Building bridges: future directions for medical error disclosure research

Disclosure of medical errors to patients by medical professionals: a protocol for a qualitative systematic review

INTRODUCTION

Although the disclosure of medical errors is an integral component of medical ethics, it remains inconsistent in practice worldwide. Despite various explanations of why healthcare professionals reveal their mistakes to patients, comprehensive comparisons and evaluations of this topic remain lacking. The objective of this review is to evaluate the experience of medical error disclosure among medical professionals who have been involved in such errors.

METHODS AND ANALYSIS

This work will focus on studies involving medical professionals from various countries who work in hospital settings and have obtained an understanding of and firsthand experience with medical error disclosure. This review will include qualitative studies. Studies published in databases such as PubMed, Embase, EBSCO, OVID, Web of Science, ScienceDirect, China National Knowledge Infrastructure, Wanfang Data and Cochrane Library from 1 January 2000 to 30 April 2024 will be searched as part of this research. Additionally, OpenGrey will be searched manually to obtain supplementary information. The search will be conducted starting in May 2024 and will include both Chinese-language and English-language literature. The systematic review will follow the Joanna Briggs Institute's (JBI) methodology for systematic reviews of qualitative evidence and use the JBI System for the Unified Management, Assessment and Review of Information online program. Study authenticity will be investigated via the Qualitative Research Authenticity Evaluation Tool provided by the JBI Evidence-Based Health Care Centre, and data extraction will be performed via the Qualitative Assessment and Review Instrument data extraction tool. The results will be integrated via a pooled integration methodology and evaluated in terms of reliability via the ConQual qualitative systematic evaluation evidence grading tool.

ETHICS AND DISSEMINATION

Ethical approval is not required for the study because the review will be based on pre-existing data available in the literature. The results of this systematic review will be submitted to peer-reviewed journals and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42024494360.

Virtual reality evidence on the impact of physicians' open versus defensive communication on patients

Using virtual reality (VR) in an experimental setting, we analyse how communicating more openly about a medical incident influences patients' feelings and behavioural intentions. Using VR headsets, participants were immersed in an actual hospital room where they were told by a physician that a medical incident had occurred. In a given scenario, half of the participants were confronted by a physician who communicated openly about the medical incident, while the other half were confronted with the exact same scenario except that the physician employed a very defensive communication strategy. The employed technology allowed us to keep everything else in the environment constant. Participants exposed to open disclosure were significantly more likely to take further steps (such as contacting a lawyer to discuss options and filing a complaint against the hospital) and express more feelings of blame against the physician. At the same time, these participants rated the physician's communication skills and general impression more highly than those who were confronted with a defensive physician. Nevertheless, communicating openly about the medical incident does not affect trust in the physician and his competence, perceived incident severity and likelihood of changing physician and filing suit.

"It Matters What I Think, Not What You Say": Scientific Evidence for a Medical Error Disclosure Competence (MEDC) Model

OBJECTIVE

This study sought to validate the ability of a "Medical Error Disclosure Competence" (MEDC) model to predict the effects of physicians' communication skills on error disclosure outcomes in a simulated context.

METHOD

A random sample of 721 respondents was assigned to 16 experimental disclosure conditions that tested the MEDC model's constructs across 2 severity conditions (i.e., minor error and sentinel event).

RESULTS

Severity did not affect survey respondents' perceptions of the physician's disclosure style. Respondents who viewed the nonverbally skilled disclosure perceived the disclosure as more adequate compared to respondents in the "low nonverbal skill" disclosure condition. Interpersonal adaptability did not affect respondents' adequacy ratings. Consistent with the MEDC model, those who viewed the physician's error disclosure as inadequate indicated that they would be more prone to engage in relational distancing behaviors, while those who rated the disclosure as adequate were more likely to reinvest into their relationship with their physician. These respondents also had higher resilience scores. In the context of a sentinel event, perceived adequacy significantly predicted endorsing legal redress or remedies (e.g., lawsuit). Verbal apology (e.g., "I'm sorry," "I apologize") did not predict any significant variance in the model beyond the physician's nonverbal skill.

CONCLUSION

In a simulated disclosure setting, physicians' communicative skills-particularly effective nonverbal communication during a disclosure-trigger outcomes that affect the patient, the physician, and the provider-patient relationship. Findings from this study suggest that MEDC guidelines may be helpful in reducing financial and reputational risks to individual providers and institutions, particularly in the context of a sentinel event.

Development of the Barriers to Error Disclosure Assessment Tool

OBJECTIVES

An interprofessional group of health colleges' faculty created and piloted the Barriers to Error Disclosure Assessment tool as an instrument to measure barriers to medical error disclosure among health care providers.

