White, Andrew A. MD; Gallagher, Thomas H. MD; Krauss, Melissa J. MPH; Garbutt, Jane MB, ChB; Waterman, Amy D. PhD; Dunagan, W Claiborne MD; Fraser, Victoria J. MD; Levinson, Wendy MD; Larson, Eric B. MD, MPH
The rise of the patient-safety movement and the publication of the Institute of Medicine report To Err is Human1 have drawn the attention of both the public and physicians to the problem of medical errors. Physicians are increasingly expected to recognize, prevent, and properly disclose medical errors. In particular, ethical standards and guidelines that have emerged from accrediting organizations2 and professional bodies3 reflect a movement toward greater transparency in communicating with patients about errors. Although a few schools provide formal instruction in disclosure, these skills are largely taught via the hidden curriculum and role modeling.4,5 There is little known regarding trainees’ attitudes about and experiences with medical errors or their experience in disclosing errors to patients.
Despite the fact that patients uniformly endorse the disclosure of harmful errors,6,7 such disclosure currently seems to be uncommon.8,9 Emerging research is shedding new light on the disconnect between expectations that errors will be disclosed to patients and current clinical practice. Recent survey data from practicing physicians highlight their support for the general concept of disclosure and the difficulty they experience actually disclosing errors to patients.10,11 Although less is known about trainees’ attitudes and experiences regarding medical errors and their disclosure, the available literature suggests that most trainees have been personally involved with errors9,12,13 and that discussing these events with patients presents substantial challenges for residents.14,15 In one study, 76% of housestaff reported that they had made a serious medical error that they had not disclosed to the patient or a family member.12
Academic health centers can enhance transparency in health care by preparing new physicians for the challenges of recognizing and disclosing errors. Like all accredited organizations, they are also required by Joint Commission regulations to ensure patients are informed about unanticipated outcomes in their care.2 Improving disclosure and meeting these regulatory goals require understanding how trainees perceive, experience, and disclose errors. Therefore, we undertook a multicenter cross-sectional survey of trainees to explore their attitudes and experiences regarding medical error and error disclosure.
Setting and physician sample
Between June and October of 2003, we administered questionnaires to 629 second- and fourth-year medical students (320 and 309, respectively), to 159 interns and 211 residents in internal medicine, and to 67 interns and 72 residents in surgery from two U.S. academic medical institutions: Washington University School of Medicine (in St. Louis, Missouri), and the University of Washington (in Seattle, Washington). These institutions differ in that one (the former) is private and one is public, and they are located in two of the 18 U.S. states whose malpractice climates are reported to be “in crisis” because of the very limited availability of affordable professional liability insurance.16 The questionnaires were distributed to trainees at orientation sessions, conferences, and by e-mail. The results of giving this same questionnaire to physicians in surgery, medicine, and pediatrics have been previously reported.10,11,17
The questionnaire was refined through pilot testing and cognitive interviews. The questionnaire used the Institute of Medicine's definitions of adverse event, medical error, and near miss.1 We developed and pilot tested our own definitions of serious error and minor error. We defined a serious error as an “error that causes permanent injury or transient but potentially life-threatening harm” and a minor error as an “error that causes harm that is neither permanent nor potentially life threatening.” Questionnaire definitions were repeated on every page of the questionnaire, and key terms were capitalized or bolded throughout.
The questionnaire asked respondents about key safety topics, such as whether medical errors are a serious problem and how frequently errors occur. Questions about error disclosure included what types of errors should be disclosed, potential barriers to disclosure, and respondents’ personal experience with medical errors and disclosure. Agreement was measured on a four-point Likert scale (strongly disagree, disagree, agree, strongly agree). Demographic questions measured respondents’ age, gender, and specialty.
This anonymous questionnaire was approved by the institutional review boards at Washington University in St. Louis and the University of Washington. Respondents could complete a paper or Web-based questionnaire. Snacks, soft drinks, and coffee cards were offered as incentives for participation.
