Reporting and disclosing medical errors: pediatricians' attitudes and behaviors.

Abstract

To characterize pediatricians' attitudes and experiences regarding communicating about errors with the hospital and patients' families.
Cross-sectional survey.
St Louis, Mo, and Seattle, Wash.
University-affiliated hospital and community pediatricians and pediatric residents.
Anonymous 68-item survey (paper or Web-based) administered between July 2003 and March 2004.
Physician attitudes and experiences about error communication.
Four hundred thirty-nine pediatric attending physicians and 118 residents participated (62% response rate). Most respondents had been involved in an error (39%, serious; 72%, minor; 61%, near miss; 7%, none). Respondents endorsed reporting errors to the hospital (97%, serious; 90%, minor; 82%, near miss), but only 39% thought that current error reporting systems were adequate. Most pediatricians had used a formal error reporting mechanism, such as an incident report (65%), but many also used informal reporting mechanisms, such as telling a supervisor (47%) or senior physician (38%), and discussed errors with colleagues (72%). Respondents endorsed disclosing errors to patients' families (99%, serious; 90%, minor; 39%, near miss), and many had done so (36%, serious; 52%, minor). Residents were more likely than attending physicians to believe that disclosing a serious error would be difficult (96% vs 86%; P = .004) and to want disclosure training (69% vs 56%; P = .03).
Pediatricians are willing to report errors to hospitals and disclose errors to patients' families but believe current reporting systems are inadequate and struggle with error disclosure. Improving error reporting systems and encouraging physicians to report near misses, as well as providing training in error disclosure, could help prevent future errors and increase patient trust.

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ARTICLE
Reporting and Disclosing Medical Errors
Pediatricians’ Attitudes and Behaviors
Jane Garbutt, MBChB; Dena R. Brownstein, MD; Eileen J. Klein, MD, MPH; Amy Waterman, PhD;
Melissa J. Krauss, MPH; Edgar K. Marcuse, MD, MPH; Erik Hazel, PhD; Wm. Claiborne Dunagan, MD;
Victoria Fraser, MD; Thomas H. Gallagher, MD
Objective: To characterize pediatricians’ attitudes and
experiencesregardingcommunicatingabouterrorswith
the hospital and patients’ families.
Design: Cross-sectional survey.
Setting: St Louis, Mo, and Seattle, Wash.
Participants: University-affiliated hospital and com-
munity pediatricians and pediatric residents.
Main Exposure: Anonymous 68-item survey (paper or
Web-based)administeredbetweenJuly2003andMarch
2004.
Main Outcome Measures:Physician attitudes and ex-
periences about error communication.
Results: Four hundred thirty-nine pediatric attending
physicians and 118 residents participated (62% re-
sponse rate). Most respondents had been involved in an
error (39%, serious; 72%, minor; 61%, near miss; 7%,
none).Respondentsendorsedreportingerrorstothehos-
pital(97%,serious;90%,minor;82%,nearmiss),butonly
39% thought that current error reporting systems were
adequate. Most pediatricians had used a formal error re-
porting mechanism, such as an incident report (65%),
butmanyalsousedinformalreportingmechanisms,such
as telling a supervisor (47%) or senior physician (38%),
and discussed errors with colleagues (72%). Respon-
dentsendorseddisclosingerrorstopatients’families(99%,
serious;90%,minor;39%,nearmiss),andmanyhaddone
so(36%,serious;52%,minor).Residentsweremorelikely
thanattendingphysicianstobelievethatdisclosingase-
riouserrorwouldbedifficult(96%vs86%;P=.004)and
to want disclosure training (69% vs 56%; P=.03).
Conclusions: Pediatricians are willing to report errors
to hospitals and disclose errors to patients’ families but
believe current reporting systems are inadequate and
struggle with error disclosure. Improving error report-
ing systems and encouraging physicians to report near
misses, as well as providing training in error disclosure,
couldhelppreventfutureerrorsandincreasepatienttrust.
