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Objectives: Transparent communication after medical error includes disclosing the mistake to the patient, discussing the event with colleagues, and reporting to the institution. Little is known about whether attitudes about these transparency practices are related. Understanding these relationships could inform educational and organizational strategies to promote transparency., Methods: We analyzed responses of 3038 US and Canadian physicians to a medical error communication survey. We used bivariate correlations, principal components analysis, and linear regression to determine whether and how physician attitudes about transparent communication with patients, peers, and the institution after error were related., Results: Physician attitudes about disclosing errors to patients, peers, and institutions were correlated (all P's < 0.001) and represented 2 principal components analysis factors, namely, communication with patients and communication with peers/institution. Predictors of attitudes supporting transparent communication with patients and peers/institution included female sex, US (vs Canadian) doctors, academic (vs private) practice, the belief that disclosure decreased likelihood of litigation, and the belief that system changes occur after error reporting. In addition, younger physicians, surgeons, and those with previous experience disclosing a serious error were more likely to agree with disclosure to patients. In comparison, doctors who believed that disclosure would decrease patient trust were less likely to agree with error disclosure to patients. Previous disclosure education was associated with attitudes supporting greater transparency with peers/institution., Conclusions: Physician attitudes about discussing errors with patients, colleagues, and institutions are related. Several predictors of transparency affect all 3 practices and are potentially modifiable by educational and institutional strategies.

National guidelines call for health care organizations to provide around-the-clock coaching for medical error disclosure. However, frontline clinicians may not always seek risk managers for coaching. As part of a demonstration project designed to improve patient safety and reduce malpractice liability, we trained multidisciplinary disclosure coaches at 8 health care organizations in Washington State. The training was highly rated by participants, although not all emerged confident in their coaching skill. This multisite intervention can serve as a model for other organizations looking to enhance existing disclosure capabilities. Success likely requires cultural change and repeated practice opportunities for coaches., (© 2017 American Society for Healthcare Risk Management of the American Hospital Association.)

Importance: Surgeons are frequently faced with clinical adverse events owing to the nature of their specialty, yet not all surgeons disclose these events to patients. To sustain open disclosure programs, it is essential to understand how surgeons are disclosing adverse events, factors that are associated with reporting such events, and the effect of disclosure on surgeons., Objective: To quantitatively assess surgeons' reports of disclosure of adverse events and aspects of their experiences with the disclosure process., Design, Setting, and Participants: An observational study was conducted from January 1, 2011, to December 31, 2013, involving a 21-item baseline questionnaire administered to 67 of 75 surgeons (89%) representing 12 specialties at 3 Veterans Affairs medical centers. Sixty-two surveys of their communication about adverse events and experiences with disclosing such events were completed by 35 of these 67 surgeons (52%). Data were analyzed using mixed linear random-effects and logistic regression models., Main Outcomes and Measures: Self-reports of disclosure assessed by 8 items from guidelines and pilot research, surgeons' perceptions of the adverse event, reported personal effects from disclosure, and baseline attitudes toward disclosure., Results: Most of the surgeons completing the web-based surveys (41 responses from men and 21 responses from women) used 5 of the 8 recommended disclosure items: explained why the event happened (55 of 60 surveys [92%]), expressed regret for what happened (52 of 60 [87%]), expressed concern for the patient's welfare (57 of 60 [95%]), disclosed the adverse event within 24 hours (58 of 60 [97%]), and discussed steps taken to treat any subsequent problems (59 of 60 [98%]). Fewer surgeons apologized to patients (33 of 60 [55%]), discussed whether the event was preventable (33 of 60 [55%]), or how recurrences could be prevented (19 of 59 [32%]). Surgeons who were less likely to have discussed prevention (33 of 60 [55%]), those who stated the event was very or extremely serious (40 of 61 surveys [66%]), or reported very or somewhat difficult experiences discussing the event (16 of 61 [26%]) were more likely to have been negatively affected by the event. Surgeons with more negative attitudes about disclosure at baseline reported more anxiety about patients' surgical outcomes or events following disclosure (odds ratio, 1.54; 95% CI, 1.16-2.06)., Conclusions and Relevance: Surgeons who reported they were less likely to discuss preventability of the adverse event, or who reported difficult communication experiences, were more negatively affected by disclosure than others. Quality improvement efforts focused on recognizing the association between disclosure and surgeons' well-being may help sustain open disclosure policies.

