Beyond the medical record : Other modes of error acknowledgment

The fact that medical error is a key concern of health care providers and the general public is hardly contested. The 1999 Institute of Medicine (IOM) report brought the issue of medical error to the forefront of national attention and has ignited a series of debates concerning the incidence and nature of medical errors and the accuracy of the estimates of preventable adverse events.1–4 Much of the research that has been conducted since the release of the IOM report focuses on resolving these debates, particularly what constitutes an error5,6 and what constitutes an accurate estimate of the incidence of medical error.4,7 – 14 Other streams of research have also been building outside of medicine. These include well-developed fields like human factors engineering, medical sociology, and organizational theory and behavior.15–19 Studies from these perspectives focus less on quantifying medical errors and more on how to prevent them by understanding how errors are made visible to those working in the system so that they can be corrected before causing harm or how clinicians can learn from errors after they are manifest. Rather than using data from medical records or other archival sources, these studies try to understand the systemic aspects of error as they occur in micro-level daily events in clinical and hospital practice from the perspective of those who provide and receive care. And they are beginning to yield fruitful results, from individual case studies of patients who suffered severe consequences from medical errors20 to residents' accounts of the daily clinical pressures they face.21 The study reported here belongs in this latter category. It is a qualitative analysis of residents' descriptions of the errors in which they were involved and their understanding of how those errors were acknowledged in the health care system. Improvements in patient safety depend in large part on increasing the quality and quantity of information physicians report about medical errors. Conceptually, the ideal process is: Willingness to Report—Form of Acknowledgment—Access to Information for Prevention. This relies on practitioners documenting correctly or sharing critical information which potentially could be harmful to their image or career. Received wisdom is that because physicians are expected to be infallible and to function without error, they are unlikely to document or acknowledge their mistakes. But few studies have directly examined these ideas. To remedy this gap, in this study we focused on the actual experience of residents in a large hospital setting and sought to answer two questions. To what extent do residents acknowledge mistakes? In what ways do residents acknowledge mistakes?