Malpractice fear only one barrier to disclosing errors
Malpractice fear only one barrier to disclosing errors
Perfectionism, concern over doing harm also factors
Fear of being sued for malpractice is certainly one obstacle affecting physicians' willingness to disclose medical errors. But other, more personal and altruistic factors may play even bigger roles in whether a doctor decides to reveal his or her own medical errors, according to a University of Iowa bioethicist.
Lauris Kaldjian, MD, PhD, says a review of the factors that motivate or discourage doctors from revealing mistakes, along with a study into how those factors are processed, is revealing.
Kaldjian and his colleagues at the University of Iowa reviewed the literature on error disclosure, and identified 91 associated factors. Focus groups reviewed the findings from that study and added 27 factors.
"One comment from the focus groups clearly showed how emotionally traumatic errors are for physicians — by referring to that 'sinking feeling' when a doctor realizes that an effort to help someone has actually harmed them," Kaldjian says.
That realization that harm has been done in an attempt to help, coupled with a physician's training and innate drive to be above reproach, is among many of the steeper barriers to disclosing error. Paired with those factors are the attitudes and obstacles imposed externally; society, institutions, and colleagues (and competitors) do not create the most welcoming environment for receiving news of medical errors, Kaldjian says.
Disclosure surrounded by 'remarkable tension'
The high standards imposed on physicians by society, government, and physicians themselves are at odds with the recent drive toward more open and full disclosure of medical errors, says Kaldjian.
"There is a remarkable tension in medicine because of all the talk of disclosure," he says. "We establish very high standards for patient care on the one hand. Institutions actually advertise, celebrate the power of healing and promote that their hospitals provide the best care, so there's an expectation of ideals and perfection."
That expectation of perfection is impressed in the physician from the time he or she begins medical training, Kaldjian adds.
"Then someone gets harmed, and we hear messages of being honest about fallibility and being honest about mistakes. So there are mixed messages."
In the first of the two studies reported by Kaldjian, more than 300 previously published papers on factors that hinder or help doctors' disclosure of mistakes were reviewed. Those findings appeared in the April issue of the Joint Commission Journal on Quality and Patient Safety1. Following that literature review, Kaldjian and his colleagues presented the findings to focus groups that looked to understand the factors revealed by the first study. Those findings were reported in the May issue of Journal of General Internal Medicine.
Kaldjian says some physicians reported that the primary motivation to disclose errors was a desire to be straightforward with patients. The flip side, however, is that honesty about errors can harm careers and reputations, and that the culture of competition in medicine discourages doctors from talking about errors with patients and each other.
To disclose or not to disclose?
Kaldjian says there are both positive and negative influences on physicians when it comes to choosing to disclose medical errors, some of which are personal and some of which are rooted in the system. For example, even when an error can be traced back to a flaw in the system, institution, or with a health care team, the physician often becomes the focal point for fallout from that error.
Disclosing medical errors can contribute to quality health care by acknowledging that patients deserve to know when things go wrong, by making institutions aware of flaws, and by showing other health care providers how not to make the same mistakes.
The research team identified four positive and four negative factors that underlie error disclosure. Kaldjian says it's important, in discussing medical error reporting, to not focus only on the negatives.
The motivators considered positive are: responsibility to the patient; responsibility to the physician him- or herself (preserving the doctor's integrity); responsibility to the medical profession; and responsibility to the community as a whole.
Motivators viewed as negative, which may prevent doctors from reporting errors or, at least, may cause them to consider not reporting them, are: attitude-related barriers, such as perfectionism; uncertainties about how to disclose or whether an error actually exists; fears and anxieties about the repercussions, including malpractice litigation and loss of status; and loss of control over the situation once the error becomes known.
"Let's pretend for a minute that malpractice litigation is no longer in existence," says Kaldjian. "You still have an enormous hurdle for physicians, purely for the intrinsic reasons that exist in so many domains — the basic human desire to be a helper, and then to realize that you have been part of an action that hurt someone."
The Iowa researchers also found that physicians are sometimes frustrated when their institutions have reporting systems, but they get no feedback when errors are reported. No feedback — or getting only negative feedback — is not going to make reporting of medical errors any easier or more beneficial, Kaldjian says.
Teaching by example, the wrong way
Kaldjian says one surprise in the study findings was how frequently physicians in training roles were unwilling to admit to errors.
"People in training environments, surrounded by junior learners, are most susceptible to the pride of not wanting people to know their mistakes," he says. "And if the people trying to be role models are only a step ahead of the learners [in being open to admitting mistakes], that environment is not going to be conducive to teaching people how to report errors."
Concern over how employers, colleagues, and students might view a physician after he or she makes a report of an error is a difficult hurdle to overcome, Kaldjian admits.
He points to the work of advocates such as Lucian Leape, MD, as important in fostering a change in the culture that punishes errors. Leape, a health policy analyst nationally recognized for his work in patient safety, is an outspoken advocate of the nonpunitive systems approach to the prevention of medical errors.
"There are persistent and irresolvable tensions [surrounding medical errors], and we hold physicians to very, very high standards," Kaldjian says. "But we were encouraged to see, on the positive side, positive drivers of disclosure, the basic personal motivators, were very strong."
He says he doesn't know if it is possible to teach someone to be motivated to do the right thing when faced with the personal threats that arise in error reporting; but many doctors report that the motivation to do what is right for the patient, for medicine, and for the community is basic and strong.
"What people bring to medicine and medical ethics, personally, is very important when it comes to error disclosure," he adds. "What people bring to their medical training from outside, from the rest of their lives and their backgrounds should never be underestimated."
Sources/Resources
For more information:
- Lauris C. Kaldjian, MD, PhD, department of internal medicine; director, program in biomedical ethics & medical humanities, University of Iowa Carver College of Medicine, Iowa City, IA. E-mail: [email protected].
- 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; 32:188-198.
- Kaldjian LC, Jones EW, Rosenthal GE, et al. An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors. J Gen Intern Med, published on-line May 2006. Available on-line at www.blackwell-synergy.com/doi/abs/10.1111/j.1525-1497.2006.0489.x.
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