Background This study aims to evaluate the attending surgeons' and residents' attitudes towards error disclosure and factors that can potentially affect these tendencies in major academic hospitals affiliated with Tehran University of Medical Sciences (TUMS).
Methods and material In a cross-sectional study, self-administered questionnaires were delivered to all attending surgeons and second to fourth year surgical residents of TUMS during October and November 2009. The questionnaire contained two clinical scenarios and questions regarding physicians' attitudes towards disclosing medical error and their actual practice in the case of their last error. Of the 63 distributed questionnaires, 53 (84.1%) were completed and returned.
Results Participants were less likely to disclose minor (39.6%; 21/53) than major (49.1%; 29/53) medical errors. Participants believed that their most important concerns for not disclosing errors were fear of a malpractice lawsuit (71.7%, n=38), losing patients' trust (62.3%, n=33), and emotional reactions of the patients and their relatives (56.6%, n=30). Although most physicians indicated they would disclose errors in minor and major scenarios, only 16.7% (n=8) had disclosed their last medical errors to their patients, two of which had resulted in patients taking legal action.
Conclusion There was an obvious gap between surgeons' intentions and actual practices concerning disclosure of medical error. Education in medical error management to professionally support error disclosure might help reduce the gap.
- Medical error
- academic attending surgeon
- medical ethics
- breast surgery
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Telling the truth is one of the basic ethical principles in medicine, and appropriate clinical practice is based on an honest patient–physician relationship.1 Telling the truth will increase patients' acceptance in case of treatment side effects1 and improve treatment outcomes.2 Patients who are aware of their conditions are more satisfied with the medical care system and are less likely to change their physician.3 Medical error disclosure is an example of honesty in patient–physician relationship. Patients have the right to know and expect to be told the details of any harmful consequences of diagnostic tests or therapeutic approaches, and if competent, should be involved in decision making. In other words, making an error is not immoral per se, but not disclosing it is considered deceptive and immoral and decreases the trust patients have regarding their physicians.4 5
Although literature abounds with papers that emphasise the importance of error disclosure,5–8 a significant number of physicians do not disclose their errors. In their survey, Hingorani et al showed that only 60% of ophthalmologists, as opposed to 92% of the patients, believe that medical error should be revealed to the patient.9 According to a study in the USA in 2003, although patients wish to receive detailed information about medical errors, physicians usually disclose the adverse event but avoid stating that a medical error has happened.10 Likewise, in a hypothetical vignette-based study by Novack et al, about a third of physicians would deceive their patients by giving misleading or insufficient information.11 In the study by Gallagher et al using a scenario on diagnostic error, only 40% of radiologists stated that they would probably or definitely disclose the error to patient. Most of them indicated they would disclose if asked by the patient.12 In another survey, only 54% of house officers reported their mistake to their attending physicians, and only 24% told the patients or families.13
Literature has addressed different cultural, legal and emotional barriers that may prevent disclosure.8 11 14 15 Reviewing doctors' attitudes, concerns and beliefs towards error disclosure can help in understanding the challenges and consequently promoting medical practices that are more professional. In Iran, most researches on medical error concern the epidemiology of lawsuits, and to our knowledge, no study has examined physicians' attitude regarding error disclosure. Likewise, we found no paper on physicians' attitude towards error disclosure in other Islamic countries. According to the Islamic Sharia and national law in Iran, physicians are liable for any medical error that results in harm. In the current Iranian judicial procedures, only those directly causing harm are held liable, and these are usually doctors or nurses who are in the forefront of providing health service. In Iran a systematic approach to medical error is not practiced, and assigning blame to individuals is the dominant culture in medical error management. Moreover, there is no professional regulation in Iran to mandate physicians to disclose their error. Since some obstacles are due to cultural barriers, it would be worthwhile to evaluate physicians' views of error disclosure in Iran as an Islamic country. In order to reflect on this cultural aspects this study was done to assess the likelihood of actual and hypothetical error disclosure to patients among attending surgeons and surgical residents with >1 year experience and to determine perceived obstacles to disclosure.
In this study, which was carried out during October and November 2009, data were gathered from all attending surgeons and second to fourth year surgical residents of the department of surgery at the Tehran University of Medical Sciences. Junior residents were not considered because they had just started their residency and lacked sufficient experience in surgery.
