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To Err is Human, to Disclose It to Patients Is Optional


IOWA CITY, Iowa -- What physicians say about disclosing errors to patients and what they actually do when they make an error may be two different things, said investigators here.

IOWA CITY, Iowa, May 11 -- What physicians say about disclosing errors to patients and what they actually do when they make an error may be two different things, said investigators here.

In a survey of physician and trainee attitudes regarding disclosure of errors to patients, more than 90% of faculty physicians and residents said they would disclose errors resulting in either minor or major harm to patients, reported Lauris Kaldjian, M.D., Ph.D. and colleagues from the University of Iowa and other centers.

But reactions in real life seem to be different. Only 41% of respondents confessed to disclosing an actual, albeit minor, medical error, and only 5% said that they had told a patient about a major error resulting in disability or death, the authors wrote in the online version of the Journal of General Internal Medicine.

"Most doctors recognize that they're fallible, but they still strive for perfection and, for the most part, hold each other accountable to a high standard of practice that approximates perfection," said Dr. Kaldjian, director of the Program in Biomedical Ethics and Medical Humanities at the Carver College of Medicine.

"The idea persists that the physician rides into the clinic on the white horse," Dr. Kaldjian said. "To come in as the healer and then realize that you have harmed is a difficult thing to accept, let alone admit."

He and his colleagues at Iowa, Yale, and Penn State conducted a survey of faculty physicians, residents, and medical students at their respective centers.

They asked questions about minor errors, such as "Have you ever made a mistake that prolonged treatment or caused discomfort and told the patient (or the patient's family) that a mistake was made?" and major errors, such as "Have you ever made a mistake that caused disability or death and told the patient (or the patient's family) that a mistake was made?"

The survey participants were also presented with a hypothetical case in which a physician fails to note a patient's allergy to cephalosporins and gives him one of the drugs to treat pneumonia. They were then asked how they would respond to each of three possible outcomes: no harm to the patient, minor harm (diffuse itching and a rash) or major harm (respiratory distress, anaphylactic shock, and myocardial infarction).

Study outcome measures were actual and hypothetical error disclosure, attitudes toward disclosure, and demographic factors.

The authors received responses from 538 physicians, residents, and students for a response rate of 77%.

When it came to the hypothetical situations, they found that faculty respondents were more likely than either residents or students to disclose an error resulting in no harm, with 80% of faculty, 63% of residents, and 50% of students willing to 'fess up (P

On the other end of the spectrum, 19% said they had not disclosed an actual minor error and 4% said they had failed to tell a patient about an actual major error.

"There appears to be a gap between physicians' attitudes and practices regarding error disclosure, " the authors wrote.

"Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation."

Dr. Kaldjian said that while the survey data suggested that about half of the respondents were infallible, "it seems fair to assume that all of us have made at least a minor error, if not a major error, sometime in our careers."

The authors acknowledged that the self-report nature of the survey is subject to "social desirability" bias-that is, the tendency of respondents to put themselves or the profession in a more favorable light, despite the anonymous design of the survey).

"Under the right circumstances, physicians should be able to act with courage and compassion to communicate clearly with patients and families about errors," they wrote. "Creating such circumstances requires concerted efforts to build a culture of learning and healing that supports the physician's self-identity as a healer, at a time when it may be threatened, and promotes the dignity and well being of the patient after he or she has been harmed."

The authors also acknowledged that the study was cross-sectional and could therefore not account for changes over time or differences between the participating centers. They also pointed out that the survey was limited to faculty, residents and students in teaching hospitals and represented only internal medicine, family medicine, and pediatrics, so the results may not be generalizable to physicians in other specialties or practice types.

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