In the last post, we saw why disclosure is essential and beneficial after patients have been harmed. The decision to disclose adverse events is however often a difficult one for doctors and the institutions they work for. This difficulty was highlighted by Thomas Gallagher and Wendy Levinson in their paper titled Disclosing harmful medical errors to patients: a time for professional action. There, they characterised disclosure as ‘a very challenging communication task‘ for which ‘most physicians have never been trained in what to say and how to say it’. They added that this lack of training makes physicians often ‘unsure exactly what to say‘. They also explored the complexities and uncertainties that accompany the decision to disclose adverse events, and these include the fact that many adverse events are the result of ‘multiple active and latent errors‘ which operate ‘at both the system and the individual provider levels’; this therefore makes the cause of the event, and who bears responsibility for it, vague. They added that this lack of clarity about the physician’s ‘relative contribution to the patient’s bad outcome’ works in concert with the fear of the shame and embarrassment of disclosure to hinder the whole process.
Beyond these uncertainties, there are also more concrete barriers to disclosing adverse events to patients and their families. For example, in their paper titled Disclosure of patient safety incidents: a comprehensive review, Elaine O’Connor and colleagues identified such obstacles as worry over litigation costs, ‘fear of loss of relationship with the patient’; ‘fear of loss of reputation or damage to career progression‘; ‘lack of institutional support‘; ‘absence of training in how to go about disclosure conversations’; and ‘the emotional impact‘ of the adverse events on clinicians.
Other factors that hinder doctors from disclosing adverse events to their patients were explored by Nancy Berlinger in her book After Harm: Medical Error and the Ethics of Forgiveness, and these included the following:
- Believing that the harm is negligible
- Attempting to avoid the pain that may arise from acknowledging the patient’s experience
- Fearing that litigation will follow the disclosure
- Being unable to accept that one is fallible
Thomas Gallagher and colleagues, in their paper titled Choosing your words carefully: how physicians would disclose harmful medical errors to patients, also reviewed the barriers to disclosure. They first pointed out that a disclosure gap often exists between the patient’s desire to learn about medical errors, and the physician’s failure to disclose them. They then attributed part of this gap to the observation that ‘physicians…were less likely to disclose an error that might not be apparent to the patient’. Other factors they reiterated included the lack of disclosure training, and the uncertainty about what information to disclose.
In the next blog, we will look more closely at the practical aspects of communicating patient safety incidents to patients.