臺灣醫療專業人士對醫療失誤告知之態度

The attitudes of Taiwanese medical professionals toward medical errors disclosure

顏如娟(Yen, Ju-Chuan)

指導教授 ： 蔡淳娟

臺北醫學大學/醫學院/醫學人文研究所/碩士(2008年)

摘要

摘要
自從1999年美國醫療機構(Institute of Medicine) 出版《凡人皆可能犯錯》 (" To Err Is Human")一書以來，有關病人安全之議題的研究與討論，一直是世界各國健康照護重要的方向。因醫療失誤引起的後果可謂不小，包括了個人與社會階層方面損失，而遭逢醫療失誤的醫療機構、醫療人員、以及病人與家屬，他們對於醫療失誤的告知之態度是什麼，就倫理、法律與專業準則，應予以告知該醫療失誤，而實際情形如何？原因又為何？本研究針對不同醫療專業背景的人士，採用放聲研究法(Think-aloud Method)輔以半結構式訪談(Semi-structured Interview)方式進行質性訪談與問卷調查，而本研究受訪者分為四組，這四組分別涵蓋下列不同領域的人員: 包括醫師、護士、非醫療社會人士、醫療機構管理階層等四組人員，每組各四至五名，本研究採用一個假想的案例，內容是一個新生兒加護病房中的醫療失誤案例，針對醫師、護士、非醫療社會人士、與醫療機構管理階層等四組不同專業領域的人進行訪談，了解其是否告知實情之決策以及其背後之原因，而後指定受訪者對站在其他三種不同角色的立場，表達其態度與決策立場是否改變。這四種角色為:依序為護士(代表當事醫療人員)、醫師(醫療第三者同儕)、公正的第三者社會人士、醫療院所管理者。訪談結束後，在加上價值觀問卷了解其作此決策的主要原因。本研究另加上對台灣現今病人安全保護系統之研究:包括台灣新制醫院評鑑之標準，並以台北市立萬芳醫院(醫學中心)的病人安全保護系統為例，報告其執行的實際情況。結果顯示：四個不同的受訪群組對於是否告知的決策結果有統計上差異，其中醫師群組與社會人士群組呈現兩個極端結果，醫師組全都不願意告知醫療失誤實情，社會人士全都主張要完全告知醫療失誤實情，而在護士組與管理階層分別有(2/5)40%與25%(1/4)願意告知醫療失誤。不告知醫療失誤的醫師與護士群組中的受訪者，主要是基於其過去有醫療失誤的威脅或有不良的醫病經驗；社會人士組的五人全部(100%)認為要告知此醫療失誤，而且都認為犯錯的護士不可原諒，又認為犯錯的護士應該負起全責。管理階層組四人中有一人(25%)雖認為犯錯的護士不會獲得現今台灣社會大眾的原諒，而幾經掙扎，基於病人安全的考量，及不願見到病人與家屬受到不公平的對待，仍然選擇願意告知醫療失誤，顯見其個人具有較高之道德良心。而由訪談的內容輔以價值觀問卷發現：個人之前的醫療失誤經驗與價值觀，會影響到對於醫療失誤是否告知的決策，醫療人員若曾有醫療失誤的威脅與不良的醫病經驗，較傾向不告知醫療失誤，不願貿然告知醫療失誤以尋求較安全的個人生涯保障，避免訴訟及無法預知的損失。; 護士組裡有一位資深護理人員雖然不曾有醫療失誤的經驗，也沒有不好的醫病經驗，並且認為該名犯錯的護士不應負起全責，卻又認為她可以獲得社會大眾的原諒，但是 她卻毫無道理的決定不告知實情。也許是看多了，習以為常、不知道這是錯誤行為，沒有批判性思考，需要再教育。價值觀問卷以因素分析萃取出四個成分，分別代表:「倫理服從性」、「以病人為中心」、「追求卓越醫療」、及「防衛心」的理念。在決定告知決策時：醫師與管理階層都是以「防衛心」為主要的考量因素，護士則同時看重「防衛心」與「以病人為中心」信念，社會人士則以「倫理服從性」信念為其告知決策的最主要依歸。比較是否告知兩組受試者間的信念差異時發現,不願意告知的受訪者都不選擇「倫理服從性」信念，而願意告知的有三名選擇「倫理服從性」信念。在施行層面上，社會人士一致性要求資訊透明、完全告知該醫療失誤，提出說明，致歉，與提出預防再度發生的策略。管理階層的受訪者與其他群組不同的是：他們注意的層面必須涵蓋到犯錯的醫療人員與病人家屬雙方的情緒掌控及權益分配，以及未來預防類似的醫療失誤的策略。我們更發現受訪者很難真正站在另一方的角度來思考問題。
當發生醫療失誤時，毫無疑問的應該要告知實情，但是本研究中台灣醫療人員的處理態度上仍存在很大的差距，並不願告知實情，本研究釐清各不同背景人士所以不告知的理由，加上對當下台灣醫療體系中病人安全機制之反省，可做為改善倫理教育與溝通表達訓練的重要參考。

