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

Abstract

BACKGROUND

Disclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood.

OBJECTIVE

To survey physicians and trainees about their practices and attitudes regarding error disclosure to patients.

DESIGN AND PARTICIPANTS

Survey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States.

MEASUREMENTS

Actual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors.

RESULTS

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.

CONCLUSIONS

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.

Appendix

A hypothetical clinical vignette with outcomes of varying severity [the vignette was modified for pediatric faculty and residents (see text)].

A 67-year-old man is admitted at night to your hospital service for treatment of pneumonia. He has an allergy to cephalosporin antibiotics, which is noted in his medical record. At the time of the interview and examination, you forget to ask him about allergies, and in your efforts to expedite the start of his treatment you do not notice the antibiotic allergy documented in his medical record. You write an order for a cephalosporin antibiotic and a nurse gives the drug to the patient, intravenously.

Outcome #1 (no harm):

The next morning on rounds, you notice his cephalosporin allergy in the medical record. You are relieved to find that the patient has no new complaints and there is no evidence of an allergic reaction. You discontinue the cephalosporin and order an alternative antibiotic. The patient gives no indication that he is aware of any problems in his care. In this scenario, how likely is it that you would tell the patient that you mistakenly ordered, and he received, an antibiotic to which he was known to be allergic?

Outcome #2 (minor harm):

The next morning on rounds, the patient is moderately uncomfortable due to diffuse itching and has a rash all over his body. You discontinue the cephalosporin, order an alternative antibiotic, and the patient recovers fully from the drug reaction over the next 3 days. In this scenario, how likely is it that you would tell the patient that you mistakenly ordered, and he received, an antibiotic to which he was known to be allergic?

Outcome #3 (major harm):

Two hours after you admit the patient to the hospital, you receive a call from the ward nurse. The nurse explains that half an hour after the cephalosporin was administered, the patient was found to be in respiratory distress and then anaphylactic shock. Cardiopulmonary resuscitation was administered and the patient was transferred to the intensive care unit. Subsequent cardiac testing shows that a moderate myocardial infarct has occurred. The patient’s condition stabilizes and he is transferred out of the intensive care unit after 3 days. In this scenario, how likely is it that you would tell the patient (when stable) that you mistakenly ordered, and he received, an antibiotic to which he was known to be allergic and which caused his anaphylactic shock?