Background: Full disclosure of harmful errors to patients, including a statement of regret, an explanation, acceptance of responsibility and commitment to prevent recurrences is the current standard for physicians in the USA., Objective: To examine the extent to which primary care physicians' perceptions of event-level, physician-level and organisation-level factors influence intent to disclose a medical error in challenging situations., Design: Cross-sectional survey containing two hypothetical vignettes: (1) delayed diagnosis of breast cancer, and (2) care coordination breakdown causing a delayed response to patient symptoms. In both cases, multiple physicians shared responsibility for the error, and both involved oncology diagnoses., Setting: The study was conducted in the context of the HMO Cancer Research Network Cancer Communication Research Center., Participants: Primary care physicians from three integrated healthcare delivery systems located in Washington, Massachusetts and Georgia; responses from 297 participants were included in these analyses., Main Measures: The dependent variable intent to disclose included intent to provide an apology, an explanation, information about the cause and plans for preventing recurrences. Independent variables included event-level factors (responsibility for the event, perceived seriousness of the event, predictions about a lawsuit); physician-level factors (value of patient-centred communication, communication self-efficacy and feelings about practice); organisation-level factors included perceived support for communication and time constraints., Key Results: A majority of respondents would not fully disclose in either situation. The strongest predictors of disclosure were perceived personal responsibility, perceived seriousness of the event and perceived value of patient-centred communication. These variables were consistently associated with intent to disclose., Conclusion: To make meaningful progress towards improving disclosure; physicians, risk managers, organisational leaders, professional organisations and accreditation bodies need to understand the factors which influence disclosure. Such an understanding is required to inform institutional policies and provider training., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: The Department of Veterans Affairs (VA) mandates disclosure of large-scale adverse events to patients, even if risk of harm is not clearly present. Concerns about past disclosures warranted further examination of the impact of this policy., Objective: Through a collaborative partnership between VA leaders, policymakers, researchers and stakeholders, the objective was to empirically identify critical aspects of disclosure processes as a first step towards improving future disclosures., Design: Semi-structured interviews were conducted with participants at nine VA facilities where recent disclosures took place., Participants: Ninety-seven stakeholders participated in the interviews: 38 employees, 28 leaders (from facilities, regions and national offices), 27 Veteran patients and family members, and four congressional staff members., Approach: Facility and regional leaders were interviewed by telephone, followed by a two-day site visit where employees, patients and family members were interviewed face-to-face. National leaders and congressional staff also completed telephone interviews. Interviews were analyzed using rapid qualitative assessment processes. Themes were mapped to the stages of the Crisis and Emergency Risk Communication model: pre-crisis, initial event, maintenance, resolution and evaluation., Key Results: Many areas for improvement during disclosure were identified, such as preparing facilities better (pre-crisis), creating rapid communications, modifying disclosure language, addressing perceptions of harm, reducing complexity, and seeking assistance from others (initial event), managing communication with other stakeholders (maintenance), minimizing effects on staff and improving trust (resolution), and addressing facilities' needs (evaluation)., Conclusions: Through the partnership, five recommendations to improve disclosures during each stage of communication have been widely disseminated throughout the VA using non-academic strategies. Some improvements have been made; other recommendations will be addressed through implementation of a large-scale adverse event disclosure toolkit. These toolkit strategies will enable leaders to provide timely and transparent information to patients and families, while reducing the burden on employees and the healthcare system during these events.

The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians' errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.

Disclosing harmful medical errors to patients is a prominent component of the patient safety movement. Patients expect it and safety agencies and experts advocate its implementation. Obstetrics presents unique challenges to carrying out disclosure recommendations: childbirth is a life-changing, emotionally charged, and dynamic family event characterized by high expectations and unpredictability, and perinatal care is provided by complex ad hoc teams in a litigious area of medicine. Despite these challenges, transparent communication with parents about unexpected adverse birth outcomes remains critical. We call on clinicians and professional societies to pursue a deeper understanding of the unique challenges of disclosure in obstetrics and prepare themselves to conduct these difficult conversations well.

