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Academic Medicine:
Perceptions of Abuse and Failure

Factors Influencing Preceptors’ Responses to Medical Errors: A Factorial Survey

Mazor, Kathleen M.; Fischer, Melissa A.; Haley, Heather-Lyn; Hatem, David; Rogers, H Jane; Quirk, Mark E.

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Author Information

Correspondence: Kathleen M. Mazor, EdD, 630 Plantation Street, Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA 01605; e-mail: 〈Kathleen.mazor@umassmed.edu〉.

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Abstract

Background: Preceptors must respond to trainees’ medical errors, but little is known about what factors influence their responses.

Method: A total of 115 primary care preceptors from 16 medical schools responded to two medical error vignettes involving a trainee. Nine trainee-related factors were randomly varied. Preceptors indicated whether they would discuss what led to the error, provide reassurance, share responsibility, express disappointment, and adjust their written evaluation of the trainee.

Results: Almost all preceptors would discuss what led to the error; relatively few would express disappointment. The trainee’s prior history of errors, knowledge level relative to peers, receptivity to feedback, training level, emotional reaction, offering to apologize, and offering an excuse were predictive of preceptors’ responses; gender and time-in-office were not.

Conclusion: This study identified seven trainee-related factors as predictive of preceptors’ responses to medical errors. More research is needed to identify other influential factors, and to improve teaching from medical errors.

The Institute of Medicine Report, To Err Is Human, increased awareness of the problem and the prevalence of medical errors.1 Efforts to better understand the causes of medical errors and to improve patient safety are ongoing, but the complexity and uncertainty inherent in the practice of medicine make it unlikely that medical errors will ever be eliminated. This is particularly true in medical education and residency programs where trainees are, by definition, inexpert. An important but largely unexplored area of patient safety research is how preceptors respond to medical errors in the training environment. Most physicians will have their first professional involvement with a medical error in medical school or residency, and experiences with error and the consequences of error during training are likely to influence long-term attitudes and behaviors around medical errors.2 Knowledge of how preceptors respond to medical errors, and an understanding of the factors that influence these responses, are essential for developing strategies to optimize learning from medical errors.

Recent findings suggest that preceptors respond to medical errors in teaching settings by reviewing with the trainee the circumstances that led to the error, and by offering emotional and normative support.2 Preceptors in that study reported making efforts not to add to trainees’ self-recriminations with formal or informal negative evaluations, and appeared hesitant to express negative reactions to trainees’ errors. Several factors appeared to influence how preceptors would be likely to respond to a given error situation, but the qualitative approach did not allow systematic evaluation of the relative impact of these factors. Prior studies have highlighted the importance of contextual features that influence learners’ decision making in professionally challenging situations,3 suggesting that contextual features may also influence preceptors’ decision making. Therefore, this study sought to investigate preceptors’ responses to trainees’ medical errors, and to identify the factors that influence those responses.

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Method

A factorial survey methodology was used.4 The study sample and the instrument are described below.

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Setting and participants

Participants were primary care preceptors attending a faculty development conference series on educational planning and teaching sponsored by the University of Massachusetts Medical School Community Faculty Development Center. Attendees were drawn from general internal medicine, family medicine, and pediatrics departments of 16 medical schools in the northeastern United States. The anonymous questionnaire was included with conference materials provided to two cohorts of attendees, in November 2003 and January 2004. Participants completed and returned the questionnaires prior to the start of conference sessions.

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Questionnaire

The questionnaire presented two fictional vignettes describing medical errors occurring in a preceptor’s office. The first vignette described administration of the wrong immunization to a two-year-old boy; the boy suffered no injury, but needed to return for an additional appointment. The second vignette described an error in which a 25-year-old woman with a documented penicillin allergy was given a prescription for dicloxacillin. She is contacted before taking the medication, and no harm occurs. The vignettes differed along several dimensions, including the age and gender of the patient, the specific error involved, and the preceptor’s relationship with the trainee. In neither vignette did the patient suffer significant harm as a result of the error.

Within each vignette, nine trainee-related factors were randomly varied, resulting in 768 possible versions of the questionnaire. The factors and the levels of each factor are presented in Table 1. Individual questionnaires were generated using a random number generator to specify factor levels for each questionnaire. With the exception of trainee gender, factors had been identified as possible influences on preceptors’ responses in an earlier study.2 Participants were instructed to respond as if they were the preceptor in the vignette. Five items, developed based on focus-group findings,2 queried how likely the preceptor would be to: (1) further discuss what happened to determine what led to the error; (2) reassure the trainee that everyone makes errors; (3) tell the trainee that such errors are not acceptable, and express disappointment; (4) assume some responsibility for the error; and (5) be negatively influenced in their written evaluation. Responses were on a seven-point scale, with 1 labeled “definitely would NOT” and 7 labeled “definitely WOULD.” Responses of 5, 6, or 7 were coded as endorsements in calculating percentages.

