When patient safety incidents occur, managing them is an important issue. In particular, policies and interventions that are adopted in order to respond to patient safety incidents are intended to manage such incidents and minimize any additional harm [1]. Tort law, no-fault liability for compensation, the alternative dispute resolution system, and disclosure of patient safety incidents (DPSI) are examples of legislations and institutions involved in the handling of patient safety incidents. Among them, DPSI is more advanced than tort law or the alternative dispute resolution system because it can prevent potential medical disputes in advance [2]. DPSI is defined as follows [3]: “When a patient safety incident occurs, medical professionals preemptively explain the incident to the patients and their caregivers, express sympathy and regret for the incident, deliver an apology and compensation appropriately if needed, and promise to prevent recurrence.”

Many countries and organizations have either implemented DPSI as their standards of accreditations [4, 5] or have developed guidelines to facilitate it [6, 7]. Such willingness to adopt DPSI stems not only from its ethical background [8–10], but also from its widely known benefits in reducing medical law suits and court costs [11]. However, studies on DPSI are confined to some Western countries, and evidence collected from non-Western countries, including South Korea (hereinafter Korea), is scarce [12, 13]. In order to introduce DPSI in a specific country, empirical evidence of the effectiveness of the DPSI is essential [14, 15]. In Korea, studies have been performed to analyze perceptions of DPSI using both qualitative [3] and quantitative [16, 17] methods. However, efforts to assess the effectiveness of DPSI are unprecedented in Korea, because DPSI has not been implemented in the real healthcare setting.

In this study, we evaluated the effectiveness of DPSI using hypothetical cases in a survey with a sample of the general public representing the Korean population. Since the disclosure policy has not been adopted in Korea, hypothetical cases can be alternatively used to measure the effectiveness of DPSI [18–20]. The results of this study are expected to serve as supporting evidence for the introduction of DPSI in Korea.

In this study, we evaluated the effectiveness of DPSI using hypothetical cases in a survey of the Korean general public. The results indicated favorable findings in support of DPSI. The odds of judging the hypothetical cases as medical errors were 0.63 times lower when DPSI was performed than when it was not. The odds of willingness to revisit and recommend a physician were 2.66 and 2.47 times higher, respectively, when patient safety incidents were disclosed than when they were not disclosed. Furthermore, the odds of an intention to file a medical lawsuit were 0.41 times lower and those of an intention to commence criminal proceedings were 0.44 times lower when incidents were disclosed than when they were not disclosed. Trust scores were 1.24 points higher when patient safety incidents were disclosed than when they were not disclosed. Furthermore, the excepted amount of compensation was smaller when patient safety incidents were disclosed than when they were not disclosed.

One of the strengths of this study is the fact that we identified the positive effects of DPSI from a relatively large sample (n = 700). Furthermore, the sample represented the general Korean population considering the comparison results of distribution of age group and gender between the survey participants and national registration population data from the Ministry of Government Administration and Home Affairs. The public preferences regarding DPSI have been well-described in previous studies conducted not only in Korea [3], but also in other countries [11]. This survey quantitatively measured and clarified the positive effects of DPSI, which validated the results of previous studies [18–20]. Several studies described various barriers and obstacle to DPSI, including fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture [11, 22]. The findings of this study might be helpful in reducing the concerns of medical professionals about negative effects of DPSI, for example, an increase in legal disputes, a damaged professional reputation among patients, and weakened trust in physicians.

DPSI is not the sole deciding factor involved in judging a situation as a medical error, the willingness to revisit and recommend a physician, the intention to file a lawsuit and commence criminal proceedings, an increase in trust, and determination of the expected amount of compensation. Some variables also showed statistically significant and meaningful relationships in the logistic and linear regressions in this study. For example, trust scores were influenced by the degree of harm and the clarity of medical errors. In addition, the amounts of compensation people were willing to accept showed a greater dependence on the degree of harm and the clarity of medical errors than DPSI. Moreover, our survey revealed that there is no statistically significant correlation between DPSI and judgment on the necessity of an apology. The effectiveness of DPSI might be misrepresented or underrepresented by such findings from the medical professionals’ point of view [3]. When medical professionals are unaccustomed to disclosing patient safety incidents, they tend to resort to past experiences and realize how other factors, such as characteristics of the patient safety incidents, can influence the credibility of physicians and intentions to take legal action. Under such circumstances, medical professionals are less likely to deem DPSI worthwhile. However, it should be noted that DPSI itself proved to be effective even when other factors, such as characteristics of the patient safety incidents or socio-demographics were adjusted. Thus, we can use these findings to promote DPSI for medical professionals who have doubts about its benefits.

Another remarkable result was that participants who had religion tended to set high ethical standards for hypothetical cases. Religious participants gave lower trust scores and expected a higher amount of compensation than those who had not religion. In addition, the odds of the intention to file a medical lawsuit and commence criminal proceedings were higher when participants were religious than when they were not. Although DPSI is an important ethical issue [23], empirical evidence on relationships between DPSI and religion is scarce. Based on our results, we showed that DPSI could be viewed as a more important and inevitable ethical issue for people with religious beliefs.

Although we identified the effects of DPSI on various factors, a comprehensive and system-wide approach will be required to encourage medical professionals to conduct DPSI in real healthcare settings [9]. The creation of a patient safety culture, the introduction of guidelines for DPSI, and education or training for DPSI can facilitate medical professionals to perform DPSI [11]. Furthermore, apology law, which prohibits the use of physicians’ apologies as evidence of their negligence in medical lawsuits, could reduce a medical professional’s reluctance to conduct DPSI [24]. In addition, more empirical evidence of DPSI in real healthcare settings is needed to implement a policy for DPSI in hospitals [11].

This study has some limitations. First, we could only confirm the hypothetical effects of DPSI; we do not know whether the participants will show consistency between hypothetical and actual thoughts and behaviors. Further studies to confirm the impact of a DPSI program or policy in the real world settings should be conducted. In fact, only a very small number of studies have been conducted to monitor the opinions of stakeholders, or to compare situations before and after the adoption of DPSI policy in hospitals. For instance, according to the systematic review [11], there were only 2 previous studies that showed a decline in the number of medical lawsuits and related costs after implementing a DPSI program [25, 26]. Many more studies on real-life hospitals that have adopted a DPSI policy need to be conducted to evaluate its various effects.

Second, the order in which the hypothetical cases were presented seemed to influence a participant’s response. The survey layout showed statistically significant relationships with some outcome variables; however, consistent and specific trends were not observed in the results of logistic and linear regressions. Furthermore, DPSI still showed statistical significance even when the results were adjusted for survey layout. However, future studies that use similar methods to ours should consider the order of presentation of the hypothetical cases.

Third, this study focuses on only 2 types of cases. We examined responses on 8 different hypothetical cases, which varied in terms of whether DPSI was performed or not, the degree of harm, and the clarity of medical errors. However, only 2 types of patient safety incidents were utilized; these were a surgical adverse events case and a medical errors case. Other types of hypothetical cases, such as diagnostic errors, diagnostic delays, and healthcare-associated infection, require further exploration.

In conclusion, we evaluated the effectiveness of DPSI by surveying 700 members of the general public with 8 hypothetical cases. The results indicated the advantages of DPSI, including a reduction in the likelihood of perceiving a situation as a medical error, promotion of the willingness to revisit and recommend physicians, and discouragement of the intention to commence criminal proceedings against physicians against physicians. Furthermore, DPSI increased patients’ trust in physicians and reduced the expected amount of compensation. This study provides empirical evidence to reduce the psychological burden that DPSI introduction might place on healthcare professionals.