Arch Pediatr Adolesc Med. 2007;161:179-185
O
colleagues following errors so that the
eventcanbeanalyzedandrecurrencespre-
vented.Disclosureofharmfulerrorstopa-
tients is also recommended, both as an
ethical obligation and to comply with
emerging accreditation standards.1Yet
such transparency appears to be far from
thenorm.Errorsareunderreported,2-6and
not all harmful medical errors are dis-
closed.7-12Understanding why informa-
tion about errors is not communicated is
essential if error reduction efforts are to
succeed and if patients’ confidence in the
integrityofthehealthcaresystemistobe
restored.
PEN COMMUNICATION
about errors is the cor-
nerstone of the patient
safetymovement.Health
careworkersareurgedto
communicateopenlywithinstitutionsand
Forphysicians,thereareparticularbar-
riers to open and honest communication
about errors. Although the patient-safety
movementemphasizesthatmosterrorsare
duetosystembreakdownsratherthanin-
dividual failures,13,14medical culture has
longcherishedprofessionalautonomyand
emphasized individual accountability for
patient outcomes. Physicians’ willing-
nesstoreporterrorstothehospitalaswell
as discuss errors with colleagues and pa-
tients may be further diminished by fear
oflitigation,aswellasconcernoftarnish-
ing their professional reputation among
colleagues and patients.7,15-17
The pediatric environment poses a
uniquechallengeregardingopencommu-
nication following errors because a third
party,parents,mustbeincludedinthecon-
versation.Althoughmedicalerrorsarefre-
quentamonghospitalizedchildren,18,19most
Author Affiliations:
Department of Medicine,
Washington University School
of Medicine (Drs Garbutt,
Waterman, Hazel, Dunagan,
and Fraser and Ms Krauss) and
the Center of Health-Care
Quality and Effectiveness,
BJC HealthCare (Dr Dunagan),
St Louis, Mo; and Departments
of Pediatrics (Drs Brownstein,
Klein, and Marcuse) and
General Internal Medicine
(Dr Gallagher), University of
Washington School of
Medicine, Seattle.
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of the research to date on error reporting and disclosure
has studied physicians practicing in adult patient popu-
lations.7,10,15,20,21The absence of information about pe-
diatricians’ attitudes toward and experience with error
reporting and disclosure inhibits the design and imple-
mentation of interventions to enhance open communi-
cation followingpediatricerrors.Therefore,wesurveyed
hospital-affiliatedpediatriciansandpediatricresidentsto
characterizetheirexperiencewithmedicalerror,assesstheir
attitudes toward sharing error information, and describe
howtheycommunicateabouterrorswiththehospital,their
colleagues, and patients’ families.
METHODS
Between July 2003 and March 2004, pediatric medical attend-
ing physicians and residents completed the survey by mail or
the Internet. The study population included clinically active
residentsandacademicandcommunitypediatricianswhowere
affiliated with St Louis Children’s Hospital (Washington Uni-
versity) in St Louis, Mo, or Seattle Children’s Hospital and Re-
gional Medical Center (University of Washington) in Seattle.
In all settings, physicians could report errors or safety con-
cernsdirectlytoriskmanagementoruseincidentreportingsys-
tems. All residents and some faculty could also use an elec-
tronic incident reporting system designed to improve patient
safety. Of the initial study population, 898 (92%) of 975 pe-
diatricianswereeligibletoparticipate(52didnotcareforhos-
pitalized patients, 3 were not clinically active, 7 could not be
located, and 15 were ineligible for other reasons).
Although the survey was anonymous, respondents re-
turnedapostcardindicatingstudyparticipation.Reminderswere
sent to nonrespondents by mail, e-mail, fax, and telephone.22
The institutional review boards at both participating universi-
ties approved the survey. Token incentives were used to en-
courage participation, including $5 coffee cards (Seattle and
St Louis) and a lottery for dinner (Seattle).
SURVEY CONTENT
The questionnaire was developed by the authors and refined
after several rounds of pilot testing and cognitive interviews
to ensure clarity and item comprehension.23The final pediat-
ricquestionnaire(availableonrequest)contained68itemsand
tookapproximately15minutestocomplete.Definitionsforkey
terms (serious error and minor error, near miss, adverse event
and medical error) were provided at the beginning of the ques-
tionnaireandatthebottomofeachpage.Theseandotherstudy
definitions are provided in Table 1.
