Oct. 6, 2008 A survey of pediatricians found wide variation in whether and how they would disclose medical errors to patients and their families, and may be less likely to share information about errors that are less obvious to parents, according to a report in the October issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.
Parents want to be told when an error occurs in their child's care, but such disclosure does not always occur, according to background information in the article. "Disclosing an error to one or both parents, and possibly to the child as well, may prove to be an exceptionally challenging conversation," the authors write.
In a survey conducted by David J. Loren, M.D., of the University of Washington School of Medicine, Seattle, and colleagues, 205 pediatricians (out of 369, a 56 percent response rate) answered 11 questions about one of two scenarios. In the first, the pediatrician administered an overdose of insulin that resulted in the child's admission to the intensive care unit—an error deemed apparent to the family. The second scenario involved failure to follow up on a child's laboratory test, which resulted in an infection and hospitalization. This error was considered less obvious to parents.
A total of 176 pediatric attending physicians and 29 trainees responded to the survey. Of these:
- 161 (79 percent) described either error as serious, and 171 (83 percent) said they would feel very or extremely responsible
- 91 (44 percent) would be concerned that their reputation would be damaged by the error, and 69 (34 percent) believed it was likely to result in a lawsuit
- 109 (53 percent) would definitely disclose the error, 82 (40 percent) would probably do so and 14 (7 percent) would disclose only if asked by the parent
- 95 (46 percent) would use the word "error" when disclosing, 54 (26 percent) would include an explicit apology acknowledging the harm caused to the child and 103 (50 percent) would explain detailed plans for preventing future errors
- Compared with those who received the lab test scenario, twice as many who received the apparent error scenario would disclose the error (73 percent vs. 33 percent) and more would offer an explicit apology (33 percent vs. 20 percent)
Disclosing pediatric medical errors may be complicated because of the need to accommodate children's varying levels of understanding, the authors note. In addition, the view of children as helpless, the lack of information about how an error will affect long-term physical and intellectual development and the long statute of limitations for harm to a child may affect pediatricians' disclosure decisions.
"In conclusion, the relationship among a pediatrician, a child and a family is steeped in trust, a commodity that can be significantly diminished by the occurrence of a medical error," the authors write. "Nevertheless, parents have clearly articulated a desire to be told about errors in the medical care of their children. This study demonstrated marked variation in when and how pediatricians might disclose medical errors and found that they may be less likely to disclose an error that was less apparent to the family. Further research on the impact of professional guidelines and innovative educational interventions is warranted to help diminish the disparity between patient preferences for disclosure and current professional behavior."
Editorial: Pediatricians Can Move from Telling Half the Story to Full Disclosure
"Overall, approximately half of respondents would definitely tell the patient [about an error], half would be explicit that an error occurred, half would disclose the details of the event and half would discuss how future errors could be prevented," writes Wendy Levinson, M.D., F.R.C.P.C., of the University of Toronto, in an accompanying editorial. "The bottom line is that the respondents tell about half of the truth rather than providing full disclosure."
"This is not owing to a failure by the pediatricians in this study, however," she continues. "There are many barriers to disclosure, including physicians' feelings of embarrassment or shame, fears of malpractice suits (a third of the pediatricians thought it likely that they would be sued for such an error) and discomfort in conducting these challenging disclosure conversations. Pediatricians have the additional challenge of having to discuss the error with parents who are protecting young and vulnerable children."
"Loren and colleagues have set the stage for pediatrics by providing survey results specific to the specialty," Dr. Levinson concludes. "Like other physician groups, pediatricians have an opportunity to improve their knowledge and skills about disclosing medical errors. They can move from telling half the story to full transparent disclosure, consistent with the expectations of our patients."
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- David J. Loren, Eileen J. Klein, Jane Garbutt, Melissa J. Krauss, Victoria Fraser, W. Claiborne Dunagan, Dena R. Brownstein, Thomas H. Gallagher. Choosing Carefully What We Might Say to Parents. Arch Pediatr Adolesc Med, 2008; 162 (10): 922-927 [link]
- Wendy Levinson. We're Halfway There. Arch Pediatr Adolesc Med, 2008; 162 (10): 991-992 [link]
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