Background: Hospitals face a disclosure dilemma when large-scale adverse events affect multiple patients and the chance of harm is extremely low. Understanding the perspectives of patients who have received disclosures following such events could help institutions develop communication plans that are commensurate with the perceived or real harm and scale of the event., Methods: A mailed survey was conducted in 2008 of 266 University of Washington Medical Center (UWMC) patients who received written disclosure in 2004 about a large-scale, low-harm/low-risk adverse event involving an incomplete endoscope cleaning process. The survey measured patients' satisfaction with this disclosure, their concerns about healthcare outcomes, and their recommendations for future communication, given similar circumstances., Results: Surveys were received from 127 of 266 (48 percent) of eligible respondents; 98 percent thought that UWMC was right to inform them about this event, and mean satisfaction with the disclosure was 7.7 on a 0 to 10 scale. Of the 127 respondents, 64 percent were somewhat or very concerned that the endoscope cleaning problem might cause them health problems; 60 percent reported their impressions of UWMC's honesty and integrity had increased; 31 percent said their perceptions of the quality of care had increased; 94 percent agreed that institutions should tell patients about any error in their care, even when the risk of harm was low, although 28 percent agreed that such notifications would make them anxious. Respondents who reported concern that the event could cause them health problems were less likely to be satisfied with the institution's disclosure. Patients cited their right to know information material to their own health and healthcare as an important reason for disclosure., Conclusion: Recipients of disclosure of a large-scale, low-harm/low-risk event overwhelmingly supported being told of the event and endorsed notification of patients for similar events in the future. Although informing patients may cause concern for some, institutions should ensure their disclosure policies and procedures reflect their patients' preferences.

Objective: Guidelines on apology and disclosure after adverse events and errors have been in place for over 5 years. This study examines whether patients consider recommended responses to be appropriate and desirable, and whether clinicians' actions after adverse events are consistent with recommendations., Methods: Patients who believed that something had gone wrong during their cancer care were identified. During in-depth interviews, patients described the event, clinicians' responses, and their reactions., Results: 78 patients were interviewed. Patients' valued apology and expressions of remorse, empathy and caring, explanation, acknowledgement of responsibility, and efforts to prevent recurrences, but these key elements were often missing. For many patients, actions and evidence of clinician learning were most important., Conclusion: Patients' reports of apology and disclosure when they believe something has gone wrong in their care suggest that clinicians' responses continue to fall short of expectations., Practice Implications: Clinicians preparing to talk with patients after an adverse event or medical error should be aware that patients expect their actions to be congruent with their words of apology and caring. Healthcare systems need to support clinicians throughout the disclosure process, and facilitate both system and individual learning to prevent recurrences., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Under "disclosure-and-resolution" programs, health systems disclose adverse events to affected patients and their families; apologize; and, where appropriate, offer compensation. Early adopters of this approach have reported reduced liability costs, but the extent to which these results stem from effective disclosure and apology practices, versus compensation offers, is unknown. Using survey vignettes, we examined the effects of different compensation offers on individuals' responses to disclosures of medical errors compared to explanation and apology alone. Our results show that although two-thirds of these individuals desired compensation offers, increasing the offer amount did not improve key outcomes. Full-compensation offers did not decrease the likelihood of seeking legal advice and increased the likelihood that people perceived the disclosure and apology as motivated by providers' desire to avoid litigation. Hospitals, physicians, and malpractice insurers should consider this complex interplay as they implement similar initiatives. They may benefit from separating disclosure conversations and compensation offers and from excluding physicians from compensation discussions.

Nurses have an obligation to disclose an error when one occurs. This study explored 1180 nurses' perceptions of error disclosure in the nursing home setting. Nurse respondents found disclosure to be a difficult process. Registered nurse respondents and nurses who had prior experience disclosing a serious error were more likely to disclose a serious error. The study has implications to improve nursing education, policy, and patient safety culture in the nursing home setting.