The survey instrument included questions exploring pe-
diatricians’ attitudes and behaviors related to reporting errors
to the hospital, discussing errors with colleagues, and disclos-
ing errors to patients’ families. Respondents were asked if an
error reporting system to improve patient safety was available
forphysiciansattheirhospital,whatmechanismstheyhadused
to report errors, and to indicate features of a reporting system
thatwouldincreasetheirwillingnesstoreport.Questionsabout
errordisclosureincludedthetypesoferrorsthatshouldbedis-
closed, potential barriers to disclosure, and respondents’ per-
sonal experience with ever disclosing a serious error or dis-
closing a minor error in the past 12 months.
Respondents reported whether they had been involved in
a serious error, a minor error, or a near miss. They estimated
the probability that a hospitalized child would experience a
serious error, a minor error, or a near miss and that they
personally would be sued for malpractice during the next
year. General attitudes about errors and patient safety were
explored by assessing respondents’ level of agreement with
the statements “medical errors are one of the most serious
problems in health care,” and “medical errors are usually
caused by failure of care delivery systems, not the failure of
individuals.” Participants used 4-point Likert scales to
respond to attitudinal questions (strongly agree to strongly
disagree). Demographic questions measured respondents’
age, sex, level of training, whether they were in private or
academic practice, and the percentage of time in clinical
practice and spent caring for hospitalized patients.
STATISTICAL ANALYSIS
Descriptive statistics included means and standard deviations
for continuous variables and percentages for categorical vari-
ables.Questionsinvolvinga4-pointLikertscaleweredichoto-
mized at the midpoint (eg, agree vs disagree), and pediatri-
cians’ perception of their risk of a malpractice suit in the next
year was dichotomized at the mean (?5% vs ?5%). To com-
parecharacteristicsofrespondentsandnonrespondentsandre-
sponsesfromattendingpediatriciansandresidents,weusedthe
Wilcoxon rank sum test to compare continuous variables and
the ?2or Fischer exact test to compare proportions. In a sub-
group analysis, we used the ?2test to compare responses from
thoseinprivatepracticewithotherattendingphysicians.Two-
tailed tests (P?.05) were used throughout to determine statis-
tical significance.
Logistic regression was used to calculate odds ratios (95%
confidence intervals) for factors associated with pediatricians’
use of a formal error mechanism (reporting to risk manage-
ment, a patient safety program, or using an incident report),
controllingforleveloftraining.Forthisanalysis,priorinvolve-
ment with an error was dichotomized based on the most se-
vere error with which the pediatrician had been involved (at
least a serious error vs only a minor error, a near miss, or no
error). The ?2test was used to identify factors associated with
agreement that serious errors should be disclosed to patients’
families. Because our prior research and other studies in the
Table 1. Study Definitions
Adverse event*† An injury that was caused by medical management
rather than the patient’s underlying disease.
The failure of a planned action to be completed as
intended or the use of a wrong plan to achieve
an aim. Medical errors include serious errors,
minor errors, and near misses.
An error that causes permanent injury or transient
but potentially life-threatening harm.
An error that causes harm that is neither
permanent nor potentially life threatening.
An error that could have caused harm but did not
either by chance or timely intervention.
Reporting an error to the hospital or health care
organization.
Reporting an error to risk management or a patient
safety program or completing an incident report
(themselves or asking someone else to do so).
Reporting an error by informing a supervisor,
hospital executive, physician chief, or
departmental chairman.
Telling the patient’s family about an error.
Medical error*†
Serious error†
Minor error†
Near miss*†
Error reporting
Formal error
reporting
mechanism
Informal
reporting
mechanism
Error disclosure
*Definitions were taken from To Err is Human: Building a Safer Health
System.24
†These definitions were provided on the face page of the survey and at the
bottom of each page.
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literature1,25-27suggested that most pediatricians would en-
dorse disclosure of serious errors, this variable was dichoto-
mized as “strongly agree” vs “other.” All analyses were per-
formed using SAS (version 9.0; SAS Institute Inc, Cary, NC).
