In this diverse primary care sample, 15% of participants perceived mistakes in the ambulatory care setting and 14% changed their physicians because of this fact. Participants perceived mistakes in both diagnostic care and medical treatment. Mistakes were perceived to have caused harm across the spectrum of severity. Around 8% of participants reported “a lot” or “severe” harm for either diagnostic and treatment mistakes. Factors that were independently associated with a higher likelihood of reporting a mistake included higher levels of educational attainment, report of poor physical health, and chronic back pain, whereas African-Americans were less likely to perceive mistakes in their care.
This study, which included a large geographic area with urban and rural settings, as well as insured and uninsured groups of patients, found that perceptions of mistakes in ambulatory care are fairly widespread. Fifteen percent of our cohort reported a medical mistake, which is similar to 11% reported in the Solberg et al. study of patient perceptions of mistakes in ambulatory care conducted in 2005.5
If an average physician sees 30 patients a day, as many as 4 to 5 of these patients will feel that they have experienced a mistake in their care at some point.
A significant minority of participants who reported mistakes felt they had suffered “a lot” or “severe” harm. This finding conflicts with published reports of adverse events, which have concluded that most do not cause serious harm.32-34
It has been argued that not all mistakes are of concern, only those that cause, or have the potential to cause, harm.35
However patients may perceive mistakes and harm and pursue litigation even over known treatment side effects and normal diagnostic and treatment challenges when patient-physician communication is poor.36
A broader concept of mistakes and harm appears to be prevalent among patients, in which mistakes around such issues as communication about treatment side effects or normal diagnostic and treatment challenges can be perceived even when standards of care are met. These differences between patient and professional viewpoints of what qualifies as a medical mistake should be considered in any future research or policy making regarding medical errors.
Fourteen percent of participants changed their physicians because of a perceived mistake. This is somewhat higher than the 10% rate at which respondents to the National Patient Safety Foundation survey reported changing doctors because of perceived mistakes.22
Changing physicians because of a perceived mistake is a valid measure of dissatisfaction with care and, therefore, could be a useful measure to employ in efforts to improve patient satisfaction in ambulatory clinics.5
The additional qualitative information gathered in our study supports prior work that perceived mistakes involve communication or relationship problems in addition to diagnostic or therapeutic errors. Similar conclusions have been reported by other qualitative studies.8, 20
Kuzel et. al found that access and relationship issues were more commonly reported as perceived mistakes than technical issues such as misdiagnosis or improper medical treatment.8
Combined with the fact that participants may have had trouble distinguishing diagnostic from treatment mistakes, as the 7 of our 52 qualitative surveys suggests, this broad view of mistakes may mean that prior typologies of errors26
may not be as helpful in research on patient perceptions. Furthermore, our study participants frequently reported events such as medication trials or dermatologic diagnostic challenges that clinicians would consider normal diagnostic and/or treatment processes. Further cognitive interviewing about these frameworks is needed to see if these divisions in classification are applicable to patients’ perceptions. If this is indeed true, efforts to prevent true adverse events may not be sufficient to improve public perceptions of mistakes in the ambulatory care setting; the medical system may also need to improve the communication of expectations for care.
A practicing physician may find it useful to know which patients are at increased risk for perceiving mistakes in their care so they can more explicitly set expectations. Frequent utilizers of health care, due to complex disease or multiple comorbidities are clearly at increased risk of both true adverse events and perceived mistakes.23, 37, 38
It makes sense that chronic low back pain, which has a complex pathophysiology and may be therapeutically challenging would be a risk factor for a patient’s perceiving a mistake. Others have found that low education and minority status conferred an increased risk of medical errors, a finding that conflicts with our study results. 38
This discrepancy may be due to the association of minority ethnicity and lower levels of education with increased patient satisfaction39, 40
and low rates of complaints.31
This suggests that perception of mistakes may be due to both true adverse events and patient expectation, a conclusion supported by published patient satisfaction models.10, 41
Thus minorities may have lower expectations and therefore be less likely to perceive mistakes, while those with poor physical health or chronic conditions are still at increased odds due to their frequent utilization and the increased opportunity to experience an error.
While this study was limited to adult patients in primary care settings, it does represent a large, diverse state-wide sample. As all patients had a primary provider, these findings may not represent the perceptions of medical mistakes in patients without a primary care physician. However, the outcomes did focus on any perceived event in an ambulatory care setting, and are not limited solely to perceptions of primary care. As no review of the various medical records of our study participants was performed, no comparison data on documentation of reported events was available. Similarly, as this research was patient-focused, no assessment at the site level was performed other than recording the site itself.
In summary, this study is the first large diverse cross-sectional survey of patients’ perceptions of medical mistakes in the ambulatory care setting. In addition, it quantifies the impact of these perceptions in terms of perceived harm and decisions to change physicians. Our results indicate that patients with chronic low back pain, higher levels of education, and poor physical health are at increased odds of perceiving harm, across a wide range of ambulatory care settings. These perceptions have a concrete impact on the patient-physician relationship, often leading patients to seek another health care provider. It will, therefore, be important to identify ways to improve patients’ perceptions of mistakes. Such an intervention would likely include attention to not only situations defined by the medical community as adverse events, but also to patient expectations of health care encounters and to physician-communication communication around diagnostic and therapeutic processes and outcomes.