This article provides findings on the role of the nurse in simulated team-based error disclosures. Triangulation of 3 qualitative data sets revealed that a tension exists for nurses in the error disclosure process as they attempt to balance professional boundaries. Study findings point to multilevel strategies including cultural, structural, and educational approaches to enhancing the key roles that nurses need to play in error disclosure to patients and families.

Objectives: The disclosure of harmful errors to patients is recommended, but appears to be uncommon. Understanding how trainees disclose errors and how their practices evolve during training could help educators design programmes to address this gap. This study was conducted to determine how trainees would disclose medical errors., Methods: We surveyed 758 trainees (488 students and 270 residents) in internal medicine at two academic medical centres. Surveys depicted one of two harmful error scenarios that varied by how apparent the error would be to the patient. We measured attitudes and disclosure content using scripted responses., Results: Trainees reported their intent to disclose the error as 'definitely' (43%), 'probably' (47%), 'only if asked by patient' (9%), and 'definitely not' (1%). Trainees were more likely to disclose obvious errors than errors that patients were unlikely to recognise (55% versus 30%; p < 0.01). Respondents varied widely in the type of information they would disclose. Overall, 50% of trainees chose to use statements that explicitly stated that an error rather than only an adverse event had occurred. Regarding apologies, trainees were split between conveying a general expression of regret (52%) and making an explicit apology (46%). Respondents at higher levels of training were less likely to use explicit apologies (trend p < 0.01). Prior disclosure training was associated with increased willingness to disclose errors (odds ratio 1.40, p = 0.03)., Conclusions: Trainees may not be prepared to disclose medical errors to patients and worrisome trends in trainee apology practices were observed across levels of training. Medical educators should intensify efforts to enhance trainees' skills in meeting patients' expectations for the open disclosure of harmful medical errors., (© Blackwell Publishing Ltd 2011.)

Apologies are rare in the medical world, where health care providers fear that admissions of guilt or expressions of regret could be used by plaintiffs in malpractice lawsuits. Nevertheless, some states are moving toward giving health care providers legal protection so that they feel free to apologize to patients for a medical mistake. Advocates believe that these laws are beneficial for patients and providers. However, our analysis of "apology" and "disclosure" laws in thirty-four states and the District of Columbia finds that most of the laws have major shortcomings. These may actually discourage comprehensive disclosures and apologies and weaken the laws' impact on malpractice suits. Many could be resolved by improved statutory design and communication of new legal requirements and protections.

Background: Physicians are encouraged to disclose medical errors to patients, which often requires close collaboration between physicians and risk managers., Methods: An anonymous national survey of 2,988 healthcare facility-based risk managers was conducted between November 2004 and March 2005, and results were compared with those of a previous survey (conducted between July 2003 and March 2004) of 1,311 medical physicians in Washington and Missouri. Both surveys included an error-disclosure scenario for an obvious and a less obvious error with scripted response options., Results: More risk managers than physicians were aware that an error-reporting system was present at their hospital (81% versus 39%, p < .001) and believed that mechanisms to inform physicians about errors in their hospital were adequate (51% versus 17%, p < .001). More risk managers than physicians strongly agreed that serious errors should be disclosed to patients (70% versus 49%, p < .001). Across both error scenario, risk managers were more likely than physicians to definitely recommend that the error be disclosed (76% versus 50%, p < .001) and to provide full details about how the error would be prevented in the future (62% versus 51%, p < .001). However, physicians were more likely than risk managers to provide a full apology recognizing the harm caused by the error (39% versus 21%, p < .001)., Conclusions: Risk managers have more favorable attitudes about disclosing errors to patients compared with physicians but are less supportive of providing a full apology. These differences may create conflicts between risk managers and physicians regarding disclosure. Health care institutions should promote greater collaboration between these two key participants in disclosure conversations.

