3/10/2003

Patients, Physicians Differ on Error Disclosure

Kate Traynor

A report published in the Feb. 26 Journal of the American Medical Association indicates that patients and physicians have different attitudes and expectations about when and how to disclose medical errors.

The report, which is based on data from small focus groups of patients and physicians, noted that the disclosure process is complicated by patients and physicians having different ideas of what constitutes a medical error.

For the purposes of the study, patients and physicians were told that an error is the "failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." Physicians interpreted this definition to mean that errors are deviations from the accepted standard of care.

Error-Reduction Ideas for Teaching Hospitals

A brief article in the Feb. 27 New England Journal of Medicine gives suggestions from two former medical residents about reducing errors in teaching hospitals, the predominant practice setting for graduate medical education in the United States. Among the suggestions are:

  • Train residents how to coordinate care with pharmacy, nursing, and other professional staff members at the hospital.
  • Implement computerized prescriber order-entry systems with decision-support software for drug orders to reduce medication errors.
  • Develop a standardized system in the hospital for chart storage and the location of critical supplies, making it easier and more efficient for residents to work when moving between different units at the hospital.
  • Prevent frequent interruptions in patient care by use alphanumeric paging systems with priority levels, and require residents to respond immediately only to pages coded as emergency. Urgent and routine communications could be responded to at set times.
In general, patients agreed that deviations from the standard of care are errors. But patients also included in their definition of an error issues related to the quality of service, such as a long waiting time before the start of a procedure. Personality-related issues, such as rude behavior by a physician, also counted as errors. Finally, patients were likely to view unavoidable adverse events, such as previously unknown drug allergies, as medical errors. 

According to the report, physicians were "frustrated by the breadth of what patients considered to be errors and thought patients were often unduly upset over 'minor' errors."

Error scenarios discussed by the focus groups were hypothetical but realistic situations. Ten focus-group meetings included just patients or just physicians, and four groups consisted of patients and physicians. On average, 10 people participated in each focus group, with participants drawn from the St. Louis area.

The study found that, in general, patients wanted to be informed of all errors causing harm. Many physicians, however, said they preferred not to disclose harmful but "trivial" errors, harmful errors of which the patient was unaware, and errors about which a physician believed a patient would prefer to remain unaware.

After an error occurred, patients said they would want to know what had happened, how the error would affect their health, and how the error would be corrected. Patients also said that it was important to be told how future occurrences of the error would be prevented. According to the report, most patients believed that this basic information should be freely provided by the physician without the need for prodding by the patient.

Physicians' attitudes about the specifics of error disclosure were affected by fears of legal liability and concerns about how the error would affect the physician's career. According to the report, most physicians preferred to word the disclosure carefully, describing only the basic facts of the adverse event that resulted from the error but not necessarily saying that an error had occurred.

None of the physicians who participated in the study said they would tell patients how the error would be prevented in the future.

The study also examined the emotional reactions of patients and physicians to medical errors. Patients said they would feel sad, anxious, traumatized, or angry during the aftermath of an error. Physicians also reported that, after making an error, they felt upset and guilty, fearful of a lawsuit, and anxious about how the error would affect the physician's reputation. According to the report, patients were surprised to hear that errors affected physicians so strongly.

Most patients believed strongly that physicians should apologize after committing an error. Physicians said they were worried that an apology could be interpreted as an admission of legal liability. The report’s authors urged physicians to take seriously patients’ desire for an apology and frank information about the details of the error.


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