Patient Safety and Quality

Studies reveal that error disclosure is similar among American and Canadian doctors, despite different malpractice environments

Physicians disclose only 30 to 50 percent of harmful medical errors to patients, which can lead to patient distrust in physicians' integrity and may increase the likelihood of lawsuits. Both Canadian and U.S. physicians have mixed feelings about disclosing errors to patients, according to two studies supported by the Agency for Healthcare Research and Quality (HS11898 and HS14012). The first study finds that individual physicians vary widely in how they would disclose errors to patients. The second study shows that the attitudes and experiences of U.S. and Canadian physicians concerning error disclosure are similar, despite the different malpractice environments in which they work. Both studies were led by Thomas H. Gallagher, M.D., of the University of Washington School of Medicine, and were based on responses to a mailed survey of 2,637 medical and surgical physicians in the United States (Missouri and Washington) and Canada (national sample).

Gallagher, T.H., Garbutt, J.M., Waterman, A.D., and others (2006, August). "Choosing your words carefully: How physicians would disclose harmful medical errors to patients." Archives of Internal Medicine 166, pp. 1585-1593.

Individual Canadian and American physicians vary widely in how they would disclose errors to patients. While physicians generally support disclosing errors to patients, fear of lawsuits, shame, and lack of error disclosure training make them reluctant to do so. Physicians are also uncertain about what words to choose when discussing errors with patients. Patients want an explicit statement that an error has occurred, information about why the error happened, how recurrences will be prevented, and an apology.

Yet when presented with one of four scenarios depicting serious errors, which varied by specialty and how obvious the error would be to the patient if not disclosed, individual physicians had varied responses to what information they would disclose to patients. Overall, 56 percent chose statements that mentioned the harm to the patient (adverse event) but not the error, while 42 percent would explicitly state that an error occurred. Some physicians disclosed little information. For example, 19 percent would not volunteer any information about the error's cause, and 63 percent would not provide specific information about how they would prevent future errors.

Disclosure was affected by the nature of the error and physician specialty. For instance, 51 percent of physicians confronted with scenarios of more apparent errors (obvious to the patient) would explicitly mention the error. Yet, only 32 percent of physicians would explicitly mention the error in scenarios in which the error was not apparent to the patient. Also, 58 percent of medical specialists would explicitly mention the error compared with 19 percent of surgical specialists. Finally, physicians were likely to disclose more information if they had positive attitudes about error disclosure, felt responsible for the error, had prior positive disclosure experiences, and were Canadian.

Gallagher, T.H., Waterman, A.D., Garbutt, J.M., and others (2006, August). "U.S. and Canadian physicians' attitudes and experiences regarding disclosing errors to patients." Archives of Internal Medicine 166, pp. 1605-1611.

The malpractice environment is considered a major factor in physicians' willingness to disclose medical errors to patients. Due to the litigious environment of the United States, physicians must cope with escalating malpractice insurance premiums and the loss of insurability with malpractice lawsuits. While Canada shares the U.S. fault-based malpractice model, tort reforms and other legal differences (such as rare use of contingency fees or punitive damages) result in Canadian physicians being sued about one-fourth as often as their U.S. counterparts. They also pay much lower malpractice insurance premiums.

Nevertheless, this survey of both U.S. and Canadian physicians found that their error disclosure attitudes and experiences were similar. Both groups of physicians had mixed feelings about disclosing errors to patients. Nearly two-thirds (64 percent) of both groups agreed that medical errors are a serious problem. However, 50 percent disagreed that errors are usually caused by system failure.

Nearly all physicians (98 percent) endorsed disclosing serious errors to patients and 78 percent supported disclosing minor errors. However, 74 percent of physicians thought that disclosing a serious error would be very difficult. Overall, 58 percent of physicians had disclosed a serious error to a patient, and 85 percent were satisfied with the disclosure. Also, 66 percent agreed that disclosing a serious error reduced malpractice risk. Physicians were more likely to support disclosing serious errors if they thought that disclosure made patients less likely to sue, they were not in private practice, they were a surgeon, or they were Canadian.

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