Purpose: To assess radiologists' attitudes about disclosing errors to patients by using a survey with a vignette involving an error interpreting a patient's mammogram, leading to a delayed cancer diagnosis., Materials and Methods: We conducted an institutional review board-approved survey of 364 radiologists at seven geographically distinct Breast Cancer Surveillance Consortium sites that interpreted mammograms from 2005 to 2006. Radiologists received a vignette in which comparison screening mammograms were placed in the wrong order, leading a radiologist to conclude calcifications were decreasing in number when they were actually increasing, delaying a cancer diagnosis. Radiologists were asked (a) how likely they would be to disclose this error, (b) what information they would share, and (c) their malpractice attitudes and experiences., Results: Two hundred forty-three (67%) of 364 radiologists responded to the disclosure vignette questions. Radiologists' responses to whether they would disclose the error included "definitely not" (9%), "only if asked by the patient" (51%), "probably" (26%), and "definitely" (14%). Regarding information they would disclose, 24% would "not say anything further to the patient," 31% would tell the patient that "the calcifications are larger and are now suspicious for cancer," 30% would state "the calcifications may have increased on your last mammogram, but their appearance was not as worrisome as it is now," and 15% would tell the patient "an error occurred during the interpretation of your last mammogram, and the calcifications had actually increased in number, not decreased." Radiologists' malpractice experiences were not consistently associated with their disclosure responses., Conclusion: Many radiologists report reluctance to disclose a hypothetical mammography error that delayed a cancer diagnosis. Strategies should be developed to increase radiologists' comfort communicating with patients., ((c) RSNA, 2009.)

A gap exists between recommendations to disclose errors to patients and current practice. This gap may reflect important, yet unanswered questions about implementing disclosure principles. We explore some of these unanswered questions by presenting three real cases that pose challenging disclosure dilemmas. The first case involves a pancreas transplant that failed due to the pancreas graft being discarded, an error that was not disclosed partly because the family did not ask clarifying questions. Relying on patient or family questions to determine the content of disclosure is problematic. We propose a standard of materiality that can help clinicians to decide what information to disclose. The second case involves a fatal diagnostic error that the patient's widower was unaware had happened. The error was not disclosed out of concern that disclosure would cause the widower more harm than good. This case highlights how institutions can overlook patients' and families' needs following errors and emphasizes that benevolent deception has little role in disclosure. Institutions should consider whether involving neutral third parties could make disclosures more patient centered. The third case presents an intraoperative cardiac arrest due to a large air embolism where uncertainty around the clinical event was high and complicated the disclosure. Uncertainty is common to many medical errors but should not deter open conversations with patients and families about what is and is not known about the event. Continued discussion within the medical profession about applying disclosure principles to real-world cases can help to better meet patients' and families' needs following medical errors.

After a life-threatening complication of an injection for neck pain several years ago, Ms W experienced a wrong-site surgery to remove a squamous cell lesion from her nose, followed by pain, distress, and shaken trust in clinicians. Her experience highlights the challenges of communicating with patients after errors. Harmful medical errors occur relatively frequently. Gaps exist between patients' expectations for disclosure and apology and physicians' ability to deliver disclosures well. This discrepancy reflects clinicians' fear of litigation, concern that disclosure might harm patients, and lack of confidence in disclosure skills. Many institutions are developing disclosure programs, and some are reporting success in coupling disclosures with early offers of compensation to patients. However, much has yet to be learned about effective disclosure strategies. Important future developments include increased emphasis on institutions' responsibility for disclosure, involving trainees and other team members in disclosure, and strengthening the relationship between disclosure and quality improvement.

Background: Disclosure of medical errors has been conceptualized as occurring primarily in the physician-patient dyad. Yet, health care is delivered by interprofessional teams, in which nurses share in the culpability for errors, and hence, in responsibility for disclosure. This study explored nurses' perspectives on disclosure of errors to patients and the organizational factors that influence disclosure., Methods: Between October 2004 and December 2005, 11 focus groups were conducted with 96 registered nurses practicing in one of four health care organizations in the Puget Sound region of Washington State. Focus groups were analyzed using qualitative content analysis., Findings: Nurses reported routinely independently disclosing nursing errors that did not involve serious harm, but felt the attending physician should lead disclosures when patient harm had occurred or when errors involved the team. Nurses usually were not involved in the error disclosure discussion among the team to plan for the disclosure or in the actual disclosure, leading to ethically compromising situations in nurses' communication with patients and families. Awareness of existing error disclosure policies was low. Nonetheless, these nurses felt that hospital policies that fostered a collaborative process would be helpful. Nurse managers played a key role in creating a culture of transparency and in being a resource for error disclosures., Discussion: Nurses conceived of the disclosure process as a team event occurring in the context of a complex health care system rather than as a physician-patient conversation. Nurses felt excluded from these discussions, resulting in their use of ethically questionable communication strategies. The findings underscore the need for organizations to adopt a team disclosure process. Health care organizations that integrate the entire health care team into the disclosure process will likely improve the quality of error disclosure.