Table 1
Table 1
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The study was reviewed by the University of Massachusetts Medical School Institutional Review Board.

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Analysis

Descriptive statistics for the five dependent variables were computed for each vignette. The influence of the independent variables on each preceptor response was evaluated using linear regression. Each dependent variable was analyzed separately, as was each vignette. All nine independent variables were entered into a regression model simultaneously; we examined the statistical significance of the full model, and the significance of the b parameter associated with each predictor. Separate regression analyses were conducted predicting response from preceptor specialty and gender, but these variables had minimal impact and are not considered further here.

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Results

Completed questionnaires were returned by 115 of 119 preceptors for a response rate of 96.6%. Respondent characteristics were as follows: 41% practiced family medicine, 30% internal medicine, 24% pediatrics, and 5% other primary care medicine or unspecified; 35% had been teaching less than 4 years, 37% between four and ten years, 14% longer than ten years, and 15% did not specify; 63.5% were female.

The vast majority of preceptors endorsed discussing what happened in an effort to determine what led to the error (95% wrong immunization; 96% missed allergy). Fewer would tell the trainee they shared some responsibility for the error (75% wrong immunization; 78% missed allergy), and still fewer would offer reassurance (58% wrong immunization; 42% missed allergy). The incident would have a negative effect on a written evaluation for 41% of the preceptors in the wrong-immunization vignette, and for 50% in the missed-allergy vignette. However, few preceptors would express their disappointment to the trainee—only 8% would do so in wrong-immunization vignette, while 27% would do so in the missed-allergy vignette.

Results of the regression analyses are presented in Table 1. The R2 statistic quantifies how well the nine design variables as a set predict the preceptor response, and can be interpreted as the percentage of the variance in the dependent variable that is explained by the independent variables. We report adjusted R2 statistics; the adjustment takes into account the number of predictors in the model. The strongest relationships between the trainee level variables and preceptor response were found for “would have a negative effect on the written evaluation of the trainee”: for the wrong-immunization vignette, the adjusted R2 was .246, and for the missed allergy, the adjusted R2 was .261. Both of these were highly statistically significant (p < .001). The responses “offer reassurance” and “express disappointment” were also reasonably well predicted by the full set of trainee variables for both vignettes, with approximately 10–15% of the variance explained in each model (adjusted R2 ranged from .108 to .154). This was also true for predicting “discuss what led to the error” for the wrong-immunization vignette (adjusted R2 = .159) but not for the missed-allergy vignette (adjusted R2 = .017, p > .05). No association between the full set of the nine trainee variables and the preceptor response of sharing responsibility was detected (p > .05).

The regression analyses also provide tests of the predictive value of each independent variable over and above the other variables in the model. The effects and directions of the effects are summarized in text in Table 1; statistics are reported in Table 2.

Table 2
Table 2
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Discussion

Preceptors engage in a variety of responses when trainees commit medical errors. It is not surprising that almost all preceptors would discuss the circumstances that led to the error for the two error vignettes studied here. The current study did not investigate what form such discussions might take, or how preceptors would address system-level issues, the trainee’s responsibility, the preceptor’s responsibility, and the interrelationships between these. Discussions of the circumstances that led to the error may serve as informal systems analyses, and may be a reasonable first step in reducing the likelihood of future errors. Preceptors are also likely to tell the trainee that they share some responsibility for the error, probably because they are in fact in a supervisory role, and ultimately responsible for patient care. Less expected was the finding that relatively few preceptors would express their disappointment to the trainee—only one in ten would do so in the wrong-immunization vignette, and one in four in missed-allergy vignette. Preceptors were more likely to report that their written evaluation of the trainee would be influenced by the error. Taken together, these findings suggest that trainees are most likely to experience a neutral response or a supportive response following an error, rather than a negative response. This is consistent with findings from prior studies indicating that preceptors are not comfortable giving correction, and are not likely to do so;2,5,6 and findings that faculty members may avoid being explicit when discussing errors.7 If preceptors are hesitant to provide explicit corrective feedback, trainees may not be receiving clear messages about their performance, which could potentially lead to inaccurate or inflated self-assessments. In addition, a trainee who, after a rotation, receives an evaluation that is less positive than anticipated may hesitate to report a medical error in the future.

Our findings suggest that seven of the nine factors studied here do influence how preceptors respond to errors in at least some situations. The contribution of each factor varied depending on the response under consideration. For instance, whether the trainee appeared calm or distressed affected whether the preceptor would provide reassurance, but not whether he or she would express disappointment. Having made a similar error previously and being perceived as relatively less knowledgeable are the two factors that seem most influential of preceptors’ responses. It is also important to note however, that taken as a set, all nine factors accounted for no more than 26% of the variance for any of the preceptor responses. Clearly, other factors are also important, and further work in this area is needed.