RESULTS
STUDY POPULATION
Thesurveyresponseratewas62%(557/898)anddidnot
differ by site (Seattle, 307 [58%] of 531; St Louis, 231
[63%] of 369; P=.15. Site was unknown for 19 partici-
pants and 2 ineligible respondents), with 80% complet-
ingapapersurvey.Respondentsandnonrespondentsdid
not differ by sex or type of practice (attending physi-
cians) or year of training (residents). Characteristics of
respondents are provided in Table 2. Of the 439 at-
tending pediatricians, 50% were in private practice and
73%workedatleasthalf-timeinclinicalpractice.Forthis
report, unless otherwise stated, responses from attend-
ing pediatricians and residents did not differ.
ATTITUDES TOWARD ERRORS
AND ERROR EXPERIENCE
Respondents believed that errors occurred frequently
amonghospitalizedchildren,onaverageestimatingthat
16%ofpatientswouldexperienceanearmiss;16%,ami-
nor error; and 4%, a serious error during their hospital-
ization. Seventy-six percent agreed that medical errors
are one of the most serious problems in health care, and
56% agreed that “medical errors are usually caused by
failures of systems, not failures of individuals” (private
attending physicians, 45%; other attending physicians,
63%; P?.001).
Mostrespondentshadbeeninvolvedinanerror:39%
reportedpriorinvolvementwithaseriouserror(attend-
ingphysicians,45%;residents,18%;P?.001);72%,with
a minor error; and 61%, with a near miss, while 7% re-
ported no error involvement. On average, respondents
perceived their own risk of being named in a malprac-
tice suit in the next year as 5% (SD 9.3%), with a me-
dian of 2% (interquartile range, 1%-5%).
ERROR REPORTING TO THE HOSPITAL
OR HEALTH CARE ORGANIZATION
The majority of respondents believed that to improve
patient safety, they should report serious errors (97%),
minor errors (overall, 90%; attending physicians, 88%;
residents, 96%; P=.02), and near misses (82%) to their
hospital or health care organization. However, many
respondents (40%) did not know if their hospital or
health care organization had an error reporting system
that physicians could use to improve safety, 51%
believed that such a system was available at their institu-
tion, and 9% said that it was not available. Pediatricians
in private practice were more likely than other pediatri-
cians not to know if such a reporting system was avail-
able (50% vs 35%) or to believe that it was unavailable
(17% vs 5%) (P?.001).
Overall, 92% of respondents had used at least 1 for-
mal mechanism to report an error, most commonly us-
ing incident reports (65%) (Table 3). Pediatricians in
privatepracticewerelesslikelytoformallyreporterrors
than other attending physicians (72% vs 92%; P?.001).
Factors associated with use of a formal error reporting
mechanism in the bivariate analyses are presented in
Table 4. Pediatricians were more likely to report an er-
ror if they agreed that errors were one of the most seri-
ousproblemsinhealthcare(oddsratio[OR],1.78[95%
confidence interval (CI), 1.13-2.73]) or were caused by
systemratherthanindividualfailures(OR,2.74[95%CI,
1.80-4.12]).Perceivedriskforapersonalmalpracticelaw-
suit in the next year (?5% vs ?5%) was not associated
with formal reporting (OR, 1.38; [95% CI, 0.91-2.11]).
Manyrespondentsalsousedinformalmechanismsto
report errors (74%), with 8% exclusively reporting er-
rors informally. The most common informal reporting
practicewastotellasupervisorormanager(overall,47%;
attending physicians, 45%; residents, 57%; P=.02)
(Table 3).
Table 2. Characteristics of Survey Respondents
No. (%)
P Value*
?.001
Total
(N = 557)
Attending Pediatricians
(n = 439)
Pediatric Residents
(n = 118)
Sex
Male
Female
Age, y, mean (SD)
Years in practice, mean (SD)
Proportion of time spent caring
for hospitalized patients, %
0
1-25
26-50
51-75
76-100
273 (50)
271 (50)
42.6 (11.2)
12.0 (10.4)
239 (56)
190 (44)
46.2 (9.8)
14.5 (10.2)
34 (30)
81 (70)
29.5 (3.4)
2.2 (1.5)
?.001
?.001
?.001
6 (1)06 (5)
6 (5)
2 (2)
24 (21)
77 (67)
338 (62)
50 (9)
40 (7)
109 (20)
332 (78)
48 (11)
16 (4)
32 (7)
*Comparison of attending pediatricians and pediatric residents.
