7 Medical Error Disclosure Deterrents

The admission of making a mistake resulting in damage to patient trust and threat of litigation is a weight on the minds of all physicians.

Failing to address the values of error, near miss, and unsafe condition reporting with residents is detrimental to both the institution and the trainee, says David Mayer, MD, associate dean of curriculum, associate professor of anesthesiology, and coexecutive director of the Institute for Patient Safety Excellence at the University of Illinois at Chicago (UIC). 

If residents fail to report errors and unsafe conditions, the institution misses opportunities to improve systems in the hospital that affect quality. They also miss a valuable teaching opportunity for their residents, Mayer says.  

Not to mention that medical errors are extremely taxing and stressful for residents, says Sigall K. Bell, MD, assistant professor of medicine in the Division of Infectious Disease at Harvard Medical School in Boston. Bell, who has coauthored academic articles on the topic, says the following issues often make residents apprehensive about disclosing and reporting errors or adverse events: 

1. Emotional distress. Residents are often trained under the assumption that physicians do not and cannot make mistakes; the pressure for perfection can be immense. After an error, many residents feel fearful, alone, and guilty. They worry about the harm caused to their patient, their career, and their future.

2. Experience-proficiency balance. Defining medical errors in the context of teaching hospitals is difficult because residents are still learning and need clarification on what to report. 

For example, during a conversation about medical errors, Bell says a trainee asked whether taking three tries to find the cervix during a pap smear is considered a medical error. "It's an interesting question," Bell says. "Where do you draw the line on proficiency? You need experience to gain proficiency, but in many cases you need proficiency to get the experience." Trainees struggle with striking a balance between safely gaining experience and proficiency. 

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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