New framework for understanding physician medical errors

Disclosing medical errors made by physicians is extremely important yet often extremely difficult.

Two University of Iowa studies examine why this is the case and how increased understanding might help patients, doctors and health care systems overall.

One study involved a review of more than 300 previously published papers on factors that hinder or help doctors' disclosure of mistakes. Those findings appear in the April 2006 issue of the Joint Commission Journal on Quality and Patient Safety. The second study suggested a new framework for understanding these factors, based on the literature review and new research involving five focus groups. Those findings appeared in the Journal of General Internal Medicine.

"It's a challenge to understand the diversity of reasons, both positive and negative, that affect a physician's willingness to disclose his or her own errors," said Lauris Kaldjian, M.D., Ph.D., associate professor of internal medicine in the UI Roy J. and Lucille A. Carver College of Medicine and director of the college's Program in Biomedical Ethics and Medical Humanities.

"The physician's focus should always be on the patient, but at the moment of a medical error, we also must consider the professional who was involved in that error," Kaldjian said. "Often an error is not directly an individual person's fault, but a system-based problem. Yet disclosing errors can be a very individual issue because sometimes only one person knows about it and, as a result, disclosure becomes an individual responsibility."

Kaldjian said disclosing medical errors can contribute to three main goals of quality health care: patients deserve to know when things do not go the way they were expected, hospitals and clinics need to be aware of mistakes in order to improve patient safety, and sharing one's own medical mistake with colleagues can help educate other doctors so that they do not make the same error.

"Typically, these three goals are handled separately, and I believe this is a weakness in the way errors are addressed," Kaldjian said. "A better understanding of what helps or hinders error disclosure could result in ways to address these three goals together as part of one unified process."

The literature review revealed 91 factors involved in physician error disclosure, and the focus group research added an additional 27 factors.

"One comment from the focus groups clearly showed how emotionally traumatic errors are for physicians  by referring to that 'sinking feeling' when a doctor realizes that an effort to help someone has actually harmed them," Kaldjian said. "Whatever else you say about medical errors, we need to remember that it's really difficult terrain."

The research also showed that some physicians are frustrated with reporting systems set up by hospitals to encourage error reporting because there is little or no feedback.

"Some doctors said they felt like they're sending a message into a black hole. This can make them less likely to take time out of a busy schedule to report an error. So, feedback is important," Kaldjian said.

Some doctors said the "bottom line" in terms of positive motivation to report an error was the desire to be straightforward with patients. Yet, physicians also noted that talking about errors "doesn't earn you points," and that the culture of competition in medicine can discourage doctors from being straightforward about mistakes, even among colleagues.

To promote further study of positive and negative factors underlying error disclosure, the research team developed a taxonomy of four positive and four negative domains.

"Most of the literature to date has focused on the negative side, but this new taxonomy gives equal attention to the positive side. We can learn from the doctors who are wiling to talk about their errors and what helps them disclose their errors," he said.

The overall domains that motivate doctors to report errors include: responsibility to patients, responsibility to self (the physician's integrity), responsibility to the profession and responsibility to the community.

The overall domains that inhibit doctors from reporting errors include fears and anxieties (including, but not solely, malpractice), attitudinal barriers (e.g., perfectionism), uncertainties (about how to disclose errors or whether an "error" truly occurred), and feelings of helplessness, for example, that disclosing an error will result in losing control over the situation.

"A key theme is that physicians deserve support. Even the best doctors may make mistakes for reasons that are hard to understand -- we all have strange moments when we have lapses. However, we need to pay attention to the difference between honest mistakes and mistakes that happen when professionals are knowingly negligent," Kaldjian said.

Kaldjian and colleagues next will examine the many factors to see which appear to be most influential in terms of shaping physicians' beliefs and attitudes about error disclosure.