METHODS

A review of the literature guided the creation of items describing influences on the decision to disclose a medical error. Local and national experts in error disclosure used a modified Delphi process to gain consensus on the items included in the pilot. After receiving university institutional review board approval, researchers distributed the tool to a convenience sample of physicians (n = 19), pharmacists (n = 20), and nurses (n = 20) from an academic medical center. Means and SDs were used to describe the sample. Intraclass correlation coefficients were used to examine test-retest correspondence between the continuous items on the scale. Factor analysis with varimax rotation was used to determine factor loadings and examine internal consistency reliability. Cronbach α coefficients were calculated during initial and subsequent administrations to assess test-retest reliability.

RESULTS

After omitting 2 items with intraclass correlation coefficient of less than 0.40, intraclass correlation coefficients ranged from 0.43 to 0.70, indicating fair to good test-retest correspondence between the continuous items on the final draft. Factor analysis revealed the following factors during the initial administration: confidence and knowledge barriers, institutional barriers, psychological barriers, and financial concern barriers to medical error disclosure. α Coefficients of 0.85 to 0.93 at time 1 and 0.82 to 0.95 at time 2 supported test-retest reliability.

CONCLUSIONS

The final version of the 31-item tool can be used to measure perceptions about abilities for disclosing, impressions regarding institutional policies and climate, and specific barriers that inhibit disclosure by health care providers. Preliminary evidence supports the tool's validity and reliability for measuring disclosure variables.

What Can Apologies in the Electronic Health Record Tell Us About Health Care Quality, Processes, and Safety?

Supplemental digital content is available in the text.

Introduction

Apologizing to patients is an encouraged practice, yet little is known about how and why providers apologize and what insights apologies could provide in improving quality and safety.

Objective

The aim of the study was to determine whether provider apologies in the electronic health record could identify patient safety concerns and opportunities for improvement.

Methods

After performing a free-text search, we randomly selected 100 clinical notes from 1685 available containing terminology related to apology. We categorized the reason for apology, presence and classification of medical error, level of patient harm, and practice improvement opportunities. We compared patient events discovered from apologies in the medical record to standard patient incident report logs.

Results

Of 100 randomly selected apologies, 37 were related to a delay in care, 14 to misunderstanding, 11 to access to care, and 8 to information technology. For apologies related to delay, the median delay was 6 days (mean = 8.9, range = 0–41). Twenty-four (65%) of the 37 delays were related to diagnostic testing.

Medical errors were associated with 46 (46%) of the 100 apologies. Sixty-four (64%) of the 100 apologies were associated with actionable opportunities for improvement. These opportunities were classified into 37 discrete issues across 8 broad categories. When apology review was compared with standard incident report logs, 27 (73%) of the 37 discrete issues identified by patient apology review were not found in incident reporting; both methods identified similar rates of patient harm.

Conclusions

Review of apologies in the electronic health record can identify patient safety concerns and improvement opportunities not apparent through standard incident reporting.

When facing our fallibility constitutes "safe practice": Further evidence for the Medical Error Disclosure Competence (MEDC) guidelines

OBJECTIVE

This study pursues further empirical validation of the "Medical Error Disclosure Competence (MEDC)" guidelines. The following research questions are addressed: (1) What communicative skills predict patients' perceived disclosure adequacy? (2) To what extent do patients' adequacy perceptions predict disclosure effectiveness? (3) Are there any significant sex differences in the MEDC constructs?

METHODS

A sample of 193 respondents completed an online survey about a medical error they experienced in the past 5 years, and about the subsequent disclosure of that error to them.

RESULTS

One in four patients had experienced a medical error, only a third of them received a disclosure. Only interpersonal adaptability influenced disclosure adequacy, with a large effect size. Adequacy, in turn, predicted both patients' relational distancing and approach behaviors. Nonverbally skillful disclosures significantly decreased the likelihood of patient trauma. Expressions of remorse significantly increased patient resilience. Nonverbal skills (-) and a full account (+) predicted patients' tendency to harm themselves. Males were more reactive to disclosures than female patients.

CONCLUSION

MEDC guidelines-adherent disclosure communication maintains the provider-patient relationship, increase patient resilience, and decreases patient trauma after a medical error.

PRACTICE IMPLICATIONS

Given the results of this study, adherence to the MEDC-guidelines must be considered "safe practice."

Do Written Disclosures of Serious Events Increase Risk of Malpractice Claims? One Health Care System's Experience

Supplemental digital content is available in the text.

Objective

This study aimed to determine whether Pennsylvania ACT 13 of 2002 (Mcare) requiring the written and verbal disclosure of “serious events” was accompanied by increased malpractice claims or compensation costs in a large U.S. health system.

