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      Transparency in medical error disclosure: the need for formal teaching in undergraduate medical education curriculum

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      Medical Education Online
      Co-Action Publishing

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          Abstract

          Timely and explicit medical error disclosure is essential to maintain a strong bond of trust between physicians and their patients. Several surveys revealed that patients desire to be informed promptly of all medical errors (including the unintended minor ones) (1, 2), and furthermore, prefer to be debriefed in greater details than what most physicians think is needed (3). However, there is a wide gap between patients’ demands of transparency in disclosing all medical errors and attempts of healthcare providers to do so. A recent study revealed that in hypothetical situations, 90% of the healthcare providers (medical students, residents, and physicians) stated that they would disclose medical errors; however, in real-life circumstances, only 41% actually reported doing so (4). A genuine question arises: What is the reason behind this ‘demand and supply’ mismatch? Worldwide, medical errors are a disappointing, yet an unavoidable reality of the healthcare system, and there is unquestionably a high probability that medical students and residents will encounter such incidents during their training. The main dilemma, however, does not lie in the errors themselves, but rather in their full transparent disclosure. Despite the desires of medical students and residents to be open to patients and disclose medical errors, many are not sufficiently well prepared to deal with such situations (5). This is primarily because ‘formal’ instruction of transparency in medical error disclosure, a fundamental professional skill, is largely negligible and not adequately instructed in the vast majority of undergraduate medical education curricula (6–8). Hence, the poorly developed competency of professional medical error disclosure remains a ‘weakness’ as undergraduate medical students advance in their medical education and manifests in its full-blown picture during residency training when they bear far greater patient responsibilities. As a direct consequence of this near-absent teaching, many physicians-in-training (medical students, interns, and residents) are confronted with distressing challenges when they face disclosure of medical errors to patients or healthcare institutes (5). This unconsciously compels them to follow their pure gut feeling (as opposed to knowledge-based inclinations) in handling such situations by attempting to ‘conceal’ those medical errors (because of fear of lawsuit litigations, etc.) (5), which often results in further harm to patients and healthcare institutes. As ‘practice makes perfect’, we believe that the incorporation of formal teaching of transparent medical error disclosure in medical curricula is greatly needed. Medical schools play central roles in cultivating the significance and developing the communication skills needed for proficient and effective medical error disclosure. Moreover, they play key roles in resolving all barriers that may hinder transparency and full disclosure of medical errors. Such an approach is expected to educate a safe physician workforce where intrinsic drives and capabilities to remain transparent at all times – regardless of consequences – will serve as the basis for enhancing patient–doctor relationships, limiting further harm and improving overall healthcare safety (9).

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          Disclosing medical errors to patients: attitudes and practices of physicians and trainees.

          Disclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood. To survey physicians and trainees about their practices and attitudes regarding error disclosure to patients. Survey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States. Actual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors. Responses were received from 538 participants (response rate = 77%). Almost all faculty and residents responded that they would disclose a hypothetical error resulting in minor (97%) or major (93%) harm to a patient. However, only 41% of faculty and residents had disclosed an actual minor error (resulting in prolonged treatment or discomfort), and only 5% had disclosed an actual major error (resulting in disability or death). Moreover, 19% acknowledged not disclosing an actual minor error and 4% acknowledged not disclosing an actual major error. Experience with malpractice litigation was not associated with less actual or hypothetical error disclosure. Faculty were more likely than residents and students to disclose a hypothetical error and less concerned about possible negative consequences of disclosure. Several attitudes were associated with greater likelihood of hypothetical disclosure, including the belief that disclosure is right even if it comes at a significant personal cost. There appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation.
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            The attitudes and experiences of trainees regarding disclosing medical errors to patients.

            To measure trainees' attitudes and experiences regarding medical error and error disclosure. 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. 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. 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.
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              Teaching medical error disclosure to physicians-in-training: a scoping review.

              This scoping review identified published studies of error disclosure curricula targeting physicians-in-training (residents or medical students). In 2011, the authors searched electronic databases (e.g., MEDLINE, EMBASE, ERIC) for eligible studies published between 1960 and July 2011. From the studies that met their inclusion criteria, they extracted and summarized key aspects of each curriculum (e.g., level of learner, program discipline) and educational features (e.g., curriculum design, teaching and assessment methods, and learner outcomes). The authors identified 21 studies that met their inclusion criteria. These studies described 19 error disclosure curricula, which were either a stand-alone educational activity, part of a larger curriculum in patient safety or communication skills, or part of simulation training. Most curricula consisted of a brief, single encounter, combining didactic lectures or small-group discussions with role-play. Fourteen studies described learners' self-reported improvements in knowledge, skills, and attitudes. Five studies used a structured assessment and reported that learners' error disclosure skills improved after completing the curriculum; however, these studies were limited by their small to medium sample size and lack of assessment of skills retention. Attempts to assess the change in learners' error disclosure behavior in the clinical context were limited. Studies of existing error disclosure curricula demonstrate improvements in learners' knowledge, skills, and attitudes. A greater emphasis is needed on the more rigorous assessment of skills acquisition and behavior change to determine whether formal training leads to long-term effects on learner outcomes that translate into real-world clinical practice.
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                Author and article information

                Journal
                Med Educ Online
                Med Educ Online
                MEO
                Medical Education Online
                Co-Action Publishing
                1087-2981
                31 January 2014
                2014
                : 19
                : 10.3402/meo.v19.23542
                Affiliations
                College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
                Author notes
                [* ]Ahmed Abu-Zaid, College of Medicine, Alfaisal University, P.O. Box 50927, Riyadh 11533, Saudi Arabia. Tel: +966 566 305 700, Fax: +966 11 215 7611. Email: aabuzaid@ 123456live.com
                Article
                23542
                10.3402/meo.v19.23542
                3909737
                ad3f4cd7-46ec-422b-9d1c-58fce1784e8d
                © 2014 Lucman A. Anwer and Ahmed Abu-Zaid

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 10 December 2013
                : 12 December 2013
                : 02 January 2014
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