Family Practice Advance Access originally published online on November 29, 2007
Family Practice 2008 25(1):9-13; doi:10.1093/fampra/cmm071
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Responding to serious medical error in general practice—consequences for the GPs involved: analysis of 75 cases from Germany
Department of General Practice, Universitätsklinikum Düsseldorf, Moorenstrasse 5, D-40225 Düsseldorf, Germany
Correspondence to: Heinz-Harald Abholz; Email: abholz{at}med.uni-duesseldorf.de
Received 19 June 2007; Revised 5 October 2007; Accepted 25 October 2007.
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Abstract |
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Objectives. GPs’ recollections about their ‘most serious errors in treatment’ and about the consequences for themselves. Does it make a difference, who (else) contributed to the error, or to its discovery or disclosure?
Methods. Anonymous questionnaire study concerning the ‘three most serious errors in your career as a GP’. The participating doctors were given an operational definition of ‘serious error’. They applied a special recall technique, using patient-induced associations to bring to mind former ‘serious errors’. The recall method and the semi-structured 25-item questionnaire used were developed and piloted by the authors. The items were analysed quantitatively and by qualitative content analysis.
Setting. General practices in the North Rhine region in Germany: 32 GPs anonymously reported about 75 ‘most serious errors’.
Results. In more than half of the cases analysed, other people contributed considerably to the GPs’ serious errors. Most of the errors were discovered and disclosed to the patient by doctors: either by the GPs themselves, or by colleagues. A lot of GPs suffered loss of reputation and loss of patients. However, the number of patients staying with their GP clearly exceeded the number leaving their GP, depending on who else contributed to the error, who discovered it and who disclosed it to the patient.
Conclusions. The majority of patients still trusted their GP after a serious error, especially if the GP was not the only one who contributed to the error and if the GP played an active role in the discovery and disclosure or the error.
Keywords. Medical errors, general practice, handling of an error, patient's reaction.
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Introduction |
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Within the medical profession—and among GPs in particular—a culture of open, yet anonymous exchange about errors in treatment is slowly developing and a growing amount of research on patient safety and errors in treatment has been done in the recent years.1–6 In several European countries, anonymous ‘reporting and learning systems’ for errors in general practice are being established.7–12 During international conferences, workshops on ‘How to disclose medical errors to patients’ are offered13,14 and also research on the consequences of medical errors on doctors’ lives has been done.15,16 Yet fear of lawsuit or loss of patients or reputation is still common among doctors.17 Does it really help to talk to the patient about one’s own errors? Can the patient's trust be regained? Does it make a difference, who contributed to the error? Does it make a difference who helped to discover it or who disclosed it to the patient?
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Methods |
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The aim of this anonymous questionnaire study among German GPs was to get a detailed insight into the ‘three most serious errors’ of their careers as GPs. For this purpose, a random sample of 1000 GPs from the North Rhine region in Germany were asked by letter to participate in this study. In total, 217 GPs were interested and requested the study kit (recall note pad, three 25-item questionnaires). Thirty-two anonymous GPs finally took part and sent back 75 questionnaires.
