While physicians in the United States and Canada generally support disclosing medical errors to patients, they vary widely in when and how they would tell patients an error had occurred, according to two articles in the August 14/28 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Research has revealed that most patients want detailed information following a medical error, including an explicit statement that an error has occurred, an apology, information about why the error happened and an explanation of what will be done to prevent future errors. However, less than half of harmful errors may be disclosed to patients, according to background information in the articles. This may diminish trust in physicians and may also increase the risk that patients will file malpractice lawsuits.

Thomas H. Gallagher, M.D., University of Washington School of Medicine, Seattle, and colleagues surveyed physicians in the United States and Canada to gauge their attitudes regarding the disclosure of medical errors. The 2,637 physicians had an average age of 49.2 and had been in practice for an average of 16.8 years; 1,233 were from the United States (from Washington and Missouri) and 1,404 were from Canada; about half (49.7 percent) were medical specialists, 40.3 percent were surgeons, 8.5 percent were in family practice, and 1.4 percent did not list their specialty; and 78.6 percent were male and 18.6 percent female.

In the first study, the researchers presented the physicians with one of four scenarios involving a medical error. Two of the scenarios were tailored to internal medicine specialists and two to surgeons; one of each type of error would be apparent to the patient, and the others would not be apparent to the patient if he or she was not informed. For instance, the more apparent surgical error involved a sponge left inside a patient's body and the less apparent surgical error involved an internal injury that a surgeon inflicted because of unfamiliarity with a new surgical tool. The physicians answered a series of questions about the scenario they received, including how likely they would be to disclose the error, what information they would convey if they did disclose the error, how serious the error was and how likely it was to result in a lawsuit.

Eighty-five percent of the physicians agreed that the error they received was serious and 81 percent believed the physician was very or extremely responsible for the error. Overall, 65 percent would definitely disclose the error, 29 percent would probably disclose, 4 percent would disclose only if the patient asked and 1 percent would definitely not disclose. The language the physicians would use also varied widely; 42 percent would use the word "error," 56 percent would mention the adverse event but not the error, 50 percent would give the patient specific information about what the error was and 13 percent would not reveal any details not requested by the patient. Physicians who had a positive attitude toward disclosure and past positive experiences with disclosure, who felt responsible for the error or who were Canadian tended to report that they would disclose more information.

Specialty and the nature of the error affected how likely the physicians were to disclose the error. Surgeons were more likely than other physicians to say they would definitely disclose the error (81 percent vs. 54 percent) but also reported that they would disclose less information--35 percent of surgeons and 61 percent of other physicians said they would disclose specific details about the error. Those who received the more apparent errors were more likely to say they would disclose them than those who received the less apparent errors (81 percent vs. 50 percent) and would also disclose more information about them (51 percent would use the word error, vs. 32 percent). "Some dimensions of errors might justify disclosing less information, such as if the error caused only trivial harm," the authors write. "However, physicians agreed that all the scenarios represented serious errors. Basing disclosure decisions on whether the patient was aware of the error is not ethically defensible or consistent with standards such as those from the Joint Commission on Accreditation of Health Care Organizations."

In a second study based on the same survey, the researchers report that U.S. and Canadian physicians have similar attitudes toward and experiences with error disclosure despite different malpractice environments, suggesting that the probability of lawsuits is not associated with their support for disclosure. Of the 2,637 physicians:

* 64 percent agreed that errors were a serious problem

* 98 percent supported disclosing serious errors to patients and 78 percent supported disclosing minor errors

* 58 percent had disclosed an error to a patient and 85 percent of those were satisfied with the disclosure

* 66 percent agreed that disclosing a serious error reduces malpractice risk

Physicians' estimates of how likely they were to be sued did not affect whether they supported disclosing errors to patients. "The medical profession should consider whether the culture of medicine itself represents a more important barrier than the malpractice environment to the disclosure of harmful medical errors to patients," the authors conclude. "Patients justifiably expect that harmful medical errors will be disclosed to them. Increasing physician engagement in efforts to communicate openly with patients following errors and to enhance patient safety could provide a much-needed boost to patients' confidence in the quality and integrity of the health care system." (Arch Intern Med. 2006;166:1585-1593 and 1605-1611.)



Editor's Note: This study was supported by grants from the Agency for Healthcare Research and Quality and by the Greenwall Foundation Faculty Scholars Program. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Contact: Clare Hagerty
JAMA and Archives Journals