Pediatricians Find Barriers to Reporting Medical Errors

ST. LOUIS, Feb. 5 -- Pediatricians who make medical errors would like to report their mistakes to their hospitals but they fear the recriminations and time involved in formal disclosure, according to a survey.

The survey of 439 pediatric attendings and 118 residents in St. Louis and Seattle found that many would be more willing to report errors formally if they saw evidence of a system geared to improving safety rather than one that focused on punishment.

Although most of the pediatricians supported reporting medical errors to hospitals and patients' families, some 60% said formal error-reporting systems are inadequate. This, they said, left them to their own devices to struggle with personal issues of disclosure.

In the survey, most respondents reported that they had been involved in an error (39%, serious; 72%, minor; 61%, near miss; 7%, none), revealed Jane Garbutt, M.B., Ch.B., of Washington University here, and colleagues, in the February issue of the Archives of Pediatrics and Adolescent Medicine.

When respondents were asked to select features of a reporting system that would increase their willingness to report errors to the hospital, they wanted to see a nonpunitive system (89%), and a process that takes less than two minutes to use (73%), was local to their unit or department (58%), and evidence that the information was used for system improvements (89%). In particular, they wanted assurance that the information was confidential and nondiscoverable (88%).

The investigators cited particular barriers to open and honest communication about errors. The medical culture, they noted, has long cherished professional autonomy and emphasized individual accountability for patients' outcomes. Physicians may also fear litigation and damage to their reputations.

In addition, the investigators said, physicians face a unique challenge to open communication because a third party, the patient's parents, must be included in the conversation.

The survey, distributed by mail and on the Internet from July 2003 to March 2004, contained 68 questions examining the physicians' attitudes and experiences with error communication. The results were:

• Among the physicians, 97% endorsed reporting serious errors to the hospital; 90% believed minor errors should be reported, and 82% would report a near miss (an error that could have caused harm but did not, either because of chance or timely intervention);
• Overall, only 39% thought that current error-reporting systems were adequate (attending physicians, 34%; residents, 55%, P<.001).
• Most pediatricians had used a formal error-reporting mechanism, such as an incident report (65%);
• Many also used informal reporting mechanisms, such as telling a supervisor (47%) or senior physician (38%), or discussing errors with colleagues (72%);
• Respondents endorsed disclosing errors to patients' families (99%, serious; 90%, minor), but only 39% supported disclosure of a near miss;
• Only 36% had ever disclosed a serious error to a patient's family, while 52% had disclosed a minor one;
• Residents were more likely than attendings to believe that disclosing a serious error would be difficult (96% versus 86%; P=.004) and to want disclosure training (69% versus 56%; P=.03).

These barriers to communication must be addressed to improve the safety of hospitalized children, the researchers said. While the findings confirmed previously reported obstacles to error reporting, such as insufficient time to report and fear of punishment, fear of malpractice litigation did not appear to affect pediatricians' formal reporting behavior, the researchers said.

Physicians who feel responsible for errors may perceive error reporting as unnecessary, the investigators said. On the other hand, respondents who believe that errors were more likely due to system problems than individual failures were more likely to report errors, they said.

The results also highlight the challenges of disclosing errors to family members. Although physicians endorsed the concept, multiple barriers might inhibit disclosure. For example, they were less likely to report an error if they thought the family would not understand, was unaware of the error, or did not want to know. The physicians' attitudes, however, were not influenced by the likelihood of a malpractice lawsuit. In fact, three of four physicians believed that that disclosure to a family would reduce the likelihood of a lawsuit.

The study had certain limitations, the researchers noted. Data were collected from physicians associated with pediatric hospitals in only two geographic areas, perhaps limiting the generalizability of these findings. Nevertheless, they said, these issues are probably not regional and the response rate and large sample size would likely offset this limitation.

Also, the survey was self-reported, and although the respondents were asked about errors in which they were personally involved, their attitudes may have varied with their degree of involvement.

Summing up, the researchers wrote, "While pediatricians endorse reporting errors to the hospital and disclosing errors to patients' families, system changes are required to facilitate these communications.

"The hospital must facilitate the reporting of errors and near misses by pediatricians so that effective, safer systems of care can be developed and implemented. In addition, open and honest discussions following pediatric errors must occur to maintain and improve patient trust. Such open communications about errors are likely to benefit current and future pediatric patients, their families, pediatricians, and the hospital."