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Only 39% of respondents believed that current sys-
tems for pediatricians to report patient safety problems
tothehospitalwereadequate(attendingphysicians,34%;
residents,55%;P?.001).Whenrespondentswereasked
to select features of a reporting system that would in-
crease their willingness to report errors to the hospital,
the following factors were chosen: evidence that the in-
formationwasusedforsystemimprovements(89%),as-
surance that the information was confidential and non-
discoverable (88%), a nonpunitive reporting system
(89%), and a process that takes less than 2 minutes to
use(73%)andwaslocaltotheirunitordepartment(58%).
ERROR DISCUSSION WITH COLLEAGUES
Ninety-one percent of respondents endorsed discussing
errors with colleagues, and 72% identified colleagues as
a source of information about errors. Respondents had
discussed all types of errors with their colleagues, in-
cluding serious errors (overall, 48%; attending physi-
cians,51%;residents,38%;P=.02),minorerrors(69%),
and near misses (57%). When asked what types of er-
rors they had discussed with colleagues and reported to
the hospital, for each level of error severity, more phy-
sicians had discussed an error informally with col-
leagues than had reported errors to risk management or
a patient safety program (Figure).
ERROR DISCLOSURE TO FAMILIES
OF PEDIATRIC PATIENTS
Almostallrespondentsendorseddisclosureofseriouser-
rors (99%) and minor errors (90%) to families of pedi-
atric patients, but fewer supported disclosure of near
misses (overall, 39%; attending physicians, 43%; resi-
dents,25%;P?.001).Respondents’perceptionofthelike-
lihoodofapersonalmalpracticesuitinthenextyearhad
noeffectontheirendorsementofdisclosure(ofthosewho
perceivedtheirmalpracticerisktobe?5%or?5%,72%
and 69% strongly endorsed disclosure, respectively;
P=.45). Most respondents agreed that disclosing a seri-
ous error would be very difficult (overall, 88%; attend-
ingphysicians,86%;residents,96%;P=.005)andwould
makeitlesslikelythatthefamilywouldsue(overall,77%;
attendingphysicians,74%;residents,88%;P=.001).De-
spite supporting disclosure of serious errors to family
members,manyrespondents,especiallyresidents,iden-
tified factors that might make them less likely to do so
(Table 5).
Table 3. Error Reporting Mechanisms Used by Pediatricians*
No. (%)
P Value†
Total
(N = 557)
Attending Pediatricians
(n = 439)
Pediatric Residents
(n = 118)
Formal reporting
Incident report
Risk management
Patient safety program
Informal reporting
Supervisor or manager
Physician chief or department chair
Hospital/health care organization executive
360 (65)
276 (50)
64 (12)
286 (65)
254 (58)
53 (12)
74 (63)
22 (19)
11 (9)
.60
?.001
.41
263 (47)
210 (38)
58 (10)
196 (45)
181 (41)
55 (13)
67 (57)
29 (25)
3 (3)
.02
.001
.002
*Pediatricians were asked to select reporting mechanisms they had used to report errors to their hospital or health care organization to improve patient safety.
†Comparison of attending pediatricians and pediatric residents.
Table 4. Factors Associated With Formal Error
Reporting Adjusted for Level of Training*
Factor
Attitudes about patient safety and
reporting (agree vs disagree)
Physicians should report
serious errors
Physicians should report
minor errors
Physicians should report
near misses
Medical errors are usually
caused by failure of care
delivery systems, not
failure of individuals
Medical errors are one of
the most serious
problems in health care
At my institution, system
changes to improve
patient safety occur after
errors are reported
Malpractice risk
?5% Chance that will be
named in a malpractice suit
in the next year (vs ?5%)
Personal involvement in an error
(categorized by most severe
type of error involved with)
Serious error (vs other error
involvement or none)
Who Agree
or Have
Factor
Present, %
Bivariate Analysis†
OR
(95% CI)
P
Value
973.08 (1.04-9.15).04
903.45 (1.91-6.24) ?.001
82 1.85 (1.12-3.05).02
562.74 (1.80-4.12) ?.001
761.78 (1.13-2.73).01
860.87 (0.45-1.70) .68
441.38 (0.91-2.11) .13
39 3.99 (2.36-6.74) ?.001
Abbreviations: CI, confidence interval; OR, odds ratio.
