To Report or not : The Dilemma of Reporting Medical Errors among Physicians

In the medical field, just as in any practice, the occurrence of errors, mistakes and inaccuracies is inevitable. However many authorities have been attempting to investigate methods of reducing and possibly eliminating human errors and their potential hazardous squeals (1,2). Over the years, manual work has been replaced by computerized digital systems in the hope of reducing human work-related errors which is extremely crucial particularly in hospitals. When it comes to a patient's life and well-being, mistakes may be unforgivable (3). Medical error can result in tremendous damage and unwanted consequences; not only the patient's health can be in turmoil but also the treating physician can be greatly affected (4,5). When any member of the health care system Abstract


Introduction
In the medical field, just as in any practice, the occurrence of errors, mistakes and inaccuracies is inevitable.However many authorities have been attempting to investigate methods of reducing and possibly eliminating human errors and their potential hazardous squeals (1,2).Over the years, manual work has been replaced by computerized digital systems

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makes a mistake, it may well jeopardize his/her mental status, emotions, and performance.Thus, it is imperative to find appropriate ways to help solve this problem (6).In our belief, one of the major aspects of reducing errors is to report these errors to the authorities in charge in the respective institutes.Actions, in terms of education, training, advice, system modifications, and possibly penalties, should be implemented following reporting.Physicians should also have a positive attitude towards this, and not shy away from their responsibility of reporting.Every member in a hospital should be encouraged to report and hence eliminate all possible errors so that patients can receive the best possible care from all providers.
Our study aimed to investigate the attitude of physicians in our hospital towards reporting their ME, and to evaluate their knowledge on reporting.Furthermore, we aimed at finding the aspects behind their practice of reporting and/or concealing their errors.We also focused on investigating the possible appropriate actions to be taken following reporting of errors in the hope of reducing their reoccurrence.

Study design
Our study was a cross-sectional descriptive study conducted in king Abdulaziz University Hospital, Jeddah, Saudi Arabia, over the period of 6 months -November 2011 to April 2012.
The study team developed a questionnaire that was designed to measure knowledge and evaluate the attitude and practice of physicians on reporting medical errors.The questionnaire constituted of 4 sections evaluating demographics of the interviewees, the knowledge on reporting errors, the physicians' attitude towards reporting, and the practice of reporting and concealing their errors.The questionnaires were then subjected to further evaluation in a pilot study to enhance its face validity.Our pilot study was conducted on 12 residents, and thus final modifications and amendments were performed prior to commencing the actual study.
A total of 250 questionnaires were printed and distributed to all physicians (Consultants, Specialists, and Residents) attending King Abdulaziz University Hospital.The study team received only 169 filled questionnaire forms back out of the 250 for analysis.The calculated return rate was found to be 67.6%.
In order to ensure the quality of the data that were to be retrieved from the questionnaires, we sub-divided our study team into 3 divisions.Division 1 was assigned to review the answered questionnaires to confirm that all questions were answered.Division 2 was assigned to review the date before entering it into the software program for analysis.Division 3 was assigned to review a random sample of the questionnaires to detect pitfalls.

Statistical analysis
Statistical package of social science (SPSS) version 18 was used for statistical analysis.The qualitative data were presented in the form of number and percentage.Chi-square test was used as a test of significance for qualitative data; Yates correction was used when the expected cell was less than 5.The quantitative data were expressed as means with standard deviations.

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participants were males, and 32.5% were females.More than 80% of the consultants and Results obtained from the section studying the practice of physicians in the questionnaire (Table 2) show that 87% (n=147) of our study sample claim that they have seen ME throughout their careers, and appears to be highest among consultants 94.5% (n=69).Only 56% (n=95) of our study sample claimed that they had reported the errors they had seen.
Reporting of errors was also significantly higher among consultants 79.7% (n=55) compared to specialists and residents (P= 0.001).Furthermore, 48% (n=81) of the participants confessed that they had made ME themselves which was statistically insignificant, and only 35% (n=59) had reported their own mistakes to authorities in charge.Although insignificantly, consultants had the highest rate of selfreporting 81.1% (n=30) .Unfortunately, only 17.2% (n=29) had their own ME investigated, and a significantly higher rate seen was amongst consultants 26% (n=19) (P= 0.015).24.9% (n=42) of the participants reported that they had been investigated for their colleagues ME; this was of a higher rate in specialists 31.6%(n=12).

Variable Specialist n=38
Consultant n=73 The level of physicians' knowledge on the subject of ME and their attitude towards reporting errors was assessed using 2 categories/formats of questions -level of agreement and level of disagreement.
The majority of participants 81% (n=137) believe/consider that reporting ME is an ethical issue with the highest level of agreement found in the consultants group 100% (n=59).Also, 60.4% (n=102) agreed that reporting ME helps alleviate the feelings of guilt associated with committing the error and its subsequent effects.This was significantly highest among the consultants' group 78% (n=46).
Regarding the effect of RME, 36.1% (n=61) thought it would decrease the rate of ME while a higher rate was observed in specialists 56.2% (n=18).82.8% (n=140) thought RME would prevent future complications with higher rate in specialist 100% (n=32).
As regards to confidentiality of reported ME, 63.9% (n=108) thought that ME should be kept confidential.Specialists were the most 81.2% (n=26) who felt that errors are best to be kept concealed.Furthermore, specialists [93.8% (n=30)] were the most who believed that ME should be discussed and solved within their respective departments and not disclosed to hospital administration (Table 3).As can be

