Kathleen M. Mazor, EdD; Steven R. Simon, MD; Robert A. Yood, MD; Brian C. Martinson, PhD; Margaret J. Gunter, PhD; George W. Reed, PhD; Jerry H. Gurwitz, MD
Acknowledgments: The authors thank Andrew Giese and Ryan Tappin for technical assistance and Maureen Mondor and Patricia O'Mara for their support.
Grant Support: By the HMO Research Network Center for Education and Research on Therapeutics (CERTs) (AHRQ U18HS10391-01), the HMO Research Network CERTs Prescribing Safety Program (AHRQ U18HS11843-01), the National Patient Safety Foundation and the Commonwealth Fund (20030288) (Drs. Mazor and Gurwitz), and a Morgan–Zinsser Fellowship from the Academy at Harvard Medical School (Dr. Simon).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Kathleen M. Mazor, EdD, Meyers Primary Care Institute, 630 Plantation Street, Worcester, MA 01605.
Current Author Addresses: Drs. Mazor, Yood, and Gurwitz: Meyers Primary Care Institute, 630 Plantation Street, Worcester, MA 01605.
Dr. Simon: Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, Sixth Floor, Boston, MA 02215.
Dr. Martinson: HealthPartners Research Foundation, 8100 34th Avenue South, PO Box 1524, Minneapolis, MN 55440-1524.
Dr. Gunter: Lovelace Clinic Foundation, 2309 Renard Place SE, Suite 103-B, Albuquerque, NM 87106.
Dr. Reed: Preventive and Behavioral Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655.
Author Contributions: Conception and design: K.M. Mazor, S.R. Simon, R.A. Yood, B.C. Martinson, M.J. Gunter, G.W. Reed, J.H. Gurwitz.
Analysis and interpretation of the data: K.M. Mazor, S.R. Simon, R.A. Yood, B.C. Martinson, M.J. Gunter, G.W. Reed, J.H. Gurwitz.
Drafting of the article: K.M. Mazor, J.H. Gurwitz.
Critical revision of the article for important intellectual content: K.M. Mazor, S.R. Simon, R.A. Yood, B.C. Martinson, G.W. Reed, J.H. Gurwitz.
Final approval of the article: K.M. Mazor, S.R. Simon, R.A. Yood, B.C. Martinson, M.J. Gunter, G.W. Reed, J.H. Gurwitz.
Provision of study materials or patients: K.M. Mazor.
Statistical expertise: G.W. Reed.
Obtaining of funding: K.M. Mazor.
Collection and assembly of data: K.M. Mazor.
Various authorities and national organizations encourage disclosing medical errors, but there is little information on how patients respond to disclosure.
To examine how the type of error, severity of adverse clinical outcome, and level of disclosure affect patients' responses to error and disclosure.
Mail questionnaire survey (8 versions were developed) varying 3 factors in a completely crossed, randomized, factorial design. Each questionnaire included a vignette describing 1) a medical error (failure to check for penicillin allergy or inadequate monitoring of antiepileptic medication); 2) an associated clinical outcome (life-threatening or less serious); and 3) a physician–patient dialogue, with either full disclosure (acceptance of responsibility and an apology) or nondisclosure (expression of regret without acceptance of responsibility or an apology).
New England–based health plan.
Random sample of 1500 adult members received the questionnaire, with a 66% response rate.
Likelihood of changing physicians, likelihood of seeking legal advice, ratings of patient satisfaction, trust and emotional reaction in response to a vignette and dialogue, and views on medical error and disclosure.
Full disclosure reduced the reported likelihood of changing physicians and increased patient satisfaction, trust, and positive emotional response. Full disclosure reduced the reported likelihood of seeking legal advice in only 1 error-and-outcome vignette. In the other vignettes, the percentage of patients indicating that they would seek legal advice was relatively high even with full disclosure. Almost all respondents (98.8%) wanted to be told of errors, most (83%) favored financial compensation if harm occurred, and few (12.7%) favored compensation if no harm occurred.
Since the study was done in the context of a managed care plan in one geographic area, it could not assess whether the results are generalizable to other populations. In addition, it could not determine whether responses to the simulated situations used predict responses to real situations.
Patients will probably respond more favorably to physicians who fully disclose medical errors than to physicians who are less forthright, but the specifics of the case and the severity of the clinical outcome also affect patients' responses. In some circumstances, the desire to seek legal advice may not diminish despite full disclosure.
Disclosing medical errors is ethically appropriate, but its effect on the doctor–patient relationship and the likelihood of patients seeking legal advice is unknown.
Clinical vignettes and questionnaires assessing patient opinion were mailed to members of a health maintenance organization. Each vignette varied the type of error, its severity, and the completeness of error disclosure. Respondents indicated that full disclosure improved trust, satisfaction, and emotional response. Decisions to seek legal advice were complex and were not necessarily deflected by full disclosure.