Descriptive statistics included means and standard deviations for continuous variables and percentages for categorical variables. Questions that used four-point Likert response scales were dichotomized at the midpoint (agree versus disagree). Categorical variables were compared using Pearson chi square, chi square for linear trend, and Fisher exact tests as appropriate. All tests were two tailed, and a P value less than .05 was considered significant. We intended the survey to be exploratory, and, therefore, we did not apply a Bonferroni adjustment to the analysis. Comparisons were limited to plausible associations. Analyses were performed using SAS version 9.0 (SAS Institute, Inc., Cary, NC).
Characteristics of respondents
Surveys were completed by 889 (281 MSII students, 209 MSIV students, 214 interns, 185 residents) of the 1,138 eligible trainees (78%). Of the respondents, 392 (44%) were in training at Washington University and 497 (56%) were from the University of Washington. Interns were more likely to respond than residents (95%, 214/226, versus 65%, 185/283; P < .001). The response rate was higher among surgical interns and residents than among medical interns and residents (91%, 126/139, versus 74%, 273/370; P < .001). See Table 1 for an overview of the characteristics of the respondents. Not all respondents completed every question, so denominators presented may be lower than the above totals for certain questions. The highest nonresponse rate for a given question was 2%, and the average nonresponse rate was less than 1%.
Medical error attitudes and experience
Most of the medical students (73%, 354/485) as well as the interns and residents (75%, 298/396) agreed that medical error is one of the most serious problems in health care. These respondents also believed that errors are common, although estimates of their frequency varied on the basis of the errors’ severity. Mean estimates of the percentage of hospitalized patients suffering serious errors, minor errors, and near misses were 6%, 20%, and 23% respectively (see Table 2 for the numbers and percentages of trainees who gave these responses). Trainees were divided on the cause of medical errors, with 53% of respondents agreeing and 47% disagreeing that “errors are caused by failures of care delivery systems, not the failure of individuals.”
Personal involvement with medical errors was common among trainees and increased with level of training (trend P < .001). By the fourth year of medical school, 79% (164/209) of students reported involvement with errors. Minor errors and near misses predominated (see Table 2). Virtually all residents (98%, 182/185) reported personal experience with errors, with 73% reporting involvement in minor errors and 45% with serious errors. Surgery residents were more likely than their medicine counterparts to have been involved with a serious error (60%, 38/63 versus 37%, 45/122; P = .002).
Essentially all trainees (99%) agreed that serious errors should be disclosed to patients. A majority of trainees (84%) also felt that minor errors should be disclosed, although this attitude decreased slightly with level of training (Table 2; trend P = .031). A minority (27%) believed that near misses should be disclosed, an attitude that also declined with level of training (Table 2; trend P = .003).
A third of the residents (34%, 62/183) reported ever disclosing a serious error to a patient. The percentage of trainees who had disclosed a serious error increased with level of training (Table 2; trend P < .001). There was no statistically significant difference between the percentage of surgery and medicine residents who had disclosed a serious error (40% versus 31%, P = .23). A total of 63% (115/183) of the residents had disclosed a minor error. Medicine residents were more likely than their surgery colleagues to have disclosed minor errors (68% versus 52%, P = .034).
Among residents who had disclosed serious errors, the majority (84%, 67/80) were satisfied with how the conversation went. Few of the residents who had disclosed serious errors (13%) felt the disclosure discussion negatively affected their relationship with the patient. Similarly, when disclosing minor errors, 94% (154/163) of interns and residents expressed satisfaction with conversations, and only 3% of interns and residents recounted the disclosure having a negative impact on their relationship with the patient.
Risks of error disclosure
The majority of trainees (76%, 668/884) agreed that disclosing serious errors decreased the risk of litigation (Table 3). Trainees who had previously disclosed a serious error shared this attitude with those who had not disclosed a serious error (81%, 75/93 versus 75%, 581/775; P = .22). About half of the trainees (49%, 438/887) were concerned that “disclosing a serious error would damage a patient's trust in my competence.” However, trainees who had previously disclosed a serious error were less likely to agree that disclosure would reduce patients’ trust than trainees who had not done so (24%, 23/94 versus 53%, 408/777; P < .001).
