Clinicians Keep Mum on Undetectable Blunders

SEATTLE, Aug. 17 -- If a patient isn't likely to learn that a clinician made a serious medical error, many physicians or surgeons will be the last to spill the beans, according to a survey here.

While more than 80% of surgeons would come clean about a glaringly obvious error-such as leaving a sponge behind after surgery-only half would disclose the less obvious but still-as-serious blunder of damaging a bile duct while using unfamiliar surgical equipment, reported Thomas H. Gallagher, M.D., of the University of Washington.

Such physician attitudes are "not ethically defensible" and starkly in conflict with national standards, Dr. Gallagher and colleagues said in the Aug. 14-28 issue of the Archives of Internal Medicine.

The researchers surveyed more than 2,600 medical and surgical specialists in the United States and Canada. Canadians were included despite the threat of malpractice generally being less than in the United States because previous research showed physician attitudes about disclosing error were largely the same in the two countries, the investigators said.

For surgeons, the survey took participants through one of two scenarios: the sponge left behind (more obvious error) and the bile duct damage (less obvious error). Follow up questions then assessed not only how likely the physician would be to tell the patient, but other factors such as how much information would be shared or whether an explicit apology would be offered.

Non-surgeons were queried about a similar pair of scenarios: a patient being given an overdose of insulin because of sloppy handwriting on an order (more obvious) and a patient experiencing tachycardia while on a new medication because the physician forgot to check potassium levels (less obvious).

Overall, 81% of doctors queried about the obvious error said they would admit error, compared with 50% of doctors asked about the not-so-obvious error (P<.001).

Similarly, 37% of those asked about the glaring error said they would offer an explicit apology, compared with 28% of those queried about the subtle error (P<.001).

Furthermore, more physicians surveyed about the hard-to-discern error said they would volunteer no information about it compared with those asked about the obvious mistake (19% versus 8%; P<.001).

Surgeons were more forthcoming about errors overall, with 81% indicating they would disclose the hypothetical error, whether obvious or subtle, compared with 54% of non-surgeons (P<.001). More specifically, 66% of surgeons said they would confess the less-obvious surgical mistake compared with 39% of non-surgeons who said they would confess the less-obvious medical mistake (P<.001).

"Surgeons routinely talk with patients about possible adverse events during the informed consent process and with colleagues during morbidity and mortality conferences," the authors said. "Medical specialists, however, may have less experience discussing adverse events with patients and colleagues."

However, despite expressing greater intention to disclose than medical specialists, surgical specialists would disclose less information.

• 19% of surgeons would use the word "error," compared with 58% of medical specialists (P_.001)
• 35% of surgeons would disclose specific details about the error compared with 61% of medical specialists (P_.001).
• Surgeons chose an explicit apology half as often as medical specialists did (21% surgical scenarios and 41% medical scenarios, P_.001).

While it might be defensible to give patients less detail about a mistake if it caused only trivial harm, "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," the authors said.

The authors acknowledged, however, that the threat of malpractice litigation is a serious obstacle to doctors coming clean with patients about medical errors. "Additional research should study how disclosure affects litigation to address this real barrier to disclosure," they said.

"By integrating empirical research and normative analyses, the medical profession can develop guidelines for what information patients can expect from their physicians following errors," they said.

"Ideally, if these guidelines can help physicians choose their words following errors in closer alignment with patients' preferences, including apologizing and providing information about preventing recurrences, such disclosure could enhance patients' confidence in the honesty and integrity of the health care system," they concluded.

On a less positive note, the authors pointed out that doctors might act less ethically in real-life than they did in the study's hypothetical scenarios. "Social desirability bias might cause our results to overestimate physicians' willingness to disclose errors," they said.