The original intent of this study was to understand whether and how clinicians would discuss medical errors. Most clinicians indicated that they would disclose an error to patients, but the qualitative analysis revealed that clinicians held a nuanced definition of “disclosure” that most often did not contain the elements desired by patients.2–4,8,9
This difference creates a potential communication gap between clinicians and patients in the aftermath of a harmful error. To many clinicians, disclosure was not a straightforward description of what happened. Instead, under the rubric of disclosure, clinicians described various forms of discussion that would communicate different impressions of the nature of the mistake and its relationship to effects experienced by the patient. The difference between what clinicians say and what patients expect—all classified as “disclosure”—might explain some of the discrepancy between reported attitudes and actual error disclosure behavior.4,12,31
Error disclosure is an essential process to ensure that patients receive the information needed to make informed decisions about their care. Ethicists, professional organizations, and researchers align in support of open disclosure of errors. According to the American College of Physicians Ethics Manual, information “should be disclosed whenever it is considered material to the patient’s understanding of his or her situation, possible treatments, and probable outcomes.... However uncomfortable for the clinician, information that is essential to and desired by the patient must be disclosed.”32
The American Medical Association’s Council on Ethical and Judicial Affairs states that “the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred.”17
Yet, the data presented here show that clinicians and administrators describe a more complex view of disclosure that incorporates the competing interests of self-preservation and duty to the patient and institution. Interestingly, professional guidelines are not explicit on what disclosure entails, how repercussions are to be handled, or approaches to resolve ethical and legal tensions. Moreover, there is very little teaching done in medical training that focuses on this important issue. Based on the grounded analysis performed in this study, we propose the following definition of disclosure of a medical error:
Error disclosure = Communication between a health care provider and a patient, family members, or the patient’s proxy that acknowledges the occurrence of an error, discusses what happened, and describes the link between the error and outcomes in a manner that is meaningful to the patient.
Such definitions are needed to advance the field and to inform practical policies.
Our study is limited because of its small size and qualitative data analysis. As such, the frequencies of disclosure types cannot and should not be interpreted in quantitative terms. The focus group sample was composed of self-selected volunteers and was not representative of the participating medical centers. In addition, we studied only academic medical centers in one region, which may not reflect other areas. All of the authors have clinical experience with error and disclosure and may bring personal biases to the analysis. We have systematically tried to be aware of our biases and use them to our advantage rather than trying to eliminate them. The qualitative analysis uncovered an unexpected range of disclosure types, and our clinical experience lent an ability to hear the contingencies that necessitated such nuanced interpretations. Moreover, the clinician participants, knowing that the authors were clinicians and likely had similar experiences, may have been more open to discuss the sensitive topic. Lastly, this analysis does not yield insight into why nuances in disclosure behaviors exist.
Our analysis identified several areas in which the disclosures we studied failed to meet the standards of patients and professional organizations. Partial disclosure and Nondisclosure satisfies neither the patient’s desires nor a clinician’s professional responsibility, yet such disclosure types accounted for the majority of all the disclosures in our sample. The preponderance of Partial disclosures is similar to that found in a recent study with surgical teams.33
Whereas these findings may underscore the fact that a gap exists, it is a credit to those who participated in the focus groups that they were willing to reveal their current thoughts and practices regarding error disclosure. Such candid discussion among a diverse set of health care professionals augurs well for the future. Our detailed description of error disclosure, built on a qualitative analysis, yielded 6 disclosure elements that could serve as criteria for clinicians and others to educate about and evaluate disclosures. These elements of disclosure might be used to create realistic guidelines for disclosure behaviors and inform practical interventions.