Barriers to error disclosure
Despite agreeing that serious errors should be disclosed, 87% (774/889) of the trainees acknowledged at least one factor that might make them less likely to do so (Table 3). Although there were no significant variations among interns by specialty, residents in surgery were less likely than those in medicine to report that they might be less likely to disclose if they thought that the patient might be angry (3% versus 17%, P = .006), might sue (11% versus 30%, P = .005), or might not want to know about the error (24% versus 46%, P = .003). The proportion of respondents who reported that possible patient anger or possible lawsuits might make them less likely to disclose errors decreased with level of training (trend P = .002, P < .001, respectively—see Table 3 for the numbers and percentages of trainees who gave these responses). However, the proportion of trainees who reported they might be less likely to disclose if they didn't know the patient well or thought the patient wouldn't understand what they were telling the patient increased with level of training (trend P < .001, P = .04, respectively—see Table 3).
Nearly all trainees (92%, 813/886) agreed that disclosing a serious error would be very difficult. The 8% (73/886) of all trainees who disagreed that disclosing a serious error would be difficult differed by specialty and level of training from those trainees who agreed with this statement. The view that error disclosure is not difficult was held by surgery residents more commonly than by medical residents (20%, 16/63 versus 7%, 12/122; P < .001) and by residents more commonly than by interns (15%, 28/185 versus 8%, 17/214; P = .02) or by students (15%, 28/185 versus 6%, 28/487; P = .002). Of the 73 trainees who did not feel that disclosing a serious error would be difficult, 80% had not ever disclosed a serious error.
How trainees were prepared for error disclosure
A minority of students (35%, 169/482) and interns and residents (31%, 120/398) reported ever receiving education or training in error-disclosure techniques. Medicine residents were more likely than their surgery colleagues to have undergone such training (40%, 49/122 versus 24%, 15/62; P = .03). Among all trainees, of those who reported disclosing a serious error to a patient, only 41% (38/92) said they had received any disclosure training. A total of 93% of the students and 90% of the interns and residents were interested in receiving general training on how to disclose errors to patients. Similarly, 97% of the students and 95% of the interns and residents were interested in receiving “just-in-time” error-disclosure coaching at the time of a serious error.
To improve the frequency and content of error disclosure as well as to maintain public trust, the next generation of physicians must be prepared to properly disclose medical errors. In this survey, trainees reported substantial involvement with medical errors, and many reported having disclosed errors to patients. However, this study also suggests that medical students, interns, and residents often perceive significant barriers to disclosing medical errors, which in turn suggests that many trainees will enter practice without adequate error-disclosure skills unless new training programs are implemented. These findings characterize an educational system that misses opportunities to instruct medical trainees on error disclosure.
Consistent with previous smaller studies, we found that the majority of residents and interns reported personal involvement with errors.11,12 Additionally, a majority of the fourth-year medical students reported involvement in an error, indicating that education on patient safety and error disclosure is important starting early in training. Trainees’ perceptions that errors are both common and important suggest they are a receptive audience for patient-safety education.
Although many trainees had disclosed errors to patients, most were not formally prepared for such disclosures. Our data do not allow us to determine whether trainees disclosed errors by themselves or under the guidance of senior clinicians or hospital administrators. Disclosures are extremely challenging discussions, in part because it is often not known whether an adverse event was attributable to an error until formal analyses have been completed. In addition, disclosures are emotionally charged conversations that require advanced communication skills. Thus, many new disclosure guidelines emphasize that it is important for all clinicians, and especially trainees, to obtain help from institutional patient-safety and risk-management resources before undertaking disclosures.18 Medical educators and institutions should develop and disseminate formal disclosure guidelines regarding the role of trainees in the disclosure process.
Removing trainees entirely from the disclosure process is also undesirable. In our survey, those trainees who reported having disclosed errors to patients had more positive attitudes about disclosure than did the trainees with no disclosure experience. Trainees who reported having disclosed errors to patients were also generally satisfied with how the conversation had gone, and few reported the disclosure had an adverse impact on their relationship with the patient. These results suggest that formal disclosure curricula along with closely mentored opportunities to disclose errors to patients could provide powerful learning opportunities for trainees.
