission on Accreditation of Healthcare Organizations, requires that patients be informed about all outcomes of care including “unanticipated outcomes,” as defined in the current terminology (Table 1). Although many aspects of patient safety and disclosure are common to all fields of clinical medicine, errors and adverse events have important specialty-specific dimensions. Oncologists face unique challenges in caring for cancer patients that may contribute to the risk of medical errors and to the difficulty of disclosing them to patients. The complexity of most cancer treatments, involving the use of different antineoplastic agents along with concurrent medications and supportive therapies, can make it especially difficult for oncologists to determine whether an adverse event was a result of treatment toxicity, a treatment adverse effect that was more severe or different than expected, or the result of a medical error. The use of detailed chemotherapy protocols makes harmful errors less likely, whereas the need for multiple concomitant medications increases the possibility of their occurrence. In addition, the involvement of interdisciplinary teams in oncology patients’ care may increase the possibility of error or, conversely, may contribute to prevention or earlier detection of some errors. Finally, cancer patients may be enrolled onto clinical trials or may receive relatively new drugs for which adverse effects are not known fully. These factors can increase the odds of adverse events, if not errors. Although most physicians agree on the importance of telling the truth to their patients when a harmful error has occurred, recent studies reveal a gap between patients’ expectations that errors will be disclosed to them and actual clinical practice. Moreover, many unanswered questions remain about how to disclose errors and how disclosure affects liability, patient satisfaction, and other outcomes. In general, oncologists are accustomed to communicating bad news about prognosis and risks in the context of the physical and psychological suffering of cancer patients. This experience makes them natural leaders in the medical profession’s efforts to improve the disclosure of harmful medical errors to patients. This article reviews recent professional approaches to patient safety and the disclosure of medical errors, and addresses some critical aspects of patients’ and physicians’ responses to harmful errors in oncology. We explore different dimensions of disclosure and suggest possible future research, policy, and clinical interventions.

The Many Faces of Error Disclosure: A Common Set of Elements and a Definition

Patients want to know when errors happen in their care. Professional associations, ethicists, and patient safety experts endorse disclosure of medical error to patients. Surveys of physicians show that they believe harmful errors should be disclosed to patients, yet errors are often not disclosed. To understand the discrepancy between patients' expectations and physicians' behavior concerning error disclosure. We conducted focus groups to determine what constitutes disclosure of medical error. Twenty focus groups, 4 at each of 5 academic centers, included 204 hospital administrators, physicians, residents, and nurses. Qualitative analysis of the focus group transcripts with attention to examples of error disclosure by clinicians and hospital administrators. Clinicians and administrators considered various forms of communication about errors to be error disclosure. Six elements of disclosure identified from focus group transcripts characterized disclosures ranging from Full disclosure (including admission of a mistake, discussion of the error, and a link from the error to harm) to Partial disclosures, which included deferral, misleading statements, and inadequate information to "connect the dots." Descriptions involving nondisclosure of harmful errors were uncommon. Error disclosure may mean different things to clinicians than it does to patients. The various forms of communication deemed error disclosure by clinicians may explain the discrepancy between error disclosure beliefs and behaviors. We suggest a definition of error disclosure to inform practical policies and interventions.

Disclosure of medical error: Is it worth the risk?

The climate within the United States is rapidly changing with respect to patient and family knowledge of medical error and their expectations of the events that should occur after an error. This article examines the history and changing tide of medical error disclosure, reviews the limited but growing body of literature surrounding patient and physician attitudes toward disclosing and discussing medical error, makes suggestions on what and how to disclose to patients and families that an error has occurred, and finally, discusses the effect of error disclosure. It seems that if disclosure of medical error is made with compassion, in a timely manner, and with good communication skills both during and after the disclosure process, patients and their families are at least no more likely to seek legal action and some lawsuits may actually be avoided.

Journal Reporting of Medical Errors: The Wisdom of Solomon, the Bravery of Achilles, and the Foolishness of Pan

Medical errors may result from lapses in judgment or lack of prudent care by individual physicians, from system errors inherent in the medical-care delivery model or, more frequently, from a combination of the two. Medical error reporting is a sensitive topic for physicians, institutions, and patients. The veil of secrecy that surrounds medical errors deprives health-care practitioners of knowledge that may help prevent similar adverse outcomes for patients in the future. Although reporting individual medical errors to involved patients is obligatory by most professional codes of conduct for physicians, no laws or professional society guidelines mandate widespread reporting of errors to professional colleagues. Furthermore, reports of medical errors in peer-reviewed journals are extremely rare. In 2000, the Joint Commission for Accreditation of Healthcare Organizations described systemic medical errors as “fundamentally an information problem” and called for the development of programs to collect and analyze medical error data. In this review, we define medical errors and detail common motivations and barriers to publication of error reports. We propose a model for confidential error communication and describe US legislation designed to improve patient safety and establish nationwide programs for error disclosure and analysis.

Medical Malpractice: Understanding the Law, Managing the Risk.

* The Law of Malpractice and Informed Consent: * Condition Critical, Prognosis Guarded * What Is and Isn't Malpractice * Legal Duty * Standard of Care * Causation * Damages * Expert Testimony * Affirmative Defenses * Physician Countersuits * Informed Consent * Patients Who Drive: A New Worry for Doctors * End-of-Life Issues * Complementary and Alternative Medicine * Products Liability * Institutional and Managed Care Liability * Medical Trainees * Risk Management: * Medical Reports and Confidentiality * Cyber-Medicine * What Do Malpractice Lawsuits Look Like? * How to Avoid Becoming a Horror Story * Medical Errors and Their Disclosure * Understanding Malpractice Insurance * What to Expect Now that You've Been Sued * Reforming the System: * Medical and Legal Reforms * Multiple Choice Questions and Answers * Glossary of Legal Terms

Reporting and Disclosing Medical Errors

To characterize pediatricians' attitudes and experiences regarding communicating about errors with the hospital and patients' families. Cross-sectional survey. St Louis, Mo, and Seattle, Wash. University-affiliated hospital and community pediatricians and pediatric residents. Anonymous 68-item survey (paper or Web-based) administered between July 2003 and March 2004. Physician attitudes and experiences about error communication. Four hundred thirty-nine pediatric attending physicians and 118 residents participated (62% response rate). Most respondents had been involved in an error (39%, serious; 72%, minor; 61%, near miss; 7%, none). Respondents endorsed reporting errors to the hospital (97%, serious; 90%, minor; 82%, near miss), but only 39% thought that current error reporting systems were adequate. Most pediatricians had used a formal error reporting mechanism, such as an incident report (65%), but many also used informal reporting mechanisms, such as telling a supervisor (47%) or senior physician (38%), and discussed errors with colleagues (72%). Respondents endorsed disclosing errors to patients' families (99%, serious; 90%, minor; 39%, near miss), and many had done so (36%, serious; 52%, minor). Residents were more likely than attending physicians to believe that disclosing a serious error would be difficult (96% vs 86%; P = .004) and to want disclosure training (69% vs 56%; P = .03). Pediatricians are willing to report errors to hospitals and disclose errors to patients' families but believe current reporting systems are inadequate and struggle with error disclosure. Improving error reporting systems and encouraging physicians to report near misses, as well as providing training in error disclosure, could help prevent future errors and increase patient trust.