More than three-quarters of physicians agree that doctors should be required to disclose medical errors to patients or their families. In practice, retrospective self-report surveys suggest fewer than a quarter actually do.
That gap is not primarily a story about cowardice. It is a story about what happens to a clinician's mind when the Swiss cheese model stops being a diagram and becomes a person lying in a hospital bed with the wrong foot removed.
The Institute of Medicine defines a medical error as the failure to complete a planned action as intended, or the use of an improper plan to achieve an aim. Medical errors contribute to preventable harm in roughly 400,000 hospitalized patients each year. The errors that produce permanent injury — disfigurement, loss of function, death — tend to fall into four categories: surgical or procedural errors, errors in postsurgical care, errors in diagnosis and treatment, and errors in systems and communication. These categories overlap more than they separate.
The errors that produce permanent injury — disfigurement, loss of function, death — tend to fall into four categories.
Consider the case of Ms. B, a 68-year-old woman with coronary artery disease, diabetes, hypertension, and peripheral vascular disease. She developed severe bilateral ischemic injuries to her lower extremities. Both limbs had comparable wounds. Her right foot was scheduled for amputation due to chronic nonhealing wounds and gangrene. Her left foot was removed instead.
Or consider D, a 40-year-old patient with type 1 diabetes and chronic kidney disease who presented to the emergency department in urgent need of dialysis. D was never asked about gender identity, sex assigned at birth, preferred pronouns, sexual orientation, or relationship status during the history and physical. During dialysis, D revealed they had been living as a man for two decades, but their sex assigned at birth was female. Had the female eGFR cutoff been used, D would have qualified for the transplant list a year earlier. D was registered as a man. The male cutoff was applied.
These are not stories about one careless individual. Wrong-site surgery, considered a "never event," occurs in 0.09 to 4.5 cases per 10,000 surgeries. In primary care, approximately 5% of patient visits result in at least one missed or delayed diagnosis. The systems-and-communication category of error often occurs in tandem with others — unclear postoperative instructions between a surgeon and a primary care physician, for example, about wound management. The harm emerges when multiple failures align.
What patients want in the aftermath is not complicated. Hospitalized patients have indicated they want and expect an apology and an explanation if an error occurs. Apologies reduce blame and anger, improve trust and relationships, and have the potential to reduce the likelihood of lawsuits and facilitate settlements. Multiple professional organizations, including the American Academy of Family Physicians and the National Quality Forum, have published guidelines outlining key elements for disclosure and apology.
Yet disclosure conversations remain difficult, and offering an authentic apology is challenging. A 2025 simulation study videotaped 49 physician-nurse teams from the U.S. and Canada as they planned and delivered error disclosures to patient-actresses. Thirty teams disclosed an insulin overdose. Nineteen surgical teams disclosed a lost specimen.
The average disclosure conversation lasted 9.8 minutes, ranging from 6.1 to 14.2 minutes. Teams offered an average of two to three apologies per disclosure, with a range of zero to nine. Apologies occurred at all points — opening, middle, closing — and were offered by both physicians and nurses. The study's authors noted a crucial distinction: clinicians sometimes linked apologies to their own emotional experience, but more frequently linked them to the patient's emotional response.
That distinction matters. An apology tied to the patient's suffering — not the clinician's discomfort — may be more effective at ensuring the patient actually hears that the remorse is about them.
The simulation study also found that clinicians tended to follow a consistent roadmap, addressing nine topics in a relatively order. With opening comments, they apologized to foreshadow bad news. With closing comments, they linked remorse to broader professional and organizational goals around patient safety and transparency. This is not improvisation. It is a learned sequence, and it can be taught.
What often goes unaddressed is what happens to the clinician after the conversation ends.
Following involvement in a harmful error, health care workers at all levels of training commonly experience guilt, self-doubt, embarrassment, disappointment, self-blame, a sense of inadequacy, and fear. Surveys have found that involvement in a harmful error can lead to difficulty sleeping, reduced job satisfaction, and anxiety about future errors. These emotions may persist for months or years.
A prospective study of residents found evidence of a vicious cycle: errors lead to burnout and depression, which in turn provoke increased involvement in errors. This compromises both patient safety and the mental health of the clinicians involved. In one survey, 79% of fourth-year medical students and 98% of senior residents reported having been personally involved in a medical error.
The emotional recovery trajectory is fairly consistent. After an initial period of confusion and inner turmoil, clinicians experience intrusive thoughts, replaying and reevaluating the event. Many then talk about the event with a trusted confidant, seeking reaffirmation of their integrity and competence. Talking about the mistake is central to recovery.
But the culture of medicine has traditionally fostered ideals of infallibility and perfectionism. In blame-oriented environments, trainees may adopt counterproductive coping mechanisms — denial, distancing, discounting the impact of the error. These approaches dampen distress but also threaten the capacity to learn from the event.
The barriers to seeking support are concrete. Physicians are reluctant to meet with counselors due to difficulty taking time, the belief that available support will not help, and fear that the discussion will not be kept appropriately confidential. Recent surveys of attending physicians throughout the United States and Canada indicate widespread deficiencies in the support they received from hospitals after errors. Many health care workers suffer and cope alone.
Coping strategies that do appear to help include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. The last of these is not incidental. When a clinician can convert the experience of error into a change in process, the error becomes something other than pure personal failure. It becomes data.
The AMA Journal of Ethics has outlined three steps for responding to a resident's diagnostic error that caused permanent harm: the resident should disclose the error to their supervisor, the supervisor should facilitate an appropriate apology to the patient, and the supervisor and hospital should provide emotional support and training to minimize cognitive biases.
Note the sequence. Disclosure to the supervisor comes first. Not to protect the institution — to protect the trainee's ability to process what happened before facing the patient.
The tension between the systemic view of error and the individual experience of blame is not resolved by choosing one frame. The Swiss cheese model is accurate. Errors are not typically the fault of one individual. But the clinician who made the error does not experience it as a system failure. They experience it as their hands, their decision, their moment of inattention.
David Hilfiker, a family physician who wrote candidly about his own errors, described the paradox this way: the drastic consequences of mistakes, the repeated opportunities to make them, the uncertainty about culpability when results are poor, and the medical and societal denial that mistakes must happen — all result in an intolerable situation for the physician.
The intolerable part is not the guilt itself. It is the isolation. The gap between what physicians say should happen and what they do is sustained by that isolation. More than three-quarters agree disclosure is required. Fewer than a quarter disclose. The difference is not principle. It is the absence of a room where a clinician can say what happened, hear that they are not only their worst moment, and then walk into the patient's room and say the same thing to the person who was harmed.