Trainees universally expressed interest in “just-in-time” disclosure coaching at the time of an error, a prominent feature of new disclosure guidelines.18 For the most serious errors, such coaching is likely to come from a senior risk manager or medical director. Attending physicians can also play an important role in mentoring trainees in disclosure. The “one-minute preceptor” skills that attending physicians use for teaching clinical medicine can also help provide on-the-fly disclosure education to trainees.19,20 In addition, attendings can share with trainees their personal experiences of error disclosures that went well and that went poorly, further reinforcing the emerging culture of transparency in medicine. Coaching should include careful planning and rehearsing of the disclosure, helping trainees anticipate likely questions from patients, and formulating appropriate responses. Attendings may well require disclosure training themselves before they are ready to effectively mentor trainees in disclosure.21 Exploring the current and ideal role that attending physicians play in disclosure by trainees represents an important topic for future study.
Disclosure education for trainees should include not only coaching from attendings but also formal lecture material as well as the opportunity to practice disclosure skills and receive feedback. Simulation using standardized patients may be a valuable tool to provide trainees the opportunity to practice disclosure skills in a consequence-free environment.22 Disclosure training should be integrated into the broader curriculum on patient safety and error prevention, reflecting emerging national guidelines that recognize disclosure as an integral component of quality improvement.18
Although trainees endorsed the principle of disclosing serious errors, nearly 90% reported barriers to doing so, such as concern about patient anger, fear of litigation, and uncertainty whether the patient would want to know about the error. In our prior work, many of these barriers were also identified by attendings.11 These disclosure barriers might represent useful topics for educators to consider as they design disclosure curricula. Whereas a longitudinal study design would allow firmer conclusions about how medical training affects disclosure attitudes, in the present study trainees’ disclosure attitudes generally matured over time in the absence of personal experience with disclosure or formal disclosure training. Through structured interviews with residents, Fischer et al23 described features of the hidden curriculum, such as the cultural notion of personal responsibility and expectations to practice defensive medicine, that influenced trainees’ reactions to medical errors, both positive and maladaptive. However, because many individuals may not have disclosure experience from their training, relying on the hidden curriculum alone to teach effective disclosure skills may result in many physicians’ entering practice unprepared for the challenges of disclosing errors to patients.
The first step in the disclosure process is recognizing that a harmful error has occurred. Our data suggest that a gap may exist between trainees’ estimates of error frequency and their perceived involvement in errors. Although the residents estimated that near misses and minor errors were common, a significant minority of the residents could not recall ever being involved in either. In a previous study, the authors describe how house officers cope with errors by minimizing and rationalizing, which may help to explain this discrepancy between perceptions and experience.11 Medical educators might focus on helping residents identify errors in their own work using methods such as resident-driven quality-improvement initiatives or root-cause analysis. Other studies have found that residents can be a resource for error-prevention ideas, suggesting an opportunity for involving trainees not only in error-disclosure training, but also in patient-safety programs.24,25
Our survey found that residents and students were split between assigning responsibility for errors to individuals or to health care systems. Although the patient-safety movement has asserted that systems failures underlie the majority of medical errors, the relative contribution of systemic versus individual factors remains a topic of active debate26 and is an ideal issue to discuss explicitly with trainees in patient-safety curricula. The 80-hour work rules mandated by the Accreditation Council on Graduate Medical Education have forced many inpatient teaching services to adopt rigid shift schedules and shared responsibility for patient care, changes that may generate communication errors.27 By incorporating a systems approach into the traditional culture of personal responsibility that exists in medicine, academic health centers may turn these challenges in the trainees’ environment into opportunities to involve residents in quality-improvement activities.28
This study has several limitations. The data came from only two academic health centers, which may limit generalizability. Additionally, this study was cross-sectional rather than longitudinal, limiting our ability to draw conclusions about the effect of training on attitudes over time. Although the response rate was robust, nonresponse bias may have affected the results. Additionally, responses may have been subject to recall bias and social desirability bias. Last, there is no consensus about the role of trainees in disclosure, making it difficult to draw normative conclusions. Despite these limitations, this study represents the largest and most comprehensive investigation to date of trainees’ attitudes and experiences regarding medical errors and their disclosure.