The definition of ‘serious error’ given to the participants was ‘error with serious or potentially serious consequences for the patient’. A special recall technique was suggested to the participating GPs, using patient-induced associations to call former ‘serious errors’ to mind, which might have stayed in ‘repression’ otherwise. The doctors were asked to carry along with them a small memo pad during their usual surgery hours/consultations for three working days, so they could make a short note immediately during the consultation when they were reminded of an error that once had happened to them, and write it down in more detail later on. After these 3 days of collecting memories, they were asked to make a ranking order of their ‘serious errors’ and report only the two or three most serious ones, using one questionnaire for each one of them. This recall method was developed by the authors based on the results of a smaller pilot study.1
Also, the questionnaire was developed and piloted by the authors. It comprises 25 items. The structured question items, which cover most of the objectives of this paper, were analysed quantitatively. The open-ended questions were analysed qualitatively according to the principles of qualitative content analysis looking especially for ‘causal’ and ‘protective factors’. These qualitative results were presented on conferences18,19 and published in a separate paper.20
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Results |
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More diagnostic than therapeutic errors were reported: 54 versus 19 cases; two cases could not be classified. Fifty-seven errors were caused by two or more identifiable ‘causal factors’ (qualitative content analysis). Table 1 gives an idea of the range of errors reported. In 54 cases, serious harm had already been done to the patient when the error finally was discovered. Fifteen patients died before disclosure of the error to the patient was possible, another eight patients died afterwards. The participating GPs stated in 53 of the 75 cases reported, that they had thought of the possibility of that particular error prior to its discovery, or at least, that they had had a ‘bad feeling’ about the case. When the error finally was discovered, they were not surprised about it in 24 of the 75 cases analysed.
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An almost equal number of male (37 cases) and female (35 cases) patients were involved in the ‘serious errors’ reported (in three cases gender was not given). The age range of patients affected covered the full spectrum of a usual general practice population in Germany16 with most of the patients being 51–70 years old. In 14 of the 75 cases reported, the GP did not know the patient by prior contacts (first contact). In 23 cases, the GP knew the patient for up to 2 years and in 25 cases for 2–10 years. In nine cases, the GP knew the patient for more than 10 years when the error happened (in four cases, we have no data on this item).
Contribution to the error—and to its discovery
The participating doctors were asked to estimate (in percentage) the degree to which other people had contributed to the error at hand. It was explicitly asked for the GPs themselves, other doctors, health care assistants (In Germany, administrational and medical GP assistance is usually provided by ‘Arzthelferinnen’. In this article, the term ‘health care assistant’ is used as a translation for ‘Arzthelferin’.), the patients themselves, relatives to the patients and ‘others’. In a second item, the same question was asked about the discovery of the error. In Table 2, any contribution, no matter how small or how important, is depicted.
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Evidently, in all 75 cases, the GPs involved stated that they had contributed to the development of their ‘most serious errors’. In 68 cases, they rated their own contribution to the error as 50% or more. Nevertheless in 42 cases, other people, mainly other doctors, the patients themselves or their relatives, were reported to have contributed to the GPs’ ‘most serious errors’. Mostly, these contributions were estimated to be less than 50% of the individual error.
Concerning the discovery of the errors reported, we found that the GPs themselves and other doctors involved in the treatment contributed the major part (Table 2). In 41 cases, the GPs themselves contributed to the discovery of the error, and in 35 of these cases their contribution was 50% or more. Other doctors were reported to have contributed to the discovery of 38 errors, and in 34 of these cases their contribution was 50% or more. Patients and their relatives also contributed to the discovery of several cases, but often with percentages less than 50%. Health care assistants and ‘others’ were rarely reported to have been involved in the development or discovery of the errors.
After the discovery
In more than half of the cases analysed (39 cases), a doctor who was involved in the treatment of the patient disclosed the error to the patient (Table 2). Among these cases, two-third of the disclosures were done by the GPs themselves (27 cases). In seven cases, the patients themselves discovered the error. In five cases, the error was disclosed to the patient by a ‘non-doctor’, mostly a relative. And in eight cases, the surviving patient never learned about the error. In one-fifth of all cases reported (15 of 75 cases), the patient died prior to disclosure of the error.
About half of the ‘serious errors’ reported did not have any ‘adverse consequences’ for the GPs involved (36 cases). In the other cases, ‘loss of reputation or loss of patients’ was commonly felt (28 cases) and lawsuit (four cases) and ‘other’ negative consequences (five cases) for the GP involved were rare. In two cases, nothing was marked on this item.
Interestingly, the number of surviving patients who stayed with their GP after the error clearly exceeded the number of patients who left their GP (27 versus 18 cases). By the time of completing the questionnaire, 23 of the patients involved had died, two were still in hospital, two had only been emergency patients and in three cases we have no data about staying or leaving their GP after the error. Table 3 therefore comprises only 45 cases.
