Trust and disclosure of medical errors

Last week I attended a discussion about the disclosing medical errors to patients. The discussion was structured around an example case in which a patient was given the wrong medication but fortunately experienced no complications as a result. As with most hospital errors, this represented a failure at several steps of a complex process, with mistakes by multiple people/departments. When the nurse realized the error, the nurse asked a member of the medical team to write a prescription for the medication the patient actually received (i.e., a prescription for the error).

In high-reliability organizations such as healthcare, aviation, and law enforcement, trust is vital. Errors could cause deaths, so workers must carefully coordinate complex actions (e.g., airline travel). High-reliability organizations prevent catastrophic errors by fostering strong relationships, honesty, and trust. For this trust to develop, there must be psychological safety. When teams share a sense of psychological safety, they feel safe admitting errors, challenging others’ views, and engaging in other types of “interpersonal risk taking” (Edmondson, 1999). Psychological safety plays a role in whether providers disclose errors within the organization—to fellow team members, to other teams, and to administrative personnel.

But what about the patient? Some research suggests that patients should be viewed as a full member of the healthcare team. For quality improvement purposes (e.g., Stoebel et al., 2005), patients can contribute unique insights on how to improve the team/system. By approaching problems from multiple perspectives, teams can find new and creative solutions.

If the patient is a full member of the team, this could also change how providers disclose errors and adverse events. Trust is a central part of adaptive team functioning. To promote trust and psychological safety, team members may compensate for one another’s weaknesses or errors. This creates a safe environment for learning and improvement within the team. At the same time, outsiders view these high-trust teams as cohesive, productive, and high-performing (a “well-oiled machine”). It seems like the disclosure process would unfold differently, depending on whether the patient is viewed as part of the team or as an outsider.

Going back to the example with the medication error, the medical team member was given a choice between: 1) violating the nurse’s trust by exposing the nurse’s error, or  2) violating the patient’s trust by writing an order for the medication the patient mistakenly received. How do people balance these trust relationships? If the patient is viewed as an outsider, providers might be less likely to disclose errors, instead choosing to maintain psychological safety within the team. I’ve heard a lot of stories about providers feeling pressured to cover up a colleague’s mistake. Even if the error does not harm the patient, disclosure is still important. Errors usually highlight problems with the system, which can only be fixed when errors are discussed openly.

In a high-reliability organization, people/teams are highly interdependent. With these interdependencies, it may be more common to have “trust dilemmas” where people must sacrifice one relationship to save another. Police officers are often unwilling to snitch on each other, even when faced with unethical or illegal activity. But for those outside an organization, we need whistleblowers to ensure our safety. Similarly, patients need to be able to trust that providers will disclose their errors, especially as healthcare becomes more complex.

Fortunately, it seems that providers have become more willing to admit to errors during the last decade. Although errors are still underreported, there has been a culture shift in favor of disclosing errors. It seems like this may be part of a larger movement toward more patient-centered care. By integrating patients more into healthcare teams, physicians can develop better relationships with their patients and provide better care. In several ways, relationships and interdependencies can be leveraged to promote disclosure of adverse events.