Enhancing the Disclosure of Medical Errors in Primary Care

Presenter: Thomas H. Gallagher, MD

Institution: University of Washington School of Medicine

Co-Authors: Amy D. Waterman, PhD; Alison Ebers, Wendy Levinson, MD; Vicky Fraser, MD

Introduction: While disclosing errors to patients is recommended, such disclosure is uncommon. Disclosing errors is especially challenging in primary care, where few systems exist to detect medical errors and institutional resources to support disclosure may be lacking. We will present our research in error disclosure (JAMA 203;289:1001-1007) and a related educational program.

Methods: We explored patients’ and physicians’ attitudes about medical error disclosure by conducting 13 focus groups with patients and physician. Fifty-two patients and 46 physicians, 66% of whom were primary care physicians, participated.

Results: The focus groups were analyzed qualitatively. Both patients and physicians had unmet needs following errors. Patients wanted disclosure of all harmful errors, and sought information about what happened, why the error happened, how the error’s consequences will be mitigated, and how recurrences will be prevented. Physicians agreed that harmful errors should be disclosed, but "choose their words carefully" when telling patients about errors. While physicians disclosed the adverse event, they often avoided stating that an error occurred, why the error happened, or how recurrences would be prevented. Patients also desired emotional support from physicians following errors, including an apology. However, physicians worried that an apology might create legal liability. Physicians were also upset when errors happen, but were unsure where to seek emotional support. We concluded that physicians may not be providing the information or emotional support that patients seek following harmful medical errors. Physicians should strive to meet patients’ desire for an apology and for information on the nature, cause, and prevention of errors. Institutions should also address the emotional needs of providers who are involved in medical errors.

Discussion: Based on this research, we have developed an error disclosure workshop for primary care trainees. This interactive 90-minute session begins by presenting basic background information about the nature and prevalence of medical errors, the rationale for error disclosure, and the existing empirical data suggesting that error disclosure at present may be infrequent. Next we present our research results highlighting the gap between patients’ preferences for error disclosure and the information physicians are willing to provide about medical errors, illuminating common barriers physicians experience to error disclosure. Then a video trigger tape of a disclosure conversation in presented, demonstrating how "choosing your words carefully" during error disclosure can be problematic. A second didactic portion follows in which a framework for error disclosure is presented. A key portion of the didactic material is encouraging participants to get help from a senior colleague and from risk managers when deciding whether and what to disclose to patients about medical errors. Participants then have the opportunity to practice error disclosure with a standardized patient portraying the error scenario from the trigger tape and to receive feedback from the audience, the standardized patient, and the presenter. Participants leave the workshop with an understanding of key conceptual issues underlying error disclosure as well as practical communication strategies to improve error disclosure conversations.