Preceptors’ tendency to respond more negatively to the missed-allergy vignette compared to the wrong-immunization vignette is probably attributable to the greater potential for harm in the former instance. However, it is noteworthy that the missed-allergy vignette is a “near miss” in that the drug was not actually administered, while the wrong-immunization vignette involves an error that did reach the patient. In neither vignette did the patient experience significant harm; preceptors may respond differently to errors that do result in harm.

Also noteworthy is an apparent parallel between preceptors’ and patients’ responses to medical errors. Patients respond more positively to full disclosure of medical errors, where the physician acknowledges the error, assumes responsibility, and apologizes.8,9 The present study suggests that preceptors also respond more positively to trainees who react without defensiveness (e.g., who do not offer excuses, and offer to apologize).

This study has limitations. While we drew preceptors from a relatively wide geographic area, all were primary care clinicians participating in a faculty development program. We do not know how generalizable our findings are to preceptors from other geographic areas, or other specialties, or even to preceptors less interested in developing their teaching skills. Responses to vignettes on a questionnaire may differ from responses to trainees’ errors in practice, as prior studies have found discrepancies between self-report of intent versus actual behavior,6 suggesting the need for additional work examining the relationship between preceptors’ actual and predicted behaviors around trainees’ errors. It is important to note that neither of the vignettes used here involved harm to the patient. Another important issue not addressed here is how trainees respond to different preceptor responses, and especially how responses impact learning.

While several questions remain unanswered, we hope these findings encourage preceptors to examine and reflect on their own responses to trainees’ errors and the factors that influence their responses. Such examination and reflection is prerequisite to an open discussion of what constitutes an optimal response when a trainee is involved in an error, and how, or whether, that response should change depending on the circumstances.

While it is premature to propose detailed guidelines for responding to medical errors, we offer the following recommendations. First, trainees need to know they are responsible for reporting medical errors, and when, how, and to whom errors should be reported. Information on what to expect subsequent to making a report—such as assurances that punitive actions would not follow, and corrective actions would—could encourage reporting. Faculty development efforts should focus on training preceptors in the difficult process of providing explicit corrective feedback, and in teaching preceptors to conduct modified root cause analyses in the context of their practice.

The authors thank Jane Parks and Mary Philbin for their assistance with questionnaire administration.

The Teaching of Tomorrow workshop series is funded by a grant from the Health Resources and Service Administration.

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References

1 Institute of Medicine. To Err is Human: Building a Safer Healthcare System. Washington DC: National Academy Press, 2000.

2 Mazor KM, Fischer MA, Haley H-L, Hatem D, Quirk ME. Teaching and learning around medical errors: primary care preceptors’ views. Med Educ. [in press].

3 Ginsburg S, Regehr G, Hatala R, et al. Context, conflict, and resolution: a new conceptual framework for evaluating professionalism. Acad Med. 2000;75:S6–S11.

4 Rossi PH, Nock SL (eds). Measuring Social Judgments: The Factorial Survey Approach. Beverly Hills: Sage, 1982.

5 Ende J, Pomerantz A, Erickson F. Preceptors’ strategies for correcting residents in an ambulatory care medicine setting: a qualitative analysis. Acad Med. 1995;70:224–29.

6 Burack JH, Irby DM, Carline JD, Root RK, Larson EB. Teaching compassion and respect: attending physicians’ responses to problematic behaviors. J Gen Intern Med. 1999;14:49–55.

7 Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290:2838–42.

8 Mazor KM, Simon SR, Yood RA, et al.. Health plan members’ views about disclosure of medical errors. Ann Intern Med. 2004;140:409–18.

9 Schwappach DLB, and Koek CM. What makes an error unacceptable? A factorial survey on the disclosure of medical errors. Int J Qual Health Care. 2004;16:317–26.

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Appendix
Vignette 1 {bold type indicates where a factor was varied}

Imagine that William, a two-year-old boy in good health, comes to your office for a well child visit. Susan, an intern who has been working with you for two weeks, sees William, taking a history, doing a physical, and administering the immunizations. Later that day, you notice that Susan made an error in giving the immunizations; specifically, she gave an immunization that was NOT needed, and neglected to give one that WAS needed. William will have to return for another appointment to get the needed immunization. This is the first time that something like this has happened with Susan. Your overall assessment of Susan is that she is generally more knowledgeable than her peers, and much less receptive to feedback. When you tell Susan that she has made an error, Susan seems distressed, and says the mother was in a hurry. Susan offers to call the mother immediately to apologize

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Section Description

Moderator: Heather Harrell, MD

Discussant: Rhee Fincher, MD

© 2005 Association of American Medical Colleges

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