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Error Identification, Disclosure, and Reporting: Practice Patterns of Three Emergency Medicine Provider Types Cherri Hobgood, MD, Jipan Xie, MD, Bryan Weiner, PhD, James Hooker, MS Abstract Objectives: To gather preliminary data on how the three major types of emergency medicine (EM) providers, physicians, nurses (RNs), and out-of-hospital personnel (EMTs), differ in error identification, disclosure, and reporting. Methods: A convenience sample of emergency department (ED) providers completed a brief survey designed to evaluate error frequency, disclosure, and reporting practices as well as error-based discussion and educational activities. Results: One hundred sixteen subjects participated: 41 EMTs (35%), 33 RNs (28%), and 42 physicians (36%). Forty-five percent of EMTs, 56% of RNs, and 21% of physicians identified no clinical errors during the preceding year. When errors were identified, physicians learned of them via dialogue with RNs (58%), patients (13%), pharmacy (35%), and attending physicians (35%). For known errors, all providers were equally unlikely to inform
the team caring for the patient. Disclosure to patients was limited and varied by provider type (19% EMTs, 23% RNs, and 74% physicians). Disclosure education was rare, with #15% of any provider type receiving such instruction. Yet, 59% of physicians had observed another provider disclose an error to a patient. Error discussions are widespread, with all providers indicating they discussed their own as well as the errors of others. Conclusions: This study suggests that error identification, disclosure, and reporting challenge all members of the ED care delivery team. Provider-specific education and enhanced teamwork training will be required to further the transformation of the ED into a high-reliability organization. Key words: patient safety; reporting systems; medical error; disclosure. ACADEMIC EMERGENCY MEDICINE 2004; 11:196–199.
Fundamental to the success of emergency department (ED) quality improvement efforts is an understanding of how providers identify, disclose, and report errors. Evaluation of physician error identification, disclosure, and reporting suggests that the lack of appropriate responses to error is multifactorial.1–5 In the ED environment, physicians are only one member of the care delivery team, and specific teamwork training has been identified as an effective error reduction strategy.6 To the best of our knowledge, no research has focused on error identification, disclosure, and reporting patterns of other ED care providers. This report provides preliminary data on how the three major types of emergency medicine (EM) providers, physicians, nurses (RNs), and out-of-hospital pro-
viders (EMTs), differ in the identification, disclosure, and reporting of medical errors.
From the Department of Emergency Medicine (CH), The University of North Carolina School of Medicine (CH, JH), Chapel Hill, NC; and Department of Heath Policy and Administration, University of North Carolina School of Public Health (JX, BW), Chapel Hill, NC. Received June 11, 2003; revision received August 15, 2003; accepted August 21, 2003. Presented at the 9th International Conference on Emergency Medicine, Edinburgh, Scotland, June 2002. Address for correspondence and reprints: Cherri Hobgood, MD, Department of Emergency Medicine, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27599. Fax: 919966-3049; e-mail:
[email protected]. doi:10.1197/j.aem.2003.08.020
METHODS Study Design. This study was a survey of providers asking them to relate their experiences with identification, disclosure, and reporting of medical error. The institutional review board approved this study. Study Setting and Population. A convenience sample of physicians, RNs, and EMTs completed a brief survey examining their error identification, disclosure, and reporting behaviors (available as an online Data Supplement at www.aemj.org). The study was performed during August 2001 in a tertiary care academic medical center ED with an annual census of 60,000 and an EM residency-training program. Survey Content and Administration. The instrument was piloted and revised on the basis of preliminary data. Trained research assistants recruited study participants, obtained informed consent, and administered the survey. Research assistants staffed the ED from 9 AM to 1 AM daily. Respondents were also provided with the Institute of Medicine’s definition of error, which is ‘‘the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.’’5 To prevent interference with patient
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care, subjects were recruited in one-hour time blocks, which sampled all shifts for physicians, RNs, and EMTs. Research assistants identified potential subjects and determined their eligibility based on predetermined criteria: 1) physicians, RNs, and EMTs staffing or delivering patients to the ED; 2) ability to complete the instrument immediately; and 3) not a student of any subgroup. All physicians were postgraduate year (PGY) 1–3 or attending level providers. All RNs were ED staff with a minimum of two years’ intensive care nursing experience. The EMTs ranged in qualification from basic emergency medical technician (EMT) to paramedic. Data Analysis. Data were collected and maintained in a confidential manner. A descriptive analysis of the data was performed.