*Formal error reporting was defined as selection by the pediatrician of at
least 1 of the following mechanisms to “report errors to the hospital or health
care organization to improve patient safety”: reporting to risk management or a
patient safety program (if one was available) or completing an incident report
(self or asked another to do so).
†Adjusted for level of training.
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Many respondents had disclosed an error to a pa-
tient’s family. Fifty-two percent had disclosed a minor
error in the past 12 months, and more attending pedia-
triciansthanresidentshadeverdisclosedaseriouserror
(overall,36%;attendingphysicians,42%;residents,12%;
P?.001).Moreresidentsthanattendingpediatricianshad
received education or training about how to disclose er-
rors(57%vs29%;P?.001).Morethanhalfofallrespon-
dentswereveryinterestedinreceiving“just-in-time”train-
ing about error disclosure after a serious error occurred
(attendingphysicians,56%;residents,69%;P=.03),and
35% were very interested in general disclosure training.
COMMENT
Understandingwhatmightmotivateordeterphysicians
from sharing error-related information as well as physi-
cians’ current practices are important first steps toward
increasingerrorreportinganddisclosure.Thisstudy,the
firsttoourknowledgetoexaminecommunicationabout
errorsinalargesampleofpediatricians,foundthatmost
pediatricians and pediatric residents had been involved
in errors and endorsed open communication about er-
rorswiththehospital,theircolleagues,andpatients’fami-
lies. Yet our study also identified barriers to transparent
error communication that must be addressed to im-
prove the safety of hospitalized children.
Pediatricians felt current reporting systems were in-
adequate.Perhapsmisgivingsaboutcurrentsystemspartly
explainthesephysicians’preferenceforinformalreport-
ing behaviors, such as discussing errors with col-
leagues.2,7,28Whilethisstudyconfirmedpreviouslyiden-
tifiedbarrierstoerrorreporting,suchasinsufficienttime
toreportandfearofpunishment,4,29-31pediatricians’fear
ofmalpracticelitigationdidnotappeartoaffecttheirself-
reported formal reporting behaviors. This study also re-
vealed that many pediatricians had problems accessing
areportingsystemtoimprovesafetyandweremorewill-
ing to report errors if they saw evidence of system-level
improvements. These findings suggest that redesigning
reporting systems to include features preferred by phy-
sicians and disseminating information about system
changes to improve patient safety would likely result in
increased error reporting by pediatricians. Training will
be required for all system users with targeted educa-
tionalprogramsforprivatephysicianswhowerelesslikely
to report errors than their colleagues working in aca-
demic or other settings. The current failure of hospital
reporting systems to capture information about errors
fromphysiciansimpedeseffortstoaccuratelycharacter-
ize the epidemiology of pediatric medical errors and to
improve the safety of hospitalized children.4,6,29
Another important barrier to error reporting may be
the culture of medicine itself—a deeply rooted culture
thatexpectserror-freepractice,emphasizesindividualac-
countability, and tends to blame the individual when he
or she fails to perform perfectly.7,32,33Our data suggest
that pediatricians, like other physicians,12have not yet
fullyembracedtheconceptofsystem-basedsolutionsto
patient-safety problems. Pediatricians who feel person-
allyresponsibleforerrorsinthecareoftheirpatientsare
likelytoinstitutelocalremediestopreventfutureerrors
and may perceive error reporting to be unnecessary. In-
deed, study respondents who believed that errors were
usuallyduetosystemratherthanindividualfailureswere
morelikelytoreporterrors.Pediatricdepartmentchairs,
hospital executives, and other opinion leaders can pro-
mote culture change by encouraging their colleagues to
regard errors as opportunities to design better systems
of care for all pediatric patients.
