This study confirms earlier findings that full disclosure results in a more positive response on the part of the patient or family member in terms of satisfaction and trust, and reduces the likelihood of changing physicians.2,26
The impact of disclosure on seeking legal advice varied across the 2 error conditions; full disclosure reduced the likelihood of seeking legal advice in the missed allergy error situation, but had no detectable impact in the inadequate monitoring error situation. This is consistent with findings from a prior study,2
which also found no statistically significant association between disclosure and seeking legal advice in the monitoring error condition. Overall, our results suggest that full disclosure is likely to have either a positive impact or no impact on patients and family members; we found no evidence that full disclosure increases the risk of negative consequences for physicians.
The relationship between disclosure and legal repercussions is a particular concern to physicians. Patient safety experts and ethicists advise physicians to be forthcoming to patients when errors occur, but empirical evidence on the relationship between disclosure and legal consequences is limited.30,31
Studies have found that patients and family members pursuing legal action subsequent to an error are often motivated by the desire for explanations and apologies32–35
; however, such studies do not provide evidence that full disclosure can prevent legal action.30,31
We anticipated that a positive relationship with the physician before the error incident could have a protective effect, mitigating negative feelings, and actions on the part of the patient or family. While we detected no statistically significant beneficial effect of a prior positive relationship, our inability to detect an impact should not be construed as evidence of no effect. First, we may not have had sufficient statistical power to detect an impact. Alternatively, our effort to simulate a prior positive relationship may have been unsuccessful. It also is possible that subjects' relationship with their own providers influenced their perceptions of the physician in the vignette. Although we included ratings of subjects' relationship with their current provider in the regression models, our models do not fully evaluate the extent to which subjects' prior experiences may have influenced responding. Our nonsignificant results are in contrast to findings suggesting that how providers communicate with patients in routine encounters is
predictive of the provider malpractice status.36,37
However, we note that findings from earlier studies of the importance of communication behaviors in predicting malpractice focused on routine encounters and physician-patient relationships, not on the question of whether a positive relationship was influential once an error occurred
. Future research should explore this issue more fully.
Our findings call into question the assumption that patients will necessarily respond positively to an offer to waive the costs associated with a medical error. While the vast majority of patients would want the medical fees related to an error waived,2
with one exception, we failed to detect a statistically significant association between offering to waive costs and patients' responses. The exception was the finding of a statistically significant interaction between the clinical outcome of the error and offering to waive costs: when the clinical outcome was less serious, offering to waive costs was associated with higher rates of intent to change physician (compared with no reference to waiving costs). It is noteworthy that in this instance the impact of offering to waive costs was negative rather than positive. The interaction effect also suggests that how patients respond to an offer to waive costs may depend on other aspects of the error situation. The finding of no effect or a negative effect of waiving costs may appear to contradict the work of Kraman and Hamm,25
who reported that full disclosure and assistance in obtaining financial compensation may reduce the amount, if not the number of claims. However, that study was conducted in the context of the Veteran's Administration (VA), an atypical system, whose providers are protected from malpractice litigation. Further, it was an institutional case study of the impact of the “extreme honesty” policy, which entailed providing information about what had occurred, an apology, and assistance in obtaining financial compensation. Thus, it was not possible to evaluate the independent effect of financial assistance, or to consider how other factors may have influenced such an effect. Finally, while introduction of the extreme honesty policy appeared to reduce the amount paid out in claims, it is less clear that it reduced the number of claims, and data on other patient outcomes were not reported.
The finding that the clinical outcome of the error has a significant impact on how patients and families respond is consistent with prior findings.2,26
It not surprising that patients and family members are likely to be more distressed by a life threatening error, as well as more likely to change providers and seek legal advice.
Using an experimental design, we were able to overcome a number of limitations inherent in observational survey studies; however, this study does have limitations. Because participants were drawn from a single geographic area, and were predominantly white, the extent to which these findings are generalizable to other geographic areas and other racial/ethnic groups is not known. Further, we are unable to assess whether the relatively high percentage of female participants biased the results. As participation required coming to a central study location, subjects were necessarily those with the ability, time, and motivation to do so. Both of these factors may have limited the extent to which those who participated are representative of the general population, even in this geographic area. The fact that subjects were recruited from the membership of an HMO may also have had an impact on generalizability; for instance, trust level may differ as a function of insurance type. Finally, we note that we did not have sufficient power to fully test interactions between design variables.
The findings from this study underscore the need for additional research, particularly into the determinants of seeking legal advice and the effects of discussions of patient-incurred costs. While simulation studies such as this are valuable in that they allow systematic manipulation of key variables, research into the content and impact of what practicing physicians actually say following medical errors is needed. It would also be informative to query patients who believe they have been harmed as a result of a medical error, but who decide not
to take legal action. Over 20% of the subjects in this study reported having personally suffered an injury or harm as the result of a medical error, but less than half of 1% reported filing a malpractice suit against a provider. These findings are consistent with findings from national surveys in the United States, where 34%10
of the public report personal experience with an error in their own care or the care of a family member, and in Germany, where 30% report an error in their own care.26
While several studies have focused on patients involved in or considering legal action,32–35
to our knowledge, there have been no studies of patients who believe they have been injured, but did not pursue legal action. This may be a promising direction for future research.
Full disclosure may seem risky to a physician faced with a patient who has experienced a medical error, but the results presented here suggest that full disclosure is likely to have either a positive impact or no impact on patients and family members; we found no evidence that full disclosure increases the risk of negative consequences for physicians. Further work is needed to clarify the impact of an existing positive physician-patient relationship, and of waiving costs associated with the error.