Do we gain when we “fully and openly” disclose our errors?

(A comment about partial disclosure: Typically, it fails to explicitly identify a possible link between the mistake and the harm, and it’s characterized by obfuscating or misleading statements.³ )

Fein and colleagues have provided an example of full disclosure after a medical error:

Because of an error on my part, you got your diabetic medications when you should not have. I apologize for that. It caused you to have very low blood sugar which caused you to have a seizure, at which time you fell out of bed and broke your hip.

An example of “nondisclosure” of the same incident?

I am so sorry you had a seizure. Let’s get you to surgery to repair your hip.

A main goal of openly disclosing adverse events and medical errors is to preserve trust in the patient–physician relationship. In a survey of patients, full disclosure was associated with, first, a greater likelihood that a patient would retain the physician who “made the mistake,” and, second, an increase in the patient’s trust, positive emotional response, and overall satisfaction.¹ In that survey, however, patients reported that full disclosure would not significantly reduce their desire to seek legal advice about pursuing a malpractice claim if they had been seriously injured during the course of treatment.

Full disclosure often identifies problems in the health system that could cause a similar error to recur. During the disclosure process, it’s common for physicians and patients to identify improvements in systems and processes that might reduce the risk of error. Many patients and their families want action taken that might prevent a similar error from occurring in the future.

Most health-care leaders believe that open disclosure and reporting of medical error may motivate members of the health system to more rapidly identify and make changes that improve the safety and reliability of health-care processes.

Does “coming clean” suppress the risk of being sued?

Many authorities believe that disclosure and rapid response to patient injury that arise from adverse events or medical error will, ultimately, reduce physicians’ risk of liability claims. For example, high-visibility disclosure and rapid-response programs are in place at various Veterans Administration facilities,⁴ the University of Michigan, and through the COPIC Insurance Company in Colorado that writes malpractice policies in that state.⁵ The hope is that disclosure/rapid-response programs will preserve the trust in some patient–physician relationships and, overall, reduce the risk of liability.

But some experts worry about a rebound effect: Disclosure programs that may soothe the anger of some patients might prompt others to investigate whether they have a plausible liability claim for what they consider harm during their care.⁶ On balance, disclosure programs might have a net modest overall impact on liability risk. A more profound effect of open disclosure and reporting is that health systems may more rapidly improve their processes as they recognize, first, the magnitude of system-based errors and, second, the opportunity to improve their systems.

Considering the human condition

Full disclosure of medical error often causes emotional turmoil—for patients and physicians alike.

Patients may be anxious, sad, or angry when they first hear about an error; often, they fear that additional errors might occur while they are receiving care to recover from their original injury. As patients recover from injury, they may become angry that an error has harmed their health and prolonged their recovery.

A patient who becomes emotionally mired in a cycle of anger and blame might find it difficult to rebuild trust in the patient–physician relationship.

Reassuringly, many patients have reported that their emotional recovery is hastened when a physician honestly discloses an error. Patients, and families, often welcome from the physician an empathic response and a willingness to express sympathy.

Physicians often feel upset and guilty when an error occurs. Sometimes, following an error, physicians experience a prolonged interval of anxiety, sleeplessness, and difficulty concentrating.

Two troubling observations: First, the professional venues in which a physician can explore her feelings after a medical error are often limited. Second, physicians, by personality and training, may find it difficult to forgive themselves.⁷

Say “sorry”?

A major challenge for physicians is how to weigh risk against benefit in considering whether to offer formal apology for a harmful medical error.⁸ Many malpractice defense attorneys express caution: Making any formal statement could be perceived as acceptance of responsibility for a harmful medical error. Some medical authorities advise that you not apologize for an event beyond your control.

In contrast, as I noted earlier, some experts believe that apologizing is 1) an important part of “full disclosure” and 2) vital to preserving trust and reducing the risk that the patient will sue the physician. The role of the apology in open disclosure is likely to continue to evolve.