In other hazardous industries, error prevention ac-
tivitiesfocusonlearningfromnearmisses,becausethey
occur more often than adverse events, have similar la-
tent causes, and are less threatening to report.34-40Al-
though most survey respondents endorsed reporting a
near miss and were more likely to have been involved in
a near miss than in a serious error, they actually re-
ported near misses less often than they did more serious
errors,afindingconsistentwithotherstudies.4,5Thisdis-
crepancy between pediatricians’ willingness to report a
near miss and their reporting behavior may be because
their prior experience of error reporting has been lim-
itedtosystemsdesignedtomanagefinancialrisksrather
thanpromotesafersystemsofcare.4,37,38,41Developingsys-
tems that encourage reporting of near misses and edu-
cating physicians in their use will reduce the future risk
of pediatric patients being harmed by more serious ad-
verse events.
Our results also highlight the challenges of disclos-
ing errors to family members. While pediatricians en-
dorsed the general concept of disclosing serious errors
tofamilies,theyalsoreportedthatmultiplebarriersmight
inhibitdisclosure.Somestudyphysicianssaidtheymight
be less likely to disclose a serious error if they thought
thepatient’sfamilywouldnotunderstand,wasunaware
oftheerror,ordidnotwanttoknow.However,mostpa-
tients want to know if an error happened, even if harm
was minor.42These physicians’ attitudes toward disclo-
sure were not influenced by their perceived likelihood
ofamalpracticelawsuit;infact,3in4physiciansthought
that disclosure would reduce the likelihood of a law-
90
70
80
60
50
40
30
20
10
0
Serious ErrorMinor ErrorNear Miss
Percentage
Discussed With Colleagues
Reported to Patient Safety∗
Reported to Risk Management
Figure. Error communication by pediatricians and pediatric residents by
error type. These analyses were limited to those physicians who reported
involvement in each error type. The samples included 219 physicians
involved in a serious error; 399, in a minor error; and 341, in a near miss.
*“Reported to Patient Safety” was limited to respondents who indicated that
such a program was available at their hospital.
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suit. While no definitive data exist regarding the impact
ofdisclosingpediatricerrorsonmalpracticeclaims,43re-
cent surveys suggest that full disclosure would reduce
the likelihood of legal action,44,45and several institu-
tions, including at least 1 major pediatric center, have
adopted formal policies of full disclosure without unfa-
vorably impacting their malpractice experience.46The
medical profession should develop disclosure guide-
lines to help physicians with this difficult task, and fur-
ther research should explore the unique barriers to er-
rordisclosureinthepediatricsettingandevaluatedifferent
disclosure strategies.
Open communication about errors presents special
challenges for physician trainees. Many pediatric resi-
dents reported prior involvement in errors and had dis-
closederrorstopatients’families.Yettheseresidentswere
more likely than attending pediatricians to express con-
cern about the difficulty and potential negative conse-
quences of disclosing errors.7,31The topic of error dis-
closure affords an ideal opportunity to integrate several
ofthecorecompetenciesmandatedintherecentGradu-
ate Medical Education guidelines,47including commu-
nication skills and professionalism. Pediatric residency
training should include formal instruction in error dis-
closure, as well as opportunities to practice disclosure
andreceivefeedback.48Opportunitiestopracticedisclo-
sure could include observing and being observed by se-
nior physicians or by disclosing hypothetical errors to
standardized patients.42,49Given the challenges in dis-
closingerrorstopatients,attendingpediatriciansshould
carefully plan these conversations in advance with the
residentandalsobepresenttoleadorassistwiththedis-
closure itself.
There are several limitations to our study. We col-
lecteddatafromphysiciansassociatedwithpediatrichos-
pitals in only 2 geographic areas. There could be both
institution-specificandstate-specificdifferencesinphy-
sician attitudes about safety related to institutional cul-
ture or educational initiatives in patient safety or to the
state malpractice and regulatory climate. These factors
mightlimittheabilitytogeneralizeourfindingstoother
settings. However, the issues associated with communi-
cation about errors are probably not regional, and our
high response rate and large sample size contribute to
thegeneralizabilityofstudyfindings.Thesurveywasall
self-reported, and we do not know how often pediatri-
ciansactuallyreportedordisclosederrors.Althoughthe
survey was anonymous, respondents’ answers may have
beeninfluencedbysocialdesirability,leadingustoover-
estimate positive attitudes and perceived desired behav-
iors. Finally, although we asked respondents about er-
rors in which they had been personally involved, their
attitudes and practices of error reporting and disclosure
may vary depending on their degree of involvement in
the event.
