Communication studyError disclosure and family members’ reactions: Does the type of error really matter?
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.
References (32)
- et al.
Building bridges: future directions for medical error disclosure research
Patient Educ Couns
(2013) - et al.
The Roter interaction analysis system (RIAS): utility and flexibility for analysis of medical interactions
Patient Educ Couns
(2002) - et al.
How surgeons disclose medical errors to patients: a study using standardized patients
Surgery
(2005) Shedding light on the dark side of doctor–patient interactions: verbal and nonverbal messages physicians communicate during error disclosures
Patient Educ Couns
(2011)- et al.
Examination of standardized patient performance: accuracy and consistency of six standardized patients over time
Patient Educ Couns
(2011) Disclosing medical errors to patients: effects of nonverbal involvement
Patient Educ Couns
(2014)Committee on Quality of Health Care in America, to err is human: building a safer health system
(2000)Disclosing medical error: a guide to an effective explanation and apology
(2007)- et al.
Talking with patients and families about medical errors
(2011) Code of medical ethics, annotated current opinions
(2004–2005)