Communicating Pathology and Laboratory Errors

Abstract

Physicians are urged to communicate more openly following medical errors, but little is known about pathologists' attitudes about reporting errors to their institution and disclosing them to patients. We undertook a survey to characterize pathologists' and laboratory medical directors' attitudes and experience regarding the communication of errors with hospitals, treating physicians, and affected patients. We invited 260 practicing pathologists and 81 academic hospital laboratory medical directors to participate in a self-administered survey. This survey included questions regarding estimated error rates and barriers to and experience with error disclosure. The majority of respondents (~95%) reported having been involved with an error, and respondents expressed near unanimous belief that errors should be disclosed to hospitals, colleagues, and patients; however, only about 48% thought that current error reporting systems were adequate. In addition, pathologists expressed discomfort with their communication skills in regard to error disclosure. Improving error reporting systems and developing robust disclosure training could help prevent future errors, improving patient safety and trust.

Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review

“…However, there were differences in the intention to conduct DPSI according to the type of medical error, similarly to what was observed with regard to actual frequency and intentions in hypothetical cases. In particular, most medical professionals still thought that DPSI was unnecessary in the case of a near miss [17,22,28-32]. For example, Evans et al [30] reported that 71.6% of radiation oncologists and trainees thought that near misses should not be disclosed, although 94.8% of them thought that serious medical errors should be disclosed.…”

“…According to the article by Evans et al [30], 38.0% of radiation oncologists and trainees thought that DPSI increased the likelihood of being sued, although 32.4% felt that DPSI decreased the likelihood of being sued. However, according to the study of Dintzis et al [28], only 11.2% of anatomic pathologists and laboratory medical directors thought that fear of being sued would influence their recommendations regarding DPSI.…”

“…Cognitive impairments and cultural differences, including language, also made it harder to perform DPSI [32,59]. Furthermore, unfamiliarity with DPSI [28,60] and busy schedules [32] were highlighted as barriers to DPSI.…”

“…Medical professionals’ simple intention to conduct DPSI showed a similar tendency [18,28,29,31]. However, DPSI was generally found to be conducted more often for minor errors than major errors [17,18].…”

“…Most medical professionals felt that DPSI is unnecessary in the case of near misses [17,22,28-32], but most of the general public believed the opposite [77]. Hearing about the occurrence of a near miss could upset patients, but it would alert patients to the type of medical errors that they should be cautious about and would reassure them that the medical systems designed to keep them safe were working [39].…”