In conclusion, medical trainees are involved in errors, events that offer educators important teachable moments about both patient safety and disclosing errors to patients. Trainees are a receptive audience for both informal and formal disclosure education. Teaching trainees how to disclose harmful medical errors to patients will be an important step toward closing the gap between patients’ justifiable expectation that harmful errors will be disclosed to them and current practice.
The Agency for Health Care Research and Quality (#1U18HS1189801, 1K08HS01401201) and the Greenwall Foundation Faculty Scholars Program.
The authors would also like to acknowledge Alison Ebers and Kerry Bommarito, MPH, for their tireless work in data collection, Eric Van Eaton for assistance in survey administration, and Carolyn Prouty for her assistance in preparing the manuscript of this report.
1 Institute of Medicine. Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
2 The Joint Commission. Hospital Accreditation Standards, 2007. Oakbrook Terrace, Ill: Joint Commission Resources; 2007.
3 American Medical Association Council on Ethical and Judicial Affairs. Code of Medical Ethics, Annotated Current Opinions. 2004–2005 ed. Chicago, Ill: American Medical Association; 2004.
4 Fischer SM, Gozansky WS, Kutner JS, Chomiak A, Kramer A. Palliative care education: An intervention to improve medical residents’ knowledge and attitudes. J Palliat Med. 2003;6:391–399.
5 Hafferty FW. Beyond curriculum reform: Confronting medicine's hidden curriculum. Acad Med. 1998;73:403–407.
6 Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933–1940.
7 Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001–1007.
9 Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Disclosing medical errors to patients: Attitudes and practices of physicians and trainees. J Gen Intern Med. 2007;22:988–996.
10 Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: How physicians would disclose harmful medical errors to patients. Arch Intern Med. 2006;166:1585–1593.
11 Gallagher TH, Waterman AD, Garbutt JM, et al. US and Canadian physicians’ attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006;166:1605–1611.
12 Mizrahi T. Managing medical mistakes: Ideology, insularity and accountability among internists-in-training. Soc Sci Med. 1984;19:135–146.
13 Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089–2094.
14 Hevia A, Hobgood C. Medical error during residency: To tell or not to tell. Ann Emerg Med. 2003;42:565–570.
15 Rosenbaum JR, Bradley EH, Holmboe ES, Farrell MH, Krumholz HM. Sources of ethical conflict in medical housestaff training: A qualitative study. Am J Med. 2004;116:402–407.
16 Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. N Engl J Med. 2003;348:2281–2284.
17 Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing medical errors: Pediatricians’ attitudes and behaviors. Arch Pediatr Adolesc Med. 2007;161:179–185.
18 Gallagher TH, Denham C, Leape L, Amori G, Levinson W. Disclosing unanticipated outcomes to patients: The art and the practice. J Patient Safety. 2007;3:158–165.
19 Irby DM, Aagaard E, Teherani A. Teaching points identified by preceptors observing one-minute preceptor and traditional preceptor encounters. Acad Med. 2004;79:50–55.
20 Bowen JL, Eckstrom E, Muller M, Haney E. Enhancing the effectiveness of One-Minute Preceptor faculty development workshops. Teach Learn Med. 2006;18:35–41.
21 Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: A busy—and occasionally hazardous—intersection. Ann Intern Med. 2006;145:592–598.
22 Halbach JL, Sullivan LL. Teaching medical students about medical errors and patient safety: Evaluation of a required curriculum. Acad Med. 2005;80:600–606.
23 Fischer MA, Mazor KM, Baril J, Alper E, DeMarco D, Pugnaire M. Learning from mistakes. Factors that influence how students and residents learn from medical errors. J Gen Intern Med. 2006;21:419–423.
24 Sorokin R, Riggio JM, Hwang C. Attitudes about patient safety: A survey of physicians-in-training. Am J Med Qual. 2005;20:70–77.
25 Volpp KG, Grande D. Residents’ suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003;348:851–855.
26 Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–1499.
27 Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351:1829–1837.
28 Van Eaton EG, Horvath KD, Pellegrini CA. Professionalism and the shift mentality: How to reconcile patient ownership with limited work hours. Arch Surg. 2005;140:230–235.