RESULTS A total of 161 subjects were approached, and 45 were excluded and not sampled; 116 participated in the study. The distribution of respondents by training category was 41 EMTs (35%), 33 RNs (28%), and 42 physicians (36%). Nurses differed demographically from other providers, because they were more likely to be female, older, and have more years of experience. There were no differences in ethnic distribution between provider classes (90% white, 4% African American, 4% Asian, and 2% Hispanic). The training status of physician respondents was 24% attending, 33% interns, and 43% PGY 2 or greater. Of all physician respondents, 57% were EM specialists, and the remaining 43% were comprised of the specialties whose services rotate as PGY-1 or PGY-2 level providers in the ED (internal medicine, family medicine, pediatrics, obstetrics–gynecology, and surgery). The frequencies of self-reported provider error identification, disclosure, and reporting are presented in Table 1. All provider groups lacked formal instruction on how to inform patients of medical error (10%, EMTs; 9%, RNs; 12%, physicians). Yet providers did not lack experiences with informal error discussion; a majority of all providers acknowledge hearing a colleague discuss their own medical error (83%, EMTs; 78%, RNs; 89%, physicians) and hearing a colleague discuss another provider’s error(s) (90%, EMTs; 84%, RNS; 95%, physicians). Despite the frequency of these discussions, the likelihood of providers other than physicians directly observing error disclosure to a patient was low (18%, EMTs; 31% RNs, 59% physicians). There were no gender-related differences identified except one: 66% of males indicated they were more likely to inform fellow workers of their errors, compared with 34% of women. Two experiencerelated differences in behavior were noted. Across all provider types, the most experienced providers (>10 years of experience) were more likely than novice
TABLE 1. Percentage of Self-reported Identification, Disclosure, and Reporting of Medical Error by Provider Types
Number of errors committed in last year* None One to two Three to four Five or more
EMTs (%)
Nurses (%)
Physicians (%)
44.7 39.5 13.2 2.6
56.2 34.4 9.4 0.0
21.4 26.2 26.2 26.2
76.9
67.7
0.0 23.1
0.0 64.5
7.7 38.5 23.1 0.0 0.0 30.8
25.8 51.6 74.2 29.0 0.0 16.1
7.1 7.1 21.4 0.0 0.0 85.7 0.0 0.0
35.5 38.1 58.1 12.9 35.5 87.1 3.2 0.0
Other parties whom the respondent informed of error Attending physician 52.1 Federal government agency 4.8 Fellow worker 57.1 Hospital patient safety committee 4.8 Nurse 38.1 Patient 19.1 Pharmacy 0.0 State government agency 9.5 Other 38.1 Parties who assisted the respondent in error awareness Attending physician 9.5 Fellow worker 19.1 Nurse 19.1 Patient 0.0 Pharmacy 0.0 Recognized own error 95.2 Supervisor 14.3 Other 0.0
*Rates of error disclosure and reporting are calculated only from those respondents who indicated they had committed an error during the previous year. EMTs = emergency medical technicians and paramedics.
providers (\1 year experience) to report they had identified their error themselves (30% vs. 6%). These experienced providers were more likely not to disclose error to patients than were novice providers (25% vs. 3%).
DISCUSSION These results highlight several key points about error management patterns in EM providers. First, although a majority of EMTs and physicians identified at least one error in their practice in the preceding year, many providers identified no errors. Given that the ED has been recognized as a ‘‘high hazard’’ environment,7 where provider decision density is among the highest in all medical fields,8 it seems unlikely that anyone could practice, even briefly, without error. This absence of error identification may represent a barrier to the conversion of the ED into a high-reliability organization. High-reliability organizations are defined by their capacity to perform high-hazard, high-risk operations in a nearly error-free manner.9 Commonly known
198 examples of high-reliability organizations are nuclear power plants, air traffic control operations, and nuclear aircraft carriers. These organizations have a unique set of operating characteristics, which Perry7 notes result in a state of mindfulness. This condition of mindfulness is the preoccupation with failure and sensitivity to operations typified by a hypervigilance surrounding safety. This preoccupation with failure endorses the recognition of both large and small events as important in the acquisition of meaningful data for systems improvement efforts.7 Once providers become mindful of error events and gain a more complete understanding of the tenets of high-reliability organizations, errors in care delivery become transparent. Second, the majority of all providers indicated that most commonly, errors were self-diagnosed. Only a small percentage of providers were assisted in enhanced error awareness by their supervisors, pharmacists, attending physicians, and fellow workers. This absence of an interdisciplinary collaborative pattern supports the lack of mindfulness across provider types and suggests the need for specific teamwork training to endorse and support the culture of patient safety across the ED system. Third, our study results indicate that, when errors do occur, little interdisciplinary information transfer occurs. In a clinical environment, the lack of such information transfer impedes corrective measures, furthers faulty analysis based on incorrect data, and diminishes systems improvement efforts designed to prevent similar errors. Likewise, patients were often not informed of errors, and although the rates of physician disclosure were significantly higher than RNs and EMTs, they still did not achieve 100%. Prior research has demonstrated that patients want to learn of all errors occurring during their care.10 If physicians are to be identified as the team member responsible for error communication, we must ensure that significantly higher interprovider information transfer occurs. Otherwise, we cannot reliably assert that our patients are being adequately informed of the errors committed during their care. Taken together, these findings are reminiscent of the allegory ‘‘See no evil, hear no evil, and speak no evil.’’ Providers have limited insight into their own error patterns, rarely assist others with error identification, and when errors are identified, often do not inform others, including the patient, of these events. These findings have important implications for the success of reporting systems and the conversion of the ED into a high-reliability organization. Reporting systems depend on providers identifying errors; without such identification, no report or corrective action can be generated. Even when errors are identified, these results support prior observations that reporting systems are limited in their ability to capture all occurrences. On average, less than a fourth of providers reported known errors to oversight
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committees or regulatory bodies. Stanhope et al. have identified a nearly identical rate of reporting in obstetric units, with less than 25% of designated incidents being communicated to risk managers for evaluation.11 Similarly, in hypothetical studies using clinical vignettes, providers have established a reluctance to report coworkers across specialty type.12 The reasons for these truncated reporting patterns have been explored in other health care environments,11–13 but no data are available specific to EM. Teamwork is fundamental to ED care delivery; if patient safety improvement strategies are to depend on reporting, further studies to define and develop successful interdisciplinary error-related communication strategies are needed. Education is an important component of performance and all provider groups report a lack of specific disclosure education; however, direct observation of peer performance and open discussion of error was reported. The nature of this discourse in terms of content or context was not explored, and the importance of this result is simply to highlight the regularity with which these discussions occur. Individual institutions must remain attentive to these types of discussions and the impact of this dialogue on the establishment of the culture of safety within an institution.
LIMITATIONS Our study suffers from several important limitations. First, the study was performed in only one ED on a small convenience sample of providers. This may significantly bias the results toward our institutionspecific culture; however, the institution is a tertiarycare academic center and, as such, is a true melting pot of care providers from many primary institutions. The EMTs also present to our institution from around the state, because we are a state and regional referral center. The survey method asked providers to recall the number of errors in the preceding year and provided only the Institute of Medicine’s definition of error with no illustrating examples. This general, nonoperational error definition without supporting examples of a variety of error types may have resulted in a wide range of respondent interpretation of error and limited their recall of specific error events. This finding, coupled with the survey instrument requirement that providers recall error events, may have negatively impacted the magnitude of the results by biasing providers toward the memory of only serious errors.
CONCLUSIONS Key to the successful transformation of the ED into a high-reliability organization is the three-step process of error recognition, disclosure, and reporting. Provider-specific educational initiatives should be de-
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veloped to enhance mindfulness, thus improving error awareness and identification. Healthy positive interdisciplinary dialogue should be supported as a means of promoting the culture of high-reliability organizations. References 1. Baylis F. Errors in medicine: nurturing truthfulness. J Clin Ethics. 1997; 8:336–40. 2. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991; 265:2089–94. 3. Rosner F, Berger JT, Kark P, Potash J, Bennett AJ. Disclosure and prevention of medical errors. Committee on Bioethical Issues of the Medical Society of the State of New York. Arch Intern Med. 2000; 160:2089–92. 4. Sweet MP, Bernat JL. A study of the ethical duty of physicians to disclose errors. J Clin Ethics. 1997; 8:341–8. 5. Kohn LT, Corrigan J, Donaldson MS, McKenzie D. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000.
199 6. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002; 37:1553–81. 7. Perry SJ. Profiles in patient safety: organizational barriers to patient safety. Acad Emerg Med. 2002; 9:848–50. 8. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002; 9:1184–204. 9. Roberts K. Some characteristics of high-reliability organizations. Organization Sci. 1990; 1:160–77. 10. Hobgood C, Peck CR, Gilbert B, Chappell K, Zou B. Medical errors-what and when: what do patients want to know? Acad Emerg Med. 2002; 9:1156–61. 11. Stanhope N, Crowley-Murphy M, Vincent C, O’Connor AM, Taylor-Adams SE. An evaluation of adverse incident reporting. J Eval Clin Pract. 1999; 5(1):5–12. 12. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care. 2002; 11(1):15–8. 13. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract. 1999; 5(1):13–21.
