Phenomenological study of medical interns reflecting on their experiences, of open disclosure communication after medication error: linking rationalisation to the conscious competency matrix

Abstract

INTRODUCTION AND OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.