Date of Award

8-10-2009

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

First Advisor

Elizabeth Claus, M.D., Ph.D.

Second Advisor

Paul Cleary, Ph.D.

Abstract

MEDICAL STUDENTS EXPOSURE AND RESPONSE TO ERROR ON THE WARDS Kimberly B. Gold, Paul D. Cleary, Department of Public Health, Yale University School of Medicine, New Haven, CT. Medical errors are common and cause extraordinary costs. Errors should be openly discussed and learned from. Medical schools have been slow to adopt curricula on medical errors, or training in how to respond to errors. Since error disclosure remains incomplete, students may be lacking both formal and informal education in error management. Our aims were to describe students knowledge about medical errors and error reporting, their attitudes toward medical errors and error reporting, their exposure to various types of errors, and their disclosure patterns. A survey instrument was developed using previously validated questions and new questions developed using the results of a focus group. The survey was refined by leading survey experts and a pilot test with students. The study sample consisted of students who had completed their third year of medical school at a single institution. A total of 99 useable surveys were received for a response rate of 48%. Many students (91.9%) witnessed at least one error during their clerkships resulting in harm to the patient. The most common types of errors witnessed by students included errors from failed medication reconciliation (73.5%), incorrect diagnoses (67.7%), missed diagnoses (66.7%), and poor or incomplete handoff (65.65%). The services where the most students reported witnessing errors resulting in harm were Medicine, OB-GYN, and Surgery. There were significant gaps in students knowledge about errors and error reporting; For example, 17.2% of students did not feel confident that they know what constitutes a medical error and 69.7% did not feel confident that they know how to report an error. The majority of students (83.84%) said that they had not received training on how to respond to errors they observe. Training was significantly associated with students knowing how to report an error (p=.006) and knowing which errors to report (p=.02). None of the 16 students who reported having formal training said that they did not report an actual error because they were unsure about whether or not something was an error. More than a quarter of students (27.94%) who witnessed an error that remained undisclosed or unacknowledged did not tell anyone about the error. Their reasons for not telling anyone include: unsure of whether or not it was an error (64.3%), fear that their team would be upset with them (42.9%), unsure of who to tell (42.9%), they did not think the information would help the patient (39.3%), and fear of a bad evaluation or grade (28.6%). Over a quarter (27.6%) of the students thought that it would be likely or very likely that their grade and evaluation would have been negatively affected and 61% felt like it would be likely or very likely that their residents and/or attending would have been upset with them if they reported an undisclosed error to the patient/patient's family on their last rotation. The involvement of the attending physician after a minor (p=.003) or major (p<.001) error significantly predicted positive actions, such as open explanations to the patient and open educational discussion among the team. Medical students frequently witness errors, but perceive a culture in which transparency is not the goal. Because training significantly increased students comfort with errors, there should be more training and education in errors for physician trainees at all levels. Since active responses to errors by attending physicians lead to positive actions after errors occurred, we should continue to train and recruit faculty who will act as positive role models for medical students with respect to safety and disclosure.

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