Objective: To determine whether and how pediatricians would disclose serious medical errors to parents., Design: Cross-sectional survey., Setting: St Louis, Missouri, and Seattle, Washington., Participants: University-affiliated hospital and community pediatricians and pediatric residents. Main Exposure Anonymous 11-item survey administered between July 1, 2003, and March 31, 2004, containing 1 of 2 scenarios (less or more apparent to the child's parent) in which the respondent had caused a serious medical error., Main Outcome Measures: Physician's intention to disclose the error to a parent and what information the physician would disclose to the parent about the error., Results: The response rate was 56% (205/369). Overall, 53% of all respondents (109) reported that they would definitely disclose the error, and 58% (108) would offer full details about how the error occurred. Twenty-six percent of all respondents (53) would offer an explicit apology, and 50% (103) would discuss detailed plans for preventing future recurrences of the error. Twice as many pediatricians who received the apparent error scenario would disclose the error to a parent (73% [75] vs 33% [34]; P < .001), and significantly more would offer an explicit apology (33% [34] vs 20% [20]; P = .04) compared with the less apparent error scenario., Conclusions: This study found marked variation in how pediatricians would disclose a serious medical error and revealed that they may be more willing to do so when the error is more apparent to the family. Further research on the impact of professional guidelines and innovative educational interventions is warranted to help improve the quality of error disclosure communication in pediatric settings.

Purpose: To measure trainees' attitudes and experiences regarding medical error and error disclosure., Method: In 2003, the authors carried out a cross-sectional survey of 629 medical students (320 in their second year, 309 in their fourth year), 226 interns (159 in medicine, 67 in surgery), and 283 residents (211 in medicine, 72 in surgery), a total 1,138 trainees at two U.S. academic health centers., Results: The response rate was 78% (889/1,138). Most trainees (74%; 652/881) agreed that medical error is among the most serious health care problems. Nearly all (99%; 875/884) agreed serious errors should be disclosed to patients, but 87% (774/889) acknowledged at least one possible barrier, including thinking that the patient would not understand the disclosure (59%; 525/889), the patient would not want to know about the error (42%; 376/889), and the patient might sue (33%; 297/889). Personal involvement with medical errors was common among the fourth-year students (78%; 164/209) and the residents (98%; 182/185). Among residents, 45% (83/185) reported involvement in a serious error, 34% (62/183) reported experience disclosing a serious error, and 63% (115/183) had disclosed a minor error. Whereas only 33% (289/880) of trainees had received training in error disclosure, 92% (808/881) expressed interest in such training, particularly at the time of disclosure., Conclusions: Although many trainees had disclosed errors to patients, only a minority had been formally prepared to do so. Formal disclosure curricula, coupled with supervised practice, are necessary to prepare trainees to independently disclose errors to patients by the end of their training.

Although physicians have been described as "reluctant partners" in reporting medical errors, this survey of 1,082 U.S. physicians found that most were willing to share their knowledge about harmful errors and near misses with their institutions and wanted to hear about innovations to prevent common errors. However, physicians found current systems to report and disseminate this information inadequate and relied on informal discussions with colleagues. Thus, much important information remains invisible to institutions and the health care system. Efforts to promote error reporting might not reach their potential unless physicians become more effectively engaged in reporting errors at their institutions.