CONCLUSIONS
Although communication about medical errors is diffi-
cult, it is also essential if pediatricians are to fulfill their
professional obligation to work with health care systems
toidentifyandreduceerrors14andtodiscloseerrorstopa-
tients’families.1Whilepediatriciansendorsereportinger-
rorstothehospitalanddisclosingerrorstopatients’fami-
lies, system changes are required to facilitate these
communications. The hospital must facilitate the report-
ing of errors and near misses by pediatricians so that ef-
fective,safersystemsofcarecanbedevelopedandimple-
mented.Inaddition,openandhonestdiscussionsfollowing
pediatric errors must occur to maintain and improve pa-
tient trust. Such open communications about errors are
likelytobenefitcurrentandfuturepediatricpatients,their
families, pediatricians, and the hospital.
Accepted for Publication: August 17, 2006.
Correspondence: Jane Garbutt, MBChB, General Medi-
cal Sciences, Washington University School of Medi-
cine,CampusBox8005,660SEuclidAve,StLouis,MO
63110 (jgarbutt@im.wustl.edu).
Author Contributions: Dr Garbutt had full access to all
the data in the study and takes responsibility for the in-
tegrity of the data and the accuracy of the data analysis.
Study concept and design: Garbutt, Brownstein, Klein,
Table 5. Factors That Might Deter a Pediatrician From Disclosing a Serious Error to a Patient’s Family*
No. (%)
P Value†
.40
Total
(N = 557)
279 (50)
Attending Pediatricians
(n = 439)
224 (51)
Pediatric Residents
(n = 118)
55 (47)“If I think the patient’s family would not
understand what I was telling them.”
“If I think the patient’s family would not
want to know about the error.”
“If I didn’t know the patient’s family well.”
“If I think I might get sued.”
“If the patient’s family is unaware that the
error happened.”
“If I think the patient’s family would
become angry with me if I did so.”
121 (22)87 (20) 34 (29).04
92 (17)
84 (15)
83 (15)
72 (16)
59 (13)
52 (12)
20 (17)
25 (21)
31 (26)
.90
.04
?.001
53 (10)39 (9)14 (12).30
*Pediatricians were asked to select factors that might make it less likely that they would disclose a serious error to a patient’s family. Response options were to
select the item or not.
†Comparison of attending pediatricians and pediatric residents.
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Page 7

Waterman, Marcuse, Dunagan, Fraser, and Gallagher.
Acquisitionofdata:Garbutt,Brownstein,Klein,Waterman,
Fraser, and Gallagher. Analysis and interpretation of
data:Garbutt,Klein,Waterman,Krauss,Marcuse,Hazel,
Fraser,andGallagher.Draftingofthemanuscript:Garbutt,
Brownstein,Klein,Waterman,Marcuse,Hazel,Dunagan,
Fraser, and Gallagher. Critical revision of the manuscript
for important intellectual content: Garbutt, Brownstein,
Klein, Waterman, Krauss, Marcuse, Hazel, Dunagan,
Fraser, and Gallagher. Statistical analysis: Krauss. Ob-
tained funding: Brownstein, Marcuse, Dunagan, Fraser,
andGallagher.Administrative,technical,andmaterialsup-
port: Klein, Marcuse, Hazel, Dunagan, and Fraser. Study
supervision: Dunagan and Fraser.
Financial Disclosure: None reported.
Funding/Support:Fundingforthisstudywasprovidedby
grants 1U18HS11890 and 1K08HS0140201 from the
AgencyforHealthcareResearchandQuality;StLouisChil-
dren’s Hospital; and Seattle Children’s Hospital and Re-
gional Medical Center. Dr Gallagher was also supported
by the Greenwall Foundation Faculty Scholars Program.
Acknowledgment:WewouldliketothankAlisonEbers
andKerryBommarito,MPH,forassistanceintheprepa-
rationoftheWeb-basedsurveyinstrument,physicianre-
cruitment, and data entry.
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I think you have to be very careful to only
speak about a few things. If you have some
credibility, it only goes a small distance.
—Bill Gates
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