Healthcare Delivery, Quality, and SafetyThe Challenges of Providing Feedback to Referring Physicians After Discovering Their Medical Errors
Introduction
Preventable medical errors represent a major public health problem.1 To prevent future errors, improve disclosure, and mitigate malpractice risks, organizations have adopted strategies for early transparent communication and emphasized quality improvement through peer review. These principles are incorporated into the Agency for Healthcare Quality Research Communication and Optimal Resolution (CANDOR) process, which facilitates 1) transparent communication, 2) learning to prevent errors, and 3) achieving optimal financial or other resolution with patients and families.2, 3
Incident reporting systems, root cause analyses, and Morbidity and Mortality (M and M) conferences are mechanisms by which institutions can investigate errors and identify areas for system, process, or provider improvement.4 M and M conferences are considered critical to provider education and have been mandated by the Accreditation Council for Graduate Medical Education since 1983.5 In an increasingly fragmented health care system, providers may discover other physician's errors that are previously unknown to the patient and responsible provider. Application of the CANDOR principle “learning to prevent errors” may be particularly complex when the discovering and responsible physicians' practice in different facilities. What physicians should do in this scenario is unclear. There are no guidelines or clear professional norms to guide physician practice or mechanisms by which discovering physicians can ensure responsible physicians or institutions learn from these errors. Further, some believe discussing other physicians' errors is unfairly judgmental and unprofessional.6, 7 Concerns for medicolegal implications and referral relationships, as well as fairness to physicians who work in different environments may also complicate the discovering providers' willingness to communicate with responsible providers and institutions.
This work focuses on specialist communication with referring physicians to provide constructive feedback regarding prereferral errors. To understand whether and how specialist physicians provide feedback and their rationales for doing so, we conducted interviews of cancer specialists from National Cancer Institute–designated centers. Our specific research questions in this study were (1) What are specialists’ attitudes and practice patterns regarding feedback to referring physicians about prereferral errors?; and (2) What barriers do specialists face in providing negative feedback? We selected a qualitative interview approach to broadly explore these research questions for which few data exist to date.
Section snippets
Methods
We conducted semistructured interviews with cancer specialists from two National Cancer Institute–designated cancer centers between July 2015 and August 2016. The interviews sought to obtain an understanding of specialists’ experience with prereferral error discovery and included their attitudes and practice patterns regarding providing feedback to referring physicians about these errors, as well as barriers they encountered in providing each (see Interview Guide in Supplementary Material).
Results
Thirty specialists participated. The median years of postgraduate training were 8 (range 4-10) and the median years of independent practice were 9 (range 2-35). Sixty percent (n = 18) of subjects were male. Participants’ specialties included general surgical oncology (n = 8), breast surgery (n = 3), head and neck oncology (n = 2), urologic oncology (n = 3), thoracic oncology (n = 2), orthopedic oncology (n = 1), colorectal surgery (n = 1), medical oncology (n = 6), and radiation oncology (n
Discussion
This study had two principal findings regarding specialists’ feedback practices to referring providers after discovering a prereferral error. First, specialists had varying practices of feedback despite a majority stating that regular, explicit feedback was ideal. Second, specialists described multiple barriers and fears that prevented feedback—some common to providing negative feedback in any scenario, and some specific to medicolegal implications and referral relationships. These barriers
Acknowledgment
Contributions of authors are as follows: (1) study conception or design was performed by Dossett, Lee, Quinn, (2) data acquisition was performed by Dossett, Kauffmann, (3) data analysis was performed by Dossett, Miller, Lee, (4) data interpretation was performed by Dossett, Jagsi, Morris, Dimick, (5) drafting or critical revisions of manuscript was performed by all authors, (6) final approval was done by all authors.
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