Data gathering tool
Data were collected using a self-administered questionnaire which was designed after extensive literature review. In the questionnaire, we provided one scenario for a minor and a major medical error to make uniform participants' understanding of error classification. In general, medical errors are classified as near miss (with no harm), minor (a mistake resulting in a non-significant outcome which only prolongs a patient hospitalisation) and major (a mistake leading to a significant life-threatening outcome) ones. In our study, we excluded near miss errors since it is not morally necessary to disclose such errors to patients.
In the minor error scenario, the doctor gets distracted and forgets to order anticoagulants which results in subsequent simple deep vein thrombosis. In the major one, the doctor forgets to follow patient's serum potassium level which leads to ventricular tachycardia and cardiopulmonary arrest, but the patient is successfully resuscitated eventually. For each scenario, two hypothetical situations were considered: (1) the patient asks about the medical error and (2) the patient does not ask. To evaluate participants' attitude a five-point Likert Scale was used.
The questionnaire also included questions regarding demographics, participants' agreement with 10 attitudinal statements regarding error disclosure, and their need for education regarding ethics and communication skills for error disclosure. We also asked them about their last experience with medical error, whether it was minor or major, if it was during the past 12 months and whether they disclosed it to the patient. If the response to the last question was affirmative, they needed to answer whether they were pleased with their decision, and whether they faced legal issues. The questionnaire also included a section with an 11 item list to choose four most important obstacles to medical error disclosure in their perceptions and an eight item list to choose one or more types of information that must be disclosed to patients about medical error. The validity of the questionnaire was evaluated by two surgeons.
Questionnaires were delivered to physicians in person. Participants were asked for verbal consent. They were not obligated to complete the questionnaire in one session, and the researcher returned later if necessary. The protocol of this study was approved by the Tehran University of Medical Sciences Research Ethics Committee.
Data processing and statistical analysis
Descriptive analysis of Likert variables (such as disclosure attitude in each scenario, participants' agreement with attitudinal statements regarding error disclosure) and nominal variables was done by calculating the frequency for each option. For their perceived four most important obstacles of error disclosure, we determined the chosen frequency for each item. We did the same for their opinion regarding needed information to be disclosed to patients. The effects of gender and professional title on participant's willingness of error disclosure in given scenarios were analysed using the χ2 test. The effect of age and clinical practice experience on their response to scenarios was analysed using ANOVA test. p Values <0.05 were considered statistically significant.
Fifty-three of 63 (84%) surgeons returned completed questionnaires; 49.1% (n=26) were attending surgeons and 50.9% (n=27) were residents (table 1).
Surgeons' tendency for medical error disclosure
Twenty-one (39.6%) and 29 (49.1%) participants were in favour of disclosing medical errors in minor and major scenarios, respectively. When the scenarios included the patient asking for information about an error, these rates increased to 67.9% and 64.2%, respectively (table 2); differences were statistically significant in minor and major error scenarios (p=0.01 and p=0.039, respectively). None of the demographic variables such as age, gender, clinical practice experience or professional title had a significant impact on the participants' attitude towards error disclosure in either scenario.
Surgeons' perception of error disclosure
Physicians' perceptions of error disclosure and its consequences are shown in table 3. The four most frequently chosen obstacles were fear of patients' legal action, fear of losing patients' trust, fear of the reactions of the patients' family members and fear of losing professional reputation (table 4).
Surgeons' perception of information transfer
According to respondents, the most important information which should be communicated to the patients was reassuring them that every attempt will be made to remediate the injury (58.5%, n=31). Other issues identified in order of importance were taking adequate actions to prevent error reoccurrence (47.2%, n=25), accepting the responsibility of the error and its side effects (39.6%, n=21), apologising (35.8%, n=19), ascertaining that the patient has understood the information (34%), explaining the reason why the error occurred (32.1%) and admitting that the patient's emotional response is understandable (32.1%).
Surgeons' reaction in their last medical error
The reaction of the participants to their last medical error was also assessed. Of the 53 respondents, 30 (56.6%) (13 among attending and 17 among resident surgeons) admitted they had made mistakes in the last year; of these 12 errors (75%) were major. Only eight persons (16.7%) had disclosed their error to the patient. Although two of these disclosures had led to lawsuits against physicians, both physicians were completely satisfied with their disclosure and on the whole seven physicians (87.5%) were completely satisfied and one physician (12.5%) was almost completely satisfied about their disclosures even though there were possibilities of legal repercussions following the disclosure.
