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.
Similar content being viewed by others
References
Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Arch Intern Med. 2004;164:1690–7.
Hobgood C, Tamayo-Sarver JH, Elms A, Weiner B. Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Pediatrics. 2005;116:1276–86.
Hobgood C, Hevia A, Tamayo-Sarver JH, Weiner B, Riviello R. The influence of the causes and contexts of medical errors on emergency medicine residents’ responses to their errors: an exploration. Acad Med. 2005;80:758–64.
American Board of Internal Medicine, American College of Physicians–American Society of Internal Medicine, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243–6.
AMA Council on Ethical and Judicial Affairs. Code of Medical Ethics: Current Opinions with Annotations (Opinion 8.12). Chicago, IL: American Medical Association; 1998. Available at http://www.ama-assn.org/ama/pub/category/2498.html. Accessed April 24, 2006.
American College of Physicians. Ethics manual. Fourth edition. American College of Physicians. Ann Intern Med. 1998;128:576–94. Available at http://www.acponline.org/ethics/ethics_man.htm. Accessed April 24, 2006.
Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med. 1997;12:770–5.
Gallagher TH, Waterman AD, Ebers AG, Faser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001–7.
Gallagher TH, Lucas MH. Should we disclose harmful medical errors to patients? If so, how? J Clin Outcomes Manag. 2005;12:253–9.
Gallagher TH, Levinson W. Disclosing harmful medical errors to patients: a time for professional action. Arch Intern Med. 2005;165:1819–24.
Rosner F, Berger JT, Kark P, Potash J, Bennett AJ. Disclosure and prevention of medical errors. Arch Intern Med. 2000;160:2089–92.
Mavroudis C, Mavroudis CD, Naunheim KS, Sade RM. Should surgical errors always be disclosed to the patient? Ann Thorac Surg. 2005;80:399–408.
Krizek TJ. Surgical error: ethical issues of adverse events. Arch Surg. 2000;135:1359–66.
Chan DK, Gallagher TH, Reznick R, Levinson W. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery. 2005;138:851–8.
Gallagher TH, Garbutt JM, Waterman AD, Flum DR, Larson EB, Waterman BM, Dunagan WC, Faser VJ, Levinson W. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med. 2006:1585–93.
Leape LL, Berwick DM. Five years after To Err is Human: What have we learned? JAMA. 2005;293:2384–90.
Banja J. Moral courage in medicine—disclosing medical error. Bioethics Forum. 2001;17:7–11.
Weber DO. Who’s sorry now? Physician Exec. 2006;32:6–14.
Weissman JS, Annas CL, Epstein AM, Schneider EC, Clarridge B, Kirle L, Gatsonis C, Feibelmann S, Ridley N. Error reporting and disclosure systems: views from hospital leaders. JAMA. 2005;293:1359–66.
Baylis F. Errors in medicine: nurturing truthfulness. J Clin Ethics. 1997;8:336–40.
Berlinger N. Avoiding cheap grace: medical harm, patient safety, and the culture(s) of forgiveness. Hastings Cent Rep. 2003;33:28–36.
Standard RI. 2.90. 2006 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH). Oak Brook, IL: Joint Commission Resources; 2005.
Kaldjian LC, Jones EW, Rosenthal GE. Facilitating and impeding factors for physicians’ error disclosure: a structured literature review. Jt Comm J Qual Patient Saf. 2006;32:188–98.
Kaldjian LC, Jones EW, Rosenthal GE, Tripp-Reimer T, Hillis SL. An empirically derived taxonomy of factors affecting physicians’ willingness to disclose medical errors. J Gen Intern Med. 2006;21:942–8.
Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med. 2004;350:283–92.
Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Does full disclosure of medical errors affect malpractice liability? Jt Comm J Qual Saf. 2003;29:503–11.
Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, Altman DE, Zapert K, Herrmann MJ, Steffenson AE. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933–40.
Nunnally JC, Bernstein IH. Psychometric Theory (3rd Ed.). New York, NY: McGraw-Hill; 1994.
Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131:963–7.
Mazor KM, Reed GW, Yood RA, Fischer MA, Baril J, Gurwitz JH. Disclosure of medical errors: what factors influence how patients respond? J Gen Intern Med. 2006;21:704–10.
Cleopas A, Villaveces A, Charvet A, Bovier PA, Kolly V, Perneger TV. Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness. Qual Saf Health Care. 2006;15:136–41.
Mazor KM, Simon SR, Yood RA, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med. 2004;140:409–18.
Shelp EE. Courage: a neglected virtue in the patient–physician relationship. Soc Sci Med. 1984;18:351–60.
Leape LL. Error in medicine. JAMA. 1994;272:1851–7.
Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
Gallagher TH, Waterman AD, Garbutt JM, Kapp JM, Chan DK, Dunagan WC, Faser VJ, Levinson W. US and Canadian physicians’ attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006;166:1605–11.
Gabbard GO. The role of compulsiveness in the normal physician. JAMA. 1985;254:2926–9.
Dubovsky SL, Schrier RW. The mystique of medical training: is teaching perfection in medical house-staff training a reasonable goal or a precursor of low self-esteem? JAMA. 1983;250:3057–8.
Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310:118–22.
Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, Gurwitz JH. Health plan members’ views on forgiving medical errors. Am J Manag Care. 2005;11:49–52.
Leape LL. Understanding the power of apology: how saying “I’m sorry” helps heal patients and caregivers. Focus Patient Saf. 2005;8:1–3. Available at http://www.npsf.org/download/Focus2005Vol8No4.pdf. Accessed April 24, 2006.
Leape LL. Full disclosure and apology—an idea whose time has come. Physician Exec. 2006;32:16–8.
Flynn E, Jackson JA, Lindgren K, Moore C, Poniatowski L, Youngberg B. Shining the light on errors: How open should we be? Oak Brook, IL: University HealthSystem Consortium; 2002.
Studdert DM, Brennan TA. No-fault compensation for medical injuries: the prospect of error prevention. JAMA. 2001;286:217–23.
Schoenbaum SC, Bovbjerg RR. Malpractice reform must include steps to prevent medical injury. Ann Intern Med. 2004;140:51–3.
Acknowledgments
Preliminary and partial data from this study were presented at the Society of General Internal Medicine’s 29th Annual Meeting in Los Angeles and have been published as an abstract [Journal of General Internal Medicine 2006;21(S4):36]. This study was funded by the Robert Wood Johnson Foundation’s Generalist Physician Faculty Scholars Program, through a grant to Dr. Kaldjian (grant # 45446). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
Conflicts of Interest
None disclosed.
Author information
Authors and Affiliations
Corresponding author
Additional information
An erratum to this article can be found at http://dx.doi.org/10.1007/s11606-007-0299-9
Appendix
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? |
Rights and permissions
About this article
Cite this article
Kaldjian, L.C., Jones, E.W., Wu, B.J. et al. Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees. J GEN INTERN MED 22, 988–996 (2007). https://doi.org/10.1007/s11606-007-0227-z
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-007-0227-z