Objective: To characterize pediatricians' attitudes and experiences regarding communicating about errors with the hospital and patients' families., Design: Cross-sectional survey., Setting: St Louis, Mo, and Seattle, Wash., Participants: University-affiliated hospital and community pediatricians and pediatric residents., Main Exposure: Anonymous 68-item survey (paper or Web-based) administered between July 2003 and March 2004., Main Outcome Measures: Physician attitudes and experiences about error communication., Results: Four hundred thirty-nine pediatric attending physicians and 118 residents participated (62% response rate). Most respondents had been involved in an error (39%, serious; 72%, minor; 61%, near miss; 7%, none). Respondents endorsed reporting errors to the hospital (97%, serious; 90%, minor; 82%, near miss), but only 39% thought that current error reporting systems were adequate. Most pediatricians had used a formal error reporting mechanism, such as an incident report (65%), but many also used informal reporting mechanisms, such as telling a supervisor (47%) or senior physician (38%), and discussed errors with colleagues (72%). Respondents endorsed disclosing errors to patients' families (99%, serious; 90%, minor; 39%, near miss), and many had done so (36%, serious; 52%, minor). Residents were more likely than attending physicians to believe that disclosing a serious error would be difficult (96% vs 86%; P = .004) and to want disclosure training (69% vs 56%; P = .03)., Conclusions: Pediatricians are willing to report errors to hospitals and disclose errors to patients' families but believe current reporting systems are inadequate and struggle with error disclosure. Improving error reporting systems and encouraging physicians to report near misses, as well as providing training in error disclosure, could help prevent future errors and increase patient trust.

Background: Calls are increasing for physicians to disclose harmful medical errors to patients, but little is known about how physicians perform this challenging task. For surgeons, communication about errors is particularly important since surgical errors can have devastating consequences. Our objective was to explore how surgeons disclose medical errors using standardized patients., Methods: Thirty academic surgeons participated in the study. Each surgeon discussed 2 of 3 error scenarios (wrong-side lumpectomy, retained surgical sponge, and hyperkalemia-induced arrhythmia) with standardized patients, yielding a total of 60 encounters. Each encounter was scored by using a scale developed to rate 5 communication elements of effective error disclosure. Half of the encounters took place face-to-face; the remainder occurred by videoconference., Results: Surgeons were rated highest on their ability to explain the medical facts about the error (mean scores for the 3 scenarios ranged from 3.93 to 4.20; maximum possible score, 5). Surgeons used the word error or mistake in only 57% of disclosure conversations, took responsibility for the error in 65% of encounters, and offered a verbal apology in 47%. Surgeons acknowledged or validated patients' emotions in 55% of scenarios. Eight percent discussed how similar errors would be prevented, and 20% offered a second opinion or transfer of care to another surgeon., Conclusions: The patient safety movement calls for disclosure of medical errors, but significant gaps exist between how surgeons disclose errors and patient preferences. Programs should be developed to teach surgeons how to communicate more effectively with patients about errors.

Context: Despite the best efforts of health care practitioners, medical errors are inevitable. Disclosure of errors to patients is desired by patients and recommended by ethicists and professional organizations, but little is known about how patients and physicians think medical errors should be discussed., Objective: To determine patients' and physicians' attitudes about error disclosure., Design, Setting, and Participants: Thirteen focus groups were organized, including 6 groups of adult patients, 4 groups of academic and community physicians, and 3 groups of both physicians and patients. A total of 52 patients and 46 physicians participated., Main Outcome Measures: Qualitative analysis of focus group transcripts to determine the attitudes of patients and physicians about medical error disclosure; whether physicians disclose the information patients desire; and patients' and physicians' emotional needs when an error occurs and whether these needs are met., Results: Both patients and physicians had unmet needs following errors. Patients wanted disclosure of all harmful errors and sought information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented. Physicians agreed that harmful errors should be disclosed but "choose their words carefully" when telling patients about errors. Although physicians disclosed the adverse event, they often avoided stating that an error occurred, why the error happened, or how recurrences would be prevented. Patients also desired emotional support from physicians following errors, including an apology. However, physicians worried that an apology might create legal liability. Physicians were also upset when errors happen but were unsure where to seek emotional support., Conclusions: Physicians may not be providing the information or emotional support that patients seek following harmful medical errors. Physicians should strive to meet patients' desires for an apology and for information on the nature, cause, and prevention of errors. Institutions should also address the emotional needs of practitioners who are involved in medical errors.