While full disclosure improved patient satisfaction, it did not prevent or increase the likelihood of seeking legal advice.
Description of conditions.
Table 1. Characteristics of Respondents
Observed responses by error type, clinical outcome, and level of disclosure.Top.Bottom.
Table 2. Predictors of Changing Physicians and Seeking Legal Advice
Table 3. Predictors of Satisfaction, Trust, and Emotional Response
Table 4. General Opinions and Preferences for Action
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Cittadinanzattiva Via mecenate 25 20138 Milan Italy
April 13, 2004
Patient complaints, disclosure of medical error and litigation
We fully agree that patients want to be told of medical errors even if there is nothing that can be done about them (1). Our independent patient's agency analyzed 100 written complaints of people about the reasons for complaining or taking legal advice. Thirty six out of 100 people wanted compensation, 18 an explanation, 14 wanted that it would not happen to anyone else, 12 that the doctors would be disciplined, 11 only for legal advice, and other reasons. We advise and encourage patients to report their complaints also to the local Health Authority: only 38, of 100 complaints we received, were reported from citizen to the hospitals' public relation offices. Twenty two were the written replay and explanations from the Institutions, sometimes with expressions of regret without acceptance of responsibility or an apology. Some doctors invited patients or their relatives to debate the case, but many people refused to meet the doctors: they do not trust them. Patients want that their complaint will be handled by an independent Agency. Unfortunately, in Italy, the National Health Service does not support a patient representative. As you wrote, decisions to seek legal advice were complex and were not necessarily deflected by a late full disclosure.
1. Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, Gurwitz JH. Health plan members' views about disclosure of medical errors. Ann Intern Med 2004; 140: 409-418.
Roberto Natangelo Retired Physician. Cittadinanzattiva ( Active Citizenship. Via Mecenate n. 25. 20138 Milan. Italy) e-mail: roberto.natangelo @ libero.it
Eric N Grosch
June 1, 2004
-Health Plan Members' Views about Disclosure of Medical Errors
The Fifth Amendment protects the individual from an obligation to be a witness against himself and creates a tension with the physician's duty to disclose errors to patients.
Tension likewise stands between the physician's accepting the risk of treating a sick patient and the urge to secure justice that a patient or his family may feel by making the perceived architect of the patient's misery suffer as the patient has suffered. Russell said:
The reformative effect of punishment is a belief that dies hard, chiefly I think, because it is so satisfying to our sadistic impulses.
In the vignettes, clinicians cannot readily conceal their errors as the affected patients could probably discern a connection between error and consequence, so circumspect clinicians would probably consider their chances poor of leaving victims none the wiser by not disclosing.
In contrast, in another (hypothetical?) nightmare-vignette, the consequence of an error of omission was lethal but the clinician, motivated, however venally, by self-preservation, covered it up.
Such a clinician may consider the instruction to parents, aboard airlines, in case of loss of cabin-pressure, to hold the oxygen-mask to one's own face before doing so for an accompanying infant. By analogy, the clinician may feel justified in concealing his clinical error on the basis that he erred but without nefarious intent. In the interest of the greater good of serving other patients in need, he may justify his non- disclosure by the need he perceives to survive financially.
Bosk, the medical sociologist and merchant of sanctimony, in his influential book on his study of a surgical residency, admitted his desire to preserve himself and his field of investigation by concealing from patients and their families the clinical errors that he had understood surgeons had committed, lest he poison his successors' path by blowing the whistle.
Even when the clinician commits an error, it often fits the description of Berwick's analogy. The injustice of penalizing a physician heavily for no more serious a mental lapse than returning a borrowed item to the wrong place, though it may have more serious consequences, demonstrates why the argument that the penalty must fit, not the error, but the consequences of the error is an illustration of why the argument from consequence is a fallacy and why tort-law reform should distribute risk more equitably by making the informed consent, containing a human-error clause, a binding contract.
Eric N. Grosch, MD
1. Russell B. Ideas That Have Harmed Mankind. Girard, Kan. E Haldeman- Julius, 1946
2. Anon. Education and debate: An ethical dilemma: Medical errors and medical culture: An error of omission. BMJ. 2001 May 19;322(7296):1236-1240
3. Bosk CL. Forgive and remember managing medical failure. Chicago, University of Chicago Press 1979, pp. 199-200
4. Berwick DM. Not again! Preventing errors lies in redesign not exhortation. BMJ. 2001 Feb 3;322(7281):247-248
5. Walton DN. Argumentation Schemes for Presumptive Reasoning. Lawrence Erlbaum Associations, Mahwah, NJ, 1996
Physician with financial interest in tort-reform in medicine
Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, et al. Health Plan Members' Views about Disclosure of Medical Errors. Ann Intern Med. 2004;140:409–418. doi: 10.7326/0003-4819-140-6-200403160-00006
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Published: Ann Intern Med. 2004;140(6):409-418.
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