3. Microscope of evaluation. Residents know they're being evaluated by their attending physicians, and they may worry that admitting an error will adversely affect their standing, Bell explains.
This inherent and unavoidable conflict also applies when residents witness their supervisors committing an error. They are hesitant to report the incident for fear of retribution.
4. Not-so-hidden curriculum. "The hidden curriculum refers to the notion that residents are shaped in very powerful ways---not just by the formal curricula, but by informal mechanisms," Bell explains, adding that residents learn the unspoken codes of conduct and habits from attending physicians and others. The hidden curriculum can be a commanding force that sometimes trumps traditional teaching methodologies.
"You can design a curriculum on how to disclose medical errors, but if that's not the practice in the clinical environment, then your teaching won't have much influence," Bell says.
Faculty and attending physicians must disclose their errors and encourage residents to do the same in order for trainees to feel comfortable coming forth.
5. Threat of litigation. Residents worry about the legal ramifications that may arise if they admit to making an error, says Mayer. Having a supportive environment that encourages error disclosure assuages these fears. Ask risk management or the legal team to speak with residents about the institution's disclosure policy and what constitutes an error. If trainees see that the legal department advocates for open error reporting, they will be more likely to come forward.
6. Rocking the boat. Medical students and residents may not report a mistake or near miss to a senior resident or attending physician because they do not want to create more stress for the team. "The sentiment is, 'Everyone is already stressed enough, and I don't want to make it worse,'" Bell says.
7. Confusion over where to go for help. Bell and Mayer say trainees in their respective institutions have indicated that they do not know the proper process for reporting an error.
Before an educational intervention, Mayer says less than 1% of the institution's event reports were made by residents. "Now, the number of occurrence reports coming from residents is almost 30% of all reports," he says.
Similarly, Bell conducted a survey of 154 medical students and residents and found that 62% had made a mistake; of those trainees, 26% were not sure how to get help.
Bell and Mayer agree that institutions need to dedicate resources and training sessions for residents that specifically address these issues. The training should include definitions of errors, examples, and hands on education on the hospital's error reporting system.
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