Main Outcomes and Measures

The primary outcome was the rate of malpractice claims. The secondary outcome was the amount paid for compensation of malpractice claims. The analyses tested the relationship between the rate of serious event disclosures and the outcome variables, adjusted for the year of the event, category of claim, and the degree of “harm” related to the event.

Results

There were 15,028 serious event disclosures and 1302 total malpractice claims among 1,587,842 patients admitted to UPMC hospitals from May 17, 2002, to June 30, 2011. As the number of serious event disclosures increased, the number of malpractice claims per 1000 admissions remained between 0.62 and 1.03. Based on a matched analysis of claims that were disclosed and those that were not (195 pairs), disclosure status was significantly associated with increased claim payout (disclosures had 2.71 times the payout; 95% confidence interval, 1.56–4.72). Claims with higher harm levels H and I were independently associated with higher payouts than claims with lower harm levels A to D (11.15 times the payout; 95% confidence interval, 2.30–54.07).

Conclusions and Relevance

Implementation of a mandated serious event disclosure law in Pennsylvania was not associated with an overall increase in malpractice claims filed. Among events of similar degree of harm, disclosed events had higher compensation paid compared with those that had not been disclosed.

Individual and Team-Based Medical Error Disclosure: Dialectical Tensions Among Health Care Providers

Researchers from disciplines of education, health communication, law and risk management, medicine, nursing, and pharmacy examined communication tensions among interprofessional (IP) health care providers regarding medical error disclosure utilizing patient simulation. Using relational dialectics theory, we examined how communication tensions manifested in both individual-provided medical error disclosure and IP team-based disclosure. Two dialectical tensions that health care providers experienced in disclosure conversations were identified: (a) leadership and support, and (b) transparency and protectionism. Whereas these tensions were identified in an IP education setting using simulation, findings support the need for future research in clinical practice, which may inform best practices for various disclosure models. Identifying dialectical tensions in disclosure conversations may enable health communication experts to effectively engage health care providers, risk management, and patient care teams in terms of support and education related to communicating about medical errors.

Tell Me Straight: Teaching Residents to Disclose Adverse Events in Surgery

OBJECTIVE

The purpose of this effort was to create an educational experience that provided learners a realistic disclosure experience and improved resident confidence discussing an adverse outcome with a patient and family.

DESIGN

Residents practiced disclosing a surgical complication to a patient/family with simulated patients (SPs). We paired professional SPs with former patient SPs to present a realistic case. Junior residents were given extra training time before their disclosure of a laparoscopic cholecystectomy conversion to an open procedure; senior residents disclosed a bile duct injury. Residents rated pre and post-module confidence levels, and skills performance using the Disclosure of a Complication Checklist.

SETTING

900-bed tertiary care hospital with surgical residency program and simulation center.

PARTICIPANTS

General surgery residents (PGY 1-5).

RESULTS

Eighteen residents participated in the disclosure module. Analysis of the medians and interquartile ranges of pre and post-module confidence scores showed significant improvement for each individual item and mean score of learners. Residents assessed their completion rates of individual Checklist tasks positively. For example, 94% self-endorsed completion of "explanation of facts," 89% self-endorsed "took responsibility," and 78% self-endorsed "apologized sincerely." Self-rated competence scores from the Checklist were low: 7% indicated they would be "extremely comfortable" entrusting their loved one's care to themselves, 11% rated their ability to explain the facts as "outstanding," and 12% felt they were "outstanding" in their "ability to disclose a complication in a professional manner."

CONCLUSION

Residents received important skills practice in our disclosure training; disclosure confidence increased after participation. Residents scored high on completion of disclosure tasks and low on comfort and proficiency of those tasks. The Checklist provided a useful set of tasks to review and complete in the exercise. Separating residents by PGY level enabled senior residents to experience a more complex scenario and junior residents extra time to practice.

Physician gender and apologies in clinical interactions

OBJECTIVE

We examine whether patients have a preference for affective (i.e., focused on patient's emotions) or cognitive (i.e., focused on the process that led to the error) apologies that are dependent on the apologizing physician's gender. We hypothesize patients will prefer gender-congruent apologies (i.e., when females offer affective apologies and males offer cognitive apologies).

METHODS

We randomly assigned analogue patients (APs: participants instructed to imagine they were a patient) to read a scenario in which a female or male physician makes an error and provides a gender-congruent or incongruent apology. APs reported on their perceptions of the physician and legal intentions.

RESULTS

An apology-type and gender congruency effect was found such that APs preferred apologies congruent with the gender of the apologizing physician. An indirect effect of congruency on legal intentions through physician perceptions was confirmed (b=-0.24, p=0.02).

CONCLUSION

Our results suggest that physician gender plays a role in patient reactions to different apology types.