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The patient’s decision
Table 3 shows how many patients stayed with their GPs or left them after the error according to the circumstances concerning the development, the discovery and the disclosure of the error. If the GP was the only one responsible for the error, the number of patients leaving their GP was as high as the number of patients staying. But if someone else had also contributed to the error, the number of patients staying with their GP clearly exceeded the number of patients leaving. Especially, if the patients themselves had also contributed to the error, they tended very much to stay with their GP afterwards. If ‘other doctors’ had also contributed to the GP’s error, they also tended to stay with their GP. If it were ‘non-doctors’ who had contributed to the error, there was no clear tendency.
Also the fact who was involved in the discovery of the error made a big difference on the number of patients staying with or leaving their GP after the error.
If the GPs themselves had contributed to the discovery of the error, the number of patients staying was much bigger than the number leaving; if the GP had not contributed to the discovery, more patients left than stayed. If other doctors had not been involved in the discovery of the error, the stay/leave ratio was slightly better for the GPs than when they had been involved. If the patients themselves had helped discover the error, they had a greater tendency to leave their GP afterwards.
If the GPs themselves told the patients about the error, more patients decided to stay with their GPs than to leave. If other doctors disclosed the GP’s error to the patient, the tendency was opposite: more patients left. Also, when the patients had discovered the error themselves, they tended to leave their GPs. In the cases where the error was not disclosed at all to the patient or when it was disclosed by relatives, health care assistants or ‘others’, all patients stayed with their GPs.
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Discussion |
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Summary of main findings
The number of patients staying with their GP after a serious error clearly exceeded the number leaving their GP, especially if the GP was not the only one involved in the development of the error and if the GP played an active role in the discovery and disclosure of the error.
Strengths and the limitations of this study
Compared with the data gained so far by freely accessible Internet-based ‘critical incident reporting systems’, like the German system ‘http://www.jeder-fehler-zaehlt.de/’ or the British ‘National Reporting and Learning System’, our study covers a much higher rate (and absolute number) of serious patient injury.11 If patients are ready to trust their GP again, even after a potentially life-threatening ‘most serious error’, it seems plausible that this is also true for less threatening incidents. On the other hand, the errors reported in our study were recalled actively from the past, sometimes dating back several years. So we cannot really exclude major recall biases. In an anonymous and completely optional study, we cannot exclude any sort of ‘reporting bias’ either. But this is true for all reporting systems so far. As the data were collected from GPs, our assumptions about patients’ decisions remain indirect.
Comparison with existing literature
A recent questionnaire study from Norway conducted by Aasland and Forde16 investigated the impact of feeling responsible for adverse events that had caused patient injury on the doctors’ lives. They found that having caused serious patient injury had a negative impact on their professional and private lives. But if the acceptance for mutual criticism and constructive feedback at the workplace was high, this impact was less severe in many cases. In our study, the consequences for the GPs—mainly in terms of loss of patients—were lower if they showed that they were open to criticism, i.e. if they played an active role in the discovery and disclosure of the error.
Implications for clinical practice
It is important for the medical profession to take measures on an individual and organizational level to avoid medical errors.21,22 And it is also important for each doctor to react adequately once an error has happened: this includes analysis of the development by discussing the error23–25 and it includes an appropriate reaction concerning the patient to whom the error has happened.26 It also includes help and emotional support for the doctor who made the mistake.17,27 Our data suggest that patients’ trust can be regained if a doctor involved even in a serious error plays an active role in the discovery and disclosure of the error.
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Declaration |
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Conflicts of interest: None.
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Notes |
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Fisseni G, Pentzek M and Abholz H-H. Responding to serious medical error in general practice—consequences for the GPs involved: analysis of 75 cases from Germany. Family Practice 2008; 25: 9–13.
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References |
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