Lane Andrew Stuart, Roberts Chris
The University of Sydney Sydney Medical School, Sydney, New South Wales, Australia
Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia.
BMJ Open. 2020 May 30;10(5):e035647. doi: 10.1136/bmjopen-2019-035647.
Errors are common within healthcare, especially those involving the prescribing of medications. Open disclosure is a policy stating doctors should apologise for such errors, discussing them with the harmed parties. Many junior doctors take part in open disclosure without any formal training or experience, which can lead to failure of the apology, and increased patient/family frustration. In this study, we explore the ways in which interns perceive the relationship between medication error and their experience of open disclosure.
Using known theoretical frameworks of apology and moral rationalisation, a qualitative study of medical interns who had been involved in open disclosure was conducted. Twelve medical interns volunteered, and were selected using purposive sampling. Face-to-face semi-structured interviews illuminated their clinical experiences of open disclosure after medication error. The data was coded and analysed using Interpretative Phenomenological Analysis. Our data supported three super-ordinate themes: (1) Rationalisation of medical error, (2) Culture of medical error and (3) Apology in practice.
The interns in this study rationalised their observations, their subsequent actions and their language. Rather than reframing their thinking, they became part of a healthcare environment that culturally accepted, promoted and perpetuated error. Rationalisation can lead to loss of context in apologising, which can be perceived as unempathic by the patients/families. However, when reflection and unpacking of their errors, they acknowledged that their reasoning was problematic, recognised the reasons why and were able to reframe their approach to apology for a future occasion.
Our data suggests the utility of a learning framework around open disclosure following medication error, for having a supervisor conversation about aspects of the interns' rationalisation of their clinical practice, in their contextualised clinical environment. Further research could clarify whether interns are 'unconsciously incompetent' or 'consciously incompetent', when addressing medication error and preparing to apologise.
医疗保健领域中的错误很常见，尤其是那些涉及药物处方的错误。公开披露是一项政策，规定医生应为此类错误道歉，并与受影响方进行讨论。许多初级医生在没有任何正式培训或经验的情况下参与公开披露，这可能导致道歉失败，并增加患者/家属的沮丧感。在本研究中，我们探讨了实习医生如何看待用药错误与他们的公开披露经历之间的关系。
运用道歉和道德合理化的已知理论框架，对参与过公开披露的医学实习生进行了定性研究。12名医学实习生自愿参与，并采用目的抽样法进行挑选。面对面的半结构化访谈揭示了他们在用药错误后进行公开披露的临床经历。使用解释现象学分析对数据进行编码和分析。我们的数据支持了三个上位主题：（1）医疗错误的合理化，（2）医疗错误文化，（3）实践中的道歉。
本研究中的实习生对他们的观察、后续行动和语言进行了合理化。他们没有重新构建自己的思维，而是成为了一个在文化上接受、促进并使错误长期存在的医疗环境的一部分。合理化可能导致道歉时脱离具体情境，这可能被患者/家属视为缺乏同理心。然而，当他们反思并剖析自己的错误时，他们承认自己的推理存在问题，认识到原因，并能够为未来的情况重新构建道歉方式。
我们的数据表明，围绕用药错误后的公开披露建立一个学习框架是有用的，以便在情境化的临床环境中就实习生对其临床实践的合理化方面与上级进行交流。进一步的研究可以阐明实习生在处理用药错误并准备道歉时是“无意识地无能力”还是“有意识地无能力”。