PRACTICE IMPLICATIONS

Apology trainings should incorporate how physician characteristics can influence how patients assess and respond to apologies.

Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes

RATIONALE

This study investigates the intrapersonal and interpersonal factors and processes that are associated with patient forgiveness of a provider in the aftermath of a harmful medical error.

OBJECTIVE

This study aims to examine what antecedents are most predictive of patient forgiveness and non-forgiveness, and the extent to which social-cognitive factors (i.e., fault attributions, empathy, rumination) influence the forgiveness process. Furthermore, the study evaluates the role of different disclosure styles in two different forgiveness models, and measures their respective causal outcomes.

METHODS

In January 2011, 318 outpatients at Wake Forest Baptist Medical Center in the United States were randomly assigned to three hypothetical error disclosure vignettes that operationalized verbally effective disclosures with different nonverbal disclosure styles (i.e., high nonverbal involvement, low nonverbal involvement, written disclosure vignette without nonverbal information). All patients responded to the same forgiveness-related self-report measures after having been exposed to one of the vignettes.

RESULTS

The results favored the proximity model of interpersonal forgiveness, which implies that factors more proximal in time to the act of forgiving (i.e., patient rumination and empathy for the offender) are more predictive of forgiveness and non-forgiveness than less proximal factors (e.g., relationship variables and offense-related factors such as the presence or absence of an apology). Patients' fault attributions had no effect on their forgiveness across conditions. The results evidenced sizeable effects of physician nonverbal involvement-patients in the low nonverbal involvement condition perceived the error as more severe, experienced the physician's apology as less sincere, were more likely to blame the physician, felt less empathy, ruminated more about the error, were less likely to forgive and more likely to avoid the physician, reported less closeness, trust, and satisfaction but higher distress, were more likely to change doctors, less compliant, and more likely to seek legal advice.

CONCLUSION

The findings of this study imply that physician nonverbal involvement during error disclosures stimulates a healing mechanism for patients and the physician-patient relationship. Physicians who disclose a medical error in a nonverbally uninvolved way, on the other hand, carry a higher malpractice risk and are less likely to promote healthy, reconciliatory outcomes.

Error disclosure and family members' reactions: does the type of error really matter?

OBJECTIVE

To describe how Italian clinicians disclose medical errors with clear and shared lines of responsibility.

METHODS

Thirty-eight volunteers were video-recorded in a simulated conversation while communicating a medical error to a simulated family member (SFM). They were assigned to a clear responsibility error scenario or a shared responsibility one. Simulations were coded for: mention of the term "error" and apology; communication content and affect using the Roter Interaction Analysis System. SFMs rated their willingness to have the patient continue care with the clinician.

RESULTS

Clinicians referred to an error and/or apologized in 55% of the simulations. The error was disclosed more frequently in the clear responsibility scenario (p<0.02). When the "error" was explicitly mentioned, the SFM was more attentive, sad and anxious (p≤0.05) and less willing to have the patient continue care (p<0.05). Communication was more patient-centered (p<0.05) and affectively dynamic with the SFMs showing greater anxiety, sadness, attentiveness and respectfulness in the clear responsibility scenario (p<0.05).

CONCLUSIONS

Disclosing errors is not a common practice in Italy. Clinicians disclose less frequently when responsibility is shared and indicative of a system failure.

PRACTICE IMPLICATIONS

Training programs to improve disclosure practice considering the type of error committed should be implemented.

(Re)Introducing communication competence to the health professions

Despite the central role that communication skills play in contemporary accounts of effective health care delivery in general, and the communication of medical error specifically, there is no common or consensual core in the health professions regarding the nature of such skills. This lack of consensus reflects, in part, the tendency for disciplines to reinvent concepts and measures without first situating such development in disciplines with more cognate specialization in such concepts. In this essay, an integrative model of communication competence is introduced, along with its theoretical background and rationale. Communication competence is defined as an impression of appropriateness and effectiveness, which is functionally related to individual motivation, knowledge, skills, and contextual facilitators and constraints. Within this conceptualization, error disclosure contexts are utilized to illustrate the heuristic value of the theory, and implications for assessment are suggested. Significance for public healthModels matter, as do the presuppositions that underlie their architecture. Research indicates that judgments of competence moderate outcomes such as satisfaction, trust, understanding, and power-sharing in relationships and in individual encounters. If the outcomes of health care encounters depend on the impression of competence that patients or their family members have of health care professionals, then knowing which specific communicative behaviors contribute to such impressions is not merely important - it is essential. To pursue such a research agenda requires that competence assessment and operationalization becomes better aligned with conceptual assumptions that separate behavioral performance from the judgments of the competence of that performance.