關鍵詞：醫療失誤、態度、告知、醫療訴訟、 放聲研究法、醫療倫理

關鍵字

醫療失誤 ； 態度 ； 告知 ； 醫療訴訟 ； 放聲研究法 ； 醫療倫理

並列摘要

Abstract
Background: Since the promulgation of “To Err Is Human”, patient safety movement has become a hot topic internationally. Miserable consequences of several medical adverse caused by medical errors events were disclosed to the public. Since then, people have demanded transparency of information about medical errors, and even for an apology and further steps to ameliorate medical injury. However, it was believed that most medical professionals hesitated to disclosure full information of errors due to possible legal suits and credential punishments. In addition, medical personnel do not master in the ways of disclosing errors due to lack of experiences and hard to handle emotional status, either. Even the ethos is expecting medical professionals to disclose medical errors. However, the reality of medical error disclosure in Taiwan remained undetermined. This study aimed to understand the attitudes of various medical professionals and lay people toward disclosure of medical errors in Taiwan.
Research design: This study used a hypothesizing case with a medical error to trigger a think-aloud and a semi-structured interview. The subjects were divided into four groups, each composed of 4-5 people of various professional (including nurses, physicians, lay people, and administrative officers of medical institutes). At the end of the interview, the subjects were asked to complete a questionnaire on value regarding patient care. This study also reviewed the patient safety standards in accreditation guideline by Taiwan Joint Commission on Hospital Accreditation and the implementation in WanFang Hospital.
Analysis: The audio-taped interviews were transcribed to verbatim data for analysis. Immersion and crystallizations method was used for qualitative analysis. As for the data derived from questionnaire, factor analysis was used to delineate the psychological construct structure underlying the decision of disclosure.
Results: The decisions to medical error disclosure are significantly different among the four groups. Physicians and laypersons were two “extreme” groups that demonstrated opposite attitudes. Physicians would not disclose medical error, while lay people demand this medical error disclosed fully to the patient and family and believed the “offender” should take full responsibilities. The willingness rate of disclosure was 60 % (3/5) by nurse’s groups and 25% (1/4) in administrative officers’ group. The experience of prior or pending medical malpractice was closely related to the willingness to medical error disclosure. Using factor analysis, the eight value items in the questionnaire extracted four factors that explained the willingness to disclosure: “defense”, “patient-centered care”, “compliance to rules”, and “pursuing excellent medical care”. To explain why the subjects make an disclosure decision, the most important factor is “defense” in physician and administrative officer group, “defense” and “patient-centered” in nurse group, and the “compliance to rules” for laypeople. The choice of “compliance to rules” can best discriminate between the groups of disclosure and non-disclosure of medical errors. As for the implementation, the medical professionals including physicians and nurses would carefully avoid medical legal suits and amends; lay people demanded full disclosure of medical error and requested effective strategies to prevent further recurrences of errors; administrative officers concerned about the ways to disclose error and the strategies of preventing recurrences, plus the care for the patients and the medical personnel. In reviewing the patient safety standards in accreditation guideline and the status in Wan-Fang Hospital, it was found the supportive environment to encourage disclosure of medical errors has not been established.
Conclusion: Without a doubt, medical ethics and legal regulations demand medical professional to fully disclose medical errors. This study unveiled the “unacceptable” attitude in Taiwanese health providers toward error disclosure. The reasons and related factors underlying the disclosure decision varied with people’s background. To enhance the willingness to disclosure, the research findings would provide valuable information enhance the ethical and communication education, and finally to improve patient safety in medical practice.

並列關鍵字

Medical Errors ； attitudes ； disclosure ； medico-legal suits ； think aloud ； medical ethics

參考文獻

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