Disclosure of medical error

One of the worst scenarios a family can face is a serious medical error. Having been at the bedside for months, I knew that the risk of an error grew with the expanding number and complexity of interventions and time in the hospital. Having met and been greatly impressed by several hospital staff working to improve patient safety, and the manner that they are including parents on committees, I found the following abstracts focusing on systems and patterns of disclosure of error to be quite interesting. The final article suggests that if there is a gap between policies and practise of open disclosure, explicit focus is needed not just on education but also on uncovering the barriers to implimentation of open disclosure policies.

A System Of Medical Error Disclosure (2002): Such a system can result using clear disclosure policies and procedures sensitive to patient and family needs, open communications with concerned, committed, and compassionate system representatives, and use of mediation methods that foster communication, allow for venting, and are flexible in their approach to resolving conflict, including using apology. Although a system may also result in conflict resolution costs, more importantly it may foster and solidify a team approach to reducing errors and promoting patient safety.

What Makes An Error Unacceptable (2004): Results. While the severity of the outcomes of errors remains the most important single factor in the choice of actions to be taken, the professional’s approach to the error is regarded as essential in the overall evaluation of errors and the consideration of consequences. In errors with a severe outcome, an honest, empathic, and accountable approach to the error decreases the probability of participants’ support for strong sanctions against the physician involved by 59%. Judgments were only marginally affected by respondents’ characteristics.

To Tell Or Not To Tell (2006) One published study [1] disclosed that only 50% of house staff physicians who admitted making serious clinical errors disclosed their errors to medical colleagues, and only 25% disclosed them to the patients or their families. In another published survey of laypersons, only a third of respondents who had experienced medical error said that the physicians involved in the error had informed them about it [2]. Still another survey asking European physicians whether they would disclose a medical error to patients found that although 70% responded that physicians should provide details of such an event, only 32% would actually disclose the details of what happened [3]. A similar percentage of American physicians, 77%, echoed the same opinion [2]. A British researcher explains this reluctance to disclose by pointing out that physicians who commit medical errors frequently question their own competence and fear being discovered; they know they should confess but "dread the prospect of potential punishment" [4]. These reactions are "reinforced during medical training; the culture of medical school and residency implies that mistakes are unacceptable and point to a failure of effort or character." Why physicians may choose to cover up rather than disclose an error was illustrated in a letter to the editor published in the Journal of the American Medical Association [5]. The letter described an incident in which a medical resident's employment in a Chicago hospital was summarily terminated after he voluntarily reported committing an error that led to the accidental exposure of a patient to HIV. The letter writer speculated that the resident's career would have remained intact and unblemished had he chosen to remain silent about the error and voiced concern that this incident would encourage an atmosphere that rewards lying. Certainly, many physicians believe that admitting mistakes invokes the so-called shame and blame mentality [6], thereby precipitating medical malpractice litigation [7-9] and leading to loss of referrals, hospital admitting privileges, preferred provider status, and even licensure [10, 11]. Other researchers [12] have emphasized that being subjected to a malpractice lawsuit is "an extremely powerful punishment that strikes at the heart of the professional's self-image as a caring and competent physician." The question of whether mistakes or errors committed by physicians should be disclosed to patients affected by them is no longer debatable. The preponderance of legal opinion, regulations of federal and state agencies, and policies of professional organizations all favor the physician's complete disclosure of all facts and information relevant to a patient's health, including complications of medical procedures and iatrogenic errors and injuries [13-16]. But the question of what physicians should say to patients as part of the disclosure of an error—in other words, whether they should apologize and, if so, what that apology should include—warrants further discussion.

Health Care Professionals' Views Of Implementing A Policy Of Open Disclosure Of Errors (2008): Results: Health professionals are positive about open disclosure and are applying the model to patient–clinician communication encounters more generally. Workforce and systems competencies enable clinicians and health service managers to implement open disclosure principles and practices, although a propensity to hide errors, wavering commitment and to exacerbate the problem inhibits implementation as policy intends. The gap between policy objectives and their implementation limits the benefits to health professionals.

Conclusion: Health services must develop organizing capabilities if open disclosure is to be implemented as intended. Activities should identify and address factors that impede implementation and enable workforce and system competencies to develop. These activities will allow health services to adapt central open disclosure policy to local conditions and to embed its principles and practices organization-wide.

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