Communication study
Error disclosure and family members’ reactions: Does the type of error really matter?

https://doi.org/10.1016/j.pec.2014.12.011Get rights and content

Highlights

  • Mentioning the error and apologizing seemed not to be common practice.

  • The type of error (clear vs shared responsibility) affected the practice of disclosure.

  • Communicating medical errors elicits strong negative emotions by patients.

  • Specific training programs to improve disclosure practice should be implemented.

Abstract

Objective

To describe how Italian clinicians disclose medical errors with clear and shared lines of responsibility.

Methods

Thirty-eight volunteers were video-recorded in a simulated conversation while communicating a medical error to a simulated family member (SFM). They were assigned to a clear responsibility error scenario or a shared responsibility one. Simulations were coded for: mention of the term “error” and apology; communication content and affect using the Roter Interaction Analysis System. SFMs rated their willingness to have the patient continue care with the clinician.

Results

Clinicians referred to an error and/or apologized in 55% of the simulations. The error was disclosed more frequently in the clear responsibility scenario (p < 0.02). When the “error” was explicitly mentioned, the SFM was more attentive, sad and anxious (p  0.05) and less willing to have the patient continue care (p < 0.05). Communication was more patient-centered (p < 0.05) and affectively dynamic with the SFMs showing greater anxiety, sadness, attentiveness and respectfulness in the clear responsibility scenario (p < 0.05).

Conclusions

Disclosing errors is not a common practice in Italy. Clinicians disclose less frequently when responsibility is shared and indicative of a system failure.

Practice implications

Training programs to improve disclosure practice considering the type of error committed should be implemented.

Introduction

The past decade has brought attention to the number of preventable deaths and injuries attributable to medical errors and they have been identified by healthcare and policy institutes as a major challenge to patient safety [1], [2]. Medical errors arise from a complex interaction of human and organizational factors and guidelines regarding honest and transparent disclosure of medical errors have been promulgated [2]. Disclosure of medical errors to patients and families is considered a core aspect of ethical practice [3] and endorsed by professional codes of conduct [4], [5]. In 2001, the US Joint Commission on Accreditation of Healthcare Organizations required hospitals to disclose all unanticipated care outcomes to patients, even those that do not lead to substantial harm.

Several studies have identified elements of appropriate disclosure [6], [7]. Patients desire an explicit statement that an error has occurred, information about what went wrong and why, specific implications so they can make informed decisions, and a sincere apology by their physician that recognizes their suffering [8]. Competent disclosure has been associated with higher patient satisfaction, greater trust and less sanctions against the physicians [9], [10]. Nevertheless, physicians are often reluctant to disclose medical errors because they fear losing their job, being involved in malpractice litigation, jeopardizing the trust of coworkers and facing their own failure [11]. Failure to disclose even hypothetical serious medical errors was reported by Gallagher and colleagues [7] to be as high as 58% based on survey responses of over 2500 medical and surgical physicians in the US and Canada. Willingness to disclose the error was especially low, averaging 32%, when the scenario represented a less obviously apparent error [7]. The emotional pressure commonly experienced after a medical error, coupled with a lack of legal protection, may reinforce clinicians’ instincts for self-preservation over their desire and professional obligation to tell patients the truth [12].

Despite growing attention to issues surrounding medical errors worldwide, few studies addressing medical error communication have been conducted within the European context [6], [13]. In Italy, a culture of medical transparency is newly emerging and disclosure policies are guided only by the ethical code [14] and ministerial recommendations, not by specific laws. While there are no national initiatives to promote the identification and the analysis of medical errors, the past few years have witnessed the development of programs in regions and local hospitals.

The aim of the current study is to contribute to this literature by conducting a small pilot study designed to explore how Italian clinicians disclose medical errors in a simulated encounter with a patient's family member. Two common medical error scenarios are explored, one with a clear line of responsibility (a drug error) and a second in which shared lines of responsibility are identified reflecting a broader system error (a missed diagnosis and poor patient supervision).

We posit the following hypotheses:

  • (1)

    Clinicians will be more likely to explicitly note that an error was made and offer an apology in the clear compared with shared responsibility scenario.

  • (2)

    Communication patterns between clinicians and simulated family members (SFM) will be more patient-centered and affectively engaged: (a) in the clear compared with shared responsibility scenario; and, (b) when an error is explicitly noted and an apology made.

  • (3)

    The SFMs will be more willing to continue care with a clinician who admits an error and offers an apology.

Section snippets

Participants

Participants in the current study were recruited from attendees at a continuing educational Program to Enhance Relational and Communication Skills (PERCS) on error disclosure [15]. Each PERCS workshop lasted 4 h and was open to interdisciplinary participants. The workshop begun with a brainstorming activity and a brief theoretical presentation including systemic definition of medical error. It continued with the enactment of two different scenarios portrayed by volunteering participants and

Error disclosure and clinicians’ apology

Clinicians first introduced the word “error” or “mistake” in 11 sessions, SFM introduced the term error in 2 sessions and error was not mentioned at all in 7 of the sessions. Clinicians mentioned the word “error” more frequently in the context of clear rather than shared responsibility (8 vs 3 error mentions, respectively; p < 0.02). Clinicians proffered an apology (e.g. “I’m sorry”; “I apologize for this”) in 11 sessions and there were no differences in the frequency of apologies when

Discussion

While there have been a few US studies that explored how physicians disclose medical errors to patients within a simulation context [21], [22], the present study is the first to describe how Italian clinicians are likely to communicate a medical error. Moreover, to our knowledge this is the first simulation study to explore differences in error disclosure under two common but importantly distinct circumstances: clear error responsibility versus shared lines of responsibility indicative of a

Conclusion

Our findings suggest that linking apology to an acknowledgment of an error is a relatively uncommon practice among Italian clinicians. Moreover, the type of error affected the practice of disclosure. When the lines of responsibility were shared, clinicians disclosed less and the conversations were less patient-centered and affectively dynamic and more task-focused. This should be considered when planning the communication to patients and families.

Finally, communicating medical errors elicits

Practice implications

Educational programs on error disclosure should address the context within which an error is committed when communicating with patients and families. Moreover, training should acknowledge the need to acknowledge and respond to negative patient emotions such as anger, sadness and anxiety that error disclosures may elicit.

The observed disclosure practice in the Italian context suggests that a revision of the legal system may be necessary in order to encourage greater clinician transparency.

Acknowledgements

We thank the actors and the clinicians who participated in the study. All authors confirm all personal identifier have been removed or disguised so the persons described are not identifiable and cannot be identified throughout the details of the story.

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