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seen in Table 4, only 7.1 %( n=12) of the participant thought it was not their responsibility to RME with highest rate in specialists 66.7% (n=4), and 6.5% (n=11) of them thought it might ruin their relationship with their colleagues with highest rate in specialists 66.7% (n=4).2.4 %( n=4) reported that they might RME with highest rate in residents 40% (n=2), and 5.9% thought confidentiality is not an issue with highest rate in consultants 42.9 %( n=6).
Reasons behind concealment of errors were also studied; results are shown in Table 5.Among our study group, 74% thought that occurrence of ME.In the questionnaires we had 6 suggested solutions.A significant number of the participants 69.2% protection of a physician's reputation is one of the main reasons behind under-reporting of ME.Specialists 78.9% (n=30) were the most to give that response.Escaping penalty (avoiding punishment) 69.2% (n=117) was the second most chosen answer by the participants as a reason behind concealment of ME.On the other hand, 47.9% (n=81) thought that physicians have no incentives to disclose errors and 40.2% (n=68) thought that one would not report their own ME simply because the error would not be discovered.A total of 160 participants (94.7%) believed that it was imperative for our hospital to develop a suitable system to reduce the thought that employing more nurses to the hospital would help to reduce the occurrence of ME, this was mostly agreed upon by consultants.Also, 94.1% (n=159) think that the training programs for employees need enhancement; specialists were the most who approved.Moreover, 79.9% (n=135), mainly consultants, believed that the use of experienced and well-trained physicians specifically in the ICU would reduce the incidence of errors.Additionally, 82.8% (n=140), with the majority being residents, agreed upon reducing working hours to reduce medical errors.The suggestion of adding pharmacists to the hospital's team rounds was appreciated by 86.4% (n=146) of the Generally, administration of inappropriate method of patient care that is opposed to standardized method of care, or failure of performing appropriate method by health care provider leads to ME. ME are usually described as human errors in healthcare e.g.(7,8).inaccurate or incomplete diagnosis or management of a disease.A recent report "To Err Is Human" released by the Institute of Medicine (IOM) drew attention on the burden of medical errors.They concluded that among the American population, there are more deaths related to ME in hospitals than there are deaths related to injuries in vehicle accidents.Since the release of that report, numerous new efforts have been initiated to help reduce the incidence of ME (9).Furthermore, a recent study conducted on 184 residents found that being involved in a medical error was associated with a significant decrease in quality of life and increased rates of depression (10,11,12).

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Lawsuits related to ME are noticed to be increasing lately.It was reported that they are higher in obstetric practice (27%), followed by general surgery (17%) and other subspecialties (13,14).Alsafi et al. evaluated the aspects behind physicians' attitudes toward medical error disclosure.They concluded that physicians are likely to disclose errors made by a colleague only if the error resulted in severe harm to the patient, and as such, ME go underreported for a variety of reasons.Their study was conducted among a single hospital in the kingdom of Saudi Arabia (15); therefore we felt the need to conduct a similar study in the hope of finding a solution to the problem in our country, and to see if results were reproducible.In our study, 87% of our participants had witnessed a medical error but only 56% of them reported those errors.This proves that errors are common but underreported.The reasons behind this needed to be investigated.Although most physicians

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believe that reporting is their responsibility (92.9%), they may still be refraining from doing it.Our results suggest that a physician's reputation (74%) and the fear of punishment (69.4%) may contribute to the problem.Our results were similar to those obtained in the above mentioned studies (10,13).Furthermore, our results significantly suggest that physicians feel that the employment of more nurses, highly qualified intensivists and clinical pharmacists to our institute can help reduce the occurrence of errors.
Limitations: Following the completion of our study, we realized that other factors must be taken into consideration.We believe that further classification of residents to juniors and seniors was needed.Since junior staff are still in training, their errors may well be higher and the fear of punishment may also prevent them from reporting.We also feel that the studies should have been conducted among nursing staff to investigate their perspectives.Additionally, we feel that the translation of the questionnaire to the staff's mother-tongue language may have helped the participants better answer the questions.
Most research papers have failed to clarify the scope of the problem because of several limitations.There are no studies that have examined the subject of ME from the perspective of different levels of physicians; only residents were included in previous studies.Also, sample sizes were small or personal narratives of individual physicians experiences following errors (16).Alsafi et al.
carried out a study in Saudi Arabia and found that physicians are likely to disclose errors made by a colleague only if patients are severely harmed, and as such, medical errors go under-reported.Assurance of confidentiality and protection from backlash would promote medical error disclosure. 15

Conclusion:
There is an agreement amongst physicians that reporting ME is an ethical issue.This however is not reflected in their practice.ME are underreported due to fear of indented reputation and suffering a penalty.Reinforcement of RME and reducing ME can be achieved by implementing strict guidelines, training personnel efficiently and using the experience of professionals in their appropriate fields.Health care institutions should adopt programs that help encourage medical professionals in reporting ME avoiding in the process the creation of a blame culture.We also recommend conducting further studies on the rates of errors and their reporting pre-and post-implementation of the above mentioned solutions.

Table 1 :
Demographic Characteristics of Participants *Statistically significant, KAUH=King abdulaziz university hospital PGE= Post graduate education UGE= Undergraduate education.

Table 2 :
Practice of the Participant Group in Regard to Reporting Accidents *Statistically significant

Table 3 :
Percentage of agreement toward some issue relater to reporting ME among the study groups *Statistically significant

Table 4 :
Percentage of disagreement toward some issue relater to reporting ME among the study *Statistically significant

Table 5 :
The percentage of agreement toward causes of concealing errors *Statistically significant Discussion ME are varied.The result is eventually the harm to patients.ME include errors in diagnosis, administration of drugs and surgical procedures amongst others.ME should be differentiated from malpractice in that the former is regarded as honest mistakes or accidents.

Table 6 :
Percentage of agreement toward actions that should be taken to prevent ME *Statistically significant