Educational needs regarding error disclosure
Regarding the participants' needs for education, only 11.8% (n=6) stated they required no training in communication skills to convey bad news to patients, and 9.8% (n=5) felt no need for receiving information regarding ethical principles and professional regulations related to medical errors. In other words, although the expressed need for education was not significantly different between attending and resident surgeons, this need was significantly higher in participants who were in favour of minor and major error disclosures (p=0.002 and 0.021, respectively).
In this research, although about half of the participants agreed with the need for error disclosure and most of them believed it was the patients' right to know about the error and its reasons, only a sixth of them had disclosed their own last medical error to their patients. This obvious gap between physicians' attitude and actual disclosure is due to various reasons. The most important obstacles for disclosure in their own opinion were fear of a lawsuit, fear of decreased patients' trust, fear of family members' emotional reaction and fear of losing professional reputation. Although legal issues were the main concern, just a fourth of our participants were sued after they had disclosed their error and, surprisingly, no one regretted their decision to disclose.
Most of participants believed that ‘error disclosure depends on physician's judgment if the patient benefits or is harmed by being told about the error’. This belief is consistent with the paternalistic culture of medical practice in Iran. It is worth mentioning that most physicians did not believe in positive outcomes of disclosing errors such as decreased likelihood of legal proceedings and increased patients' trust in physicians, and worried about its negative effects (table 3).
Considering the expressed concerns and the gap between practice and attitude, it seems that building a safer professional environment and providing emotional support can play a key role in promoting error disclosure. Although receiving insufficient education regarding ethical principles and lacking skills in communicating bad news were not important obstacles in error disclosure, considering their negative attitude and the needs of the majority of the physicians for education in this area, it appears that developing comprehensive educational programmes in this field would at least fortify clinicians who are in favour of error disclosure and help them disclose their errors appropriately and build an appropriate patient–physician relationship.
Compared with previous studies, physicians were less willing to disclose medical errors in our study. In a study by Garbutt et al performed on paediatricians using the Likert Scale, hypothetical disclosure of minor and major errors was found to be 90% and 99%, respectively.14 Likewise, in the study by Kaldjian et al performed on faculty, residents and medical students, these figures for minor and major error disclosures were 97% and 93%, respectively.16 In practice, however, Hobgood et al showed that only 28% of emergency residents had disclosed their most significant error with the patients or the patients' family.17 In his survey on West European physician members of the European Society of Intensive Care Medicine, Vincent showed while 70% felt they should give complete detailed information regarding their error to the patient, only 32% would actually do so.18 Gallagher et al studied 2637 physicians in the USA and Canada and found that 98% and 78% of participants believed that major and minor errors, respectively, should be disclosed to the patients.19 The difference observed in Iran may be the result of differences in challenges faced by physicians in the Iranian medical care system and doctors' knowledge regarding error disclosure. Social and cultural differences of our patients, lack of a support system for physicians in case of medical error and neglect of ethical issues during educational courses may also be the other reasons for this gap.
It should be noted that this study had some limitations such as choosing for analysis one medical specialty in only one university. Also, due to the small sample size, our study lacked sufficient power to show differences between attitudes of attending surgeons and residents, which might, in fact, have been significant because of differences in their responsibility towards patients and their experience with errors and lawsuits. Thus, it is not possible to generalise findings of this study to other settings. In order to overcome this limitation, we suggest a more extensive study be done in different fields and healthcare institutes.
We suggest conducting qualitative and more in-depth research in order to recognise all challenges involved in the issue of medical error disclosure. Justifiability of physicians' negative attitude towards error disclosure should be studied in other studies.
Fear of legal action is the most important obstacle of disclosing an error.
There is a gap between surgeons' attitude and practice in error disclosure.
Changes in professional environment and planning for educational programmes are needed to improve error disclosure.
Current research questions
Does error disclosure decrease patient's trust in physicians?
Does error disclosure lead to fewer lawsuits?
Will a systematic approach to medical error result in more error disclosures?
The authors wish to thank Dr Abas Rabbani and Dr Mahrokh Daemi for their collaboration in executing this study.
Funding This project was the subject matter of Dr Ghalandarpoorattar's MD thesis and was supported by TUMS.
Competing interests None.
Ethics approval Ethics approval was approved by Research ethics committee of Tehran University of Medical Sciences.
Provenance and peer review Not commissioned; externally peer reviewed.