Disclosure of patient safety incidents: a comprehensive review
International Journal for Quality in Health CarePublished 13 August 2010
Ellen O’Connor, Hilary Coates, Iain Yardley, Albert W. Wu
Citations192
SJR quartileQ2
SJR score0.85
SNIP1.11
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TL;DR
This comprehensive review of the literature on disclosure across individual and international boundaries, including patients', healthcare professionals' and other stakeholders' perspectives, suggests that disclosure practice can be improved by strengthening policy and supporting healthcare professionals in disclosing adverse events.
Abstract
This comprehensive review, which takes account of the perspectives of the patient and members of the care team across multiple jurisdictions, suggests that disclosure practice can be improved by strengthening policy and supporting healthcare professionals in disclosing adverse events. Increased openness and honesty following adverse events can improve provider-patient relationships.
Keywords
Health Professions
National Academies Press eBooksTo Err Is Human
14,096 Citations2000Institute of Medicine
A process for the preparation of prostaglandins which are known pharmaceutically active compounds and then R alpha , R omega -cyclopentenoids is described.
New England Journal of MedicineIncidence of Adverse Events and Negligence in Hospitalized Patients
4,666 Citations1991Troyen A. Brennan, Lucian L. Leape +7 more
The incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care, in New York State in 1984 were estimated.
New England Journal of MedicineThe Nature of Adverse Events in Hospitalized Patients
3,750 Citations1991Lucian L. Leape, Troyen A. Brennan +8 more
The high proportion that are due to management errors suggests that many others are potentially preventable now, and reducing the incidence of these events will require identifying their causes and developing methods to prevent error or reduce its effects.
The Medical Journal of AustraliaThe Quality in Australian Health Care Study
2,397 Citations1995R. M. Wilson, W. B. Runciman +4 more
Canadian Medical Association JournalThe Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada
2,350 Citations2004G. Ross Baker
The overall incidence rate of AEs of 7.5% in this study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.
BMJAdverse events in British hospitals: preliminary retrospective record review
2,074 Citations2001Charles Vincent, Graham Neale +1 more
These results suggest that adverse events are a serious source of harm to patients and a large drain on NHS resources.
BMJMedical error: the second victim
1,435 Citations2000Albert W. Wu
Patients, who have an understandable need to consider their doctors infallible, have colluded with doctors to deny the existence of error.
JAMAAssociation of Perceived Medical Errors With Resident Distress and Empathy
1,414 Citations2006Colin P. West, Mashele Huschka +5 more
Self-perceived medical errors are common among internal medicine residents and are associated with substantial subsequent personal distress, suggesting that perceived errors and distress may be related in a reciprocal cycle.
JAMAPatients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors
944 Citations2003Thomas H. Gallagher, Amy D. Waterman +3 more
New England Journal of MedicineViews of Practicing Physicians and the Public on Medical Errors
774 Citations2002Robert J. Blendon, Catherine M. DesRoches +8 more
Though substantial proportions of the public and practicing physicians report that they have had personal experience with medical errors, neither group has the sense of urgency expressed by many national organizations to advance their agenda.
The LancetWhy do people sue doctors? A study of patients and relatives taking legal action
692 Citations1994Charles Vincent, Andrew Phillips +1 more
Patients taking legal action wanted greater honesty, an appreciation of the severity of the trauma they had suffered, and assurances that lessons had been learnt from their experiences, and a no-fault compensation system, however well intended, would not address all patients' concerns.
JAMADo House Officers Learn From Their Mistakes?
566 Citations1991Albert W. Wu
House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice and residents were less likely to make constructive changes if they attributed the mistake to job overload.
Annals of Internal MedicineRisk Management: Extreme Honesty May Be the Best Policy
471 Citations1999Steve S. Kraman, Ginny Hamm
The benefits of telling patients the truth are reviewed and the possible consequences to the physician and the patient under various circumstances, and the high assessments were substitutes for punitive awards are reviewed.
Journal of General Internal MedicineTo tell the truth
386 Citations1997Albert W. Wu, Thomas A. Cavanaugh +3 more
While moonlighting in an emergency room, a resident physician evaluated a 35-year-old woman who was 6 months pregnant and complaining of a headache, and diagnosed a “mixed tension/sinus headache” which led to the patient's death 3 days later.
PubMedCosts of medical injuries in Utah and Colorado.
386 Citations1999Eric J. Thomas, David M. Studdert +5 more
The costs of adverse events were similar to the national costs of caring for people with HIV/AIDS, and totaled 4.8% of per capita health care expenditures in these states.
Journal of General Internal MedicineWhat can hospitalized patients tell us about adverse events? Learning from patient-reported incidents
332 Citations2005Saul N. Weingart, Odelya E. Pagovich +6 more
Engaging hospital inpatients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.
PubMed[Incidence of adverse events in hospitals. A retrospective study of medical records].
317 Citations2001Thomas Schiøler, Henriette Lipczak +6 more
The findings from the Danish Adverse Event Study are similar to the results found in Australia, United Kingdom and the United States and it is recommended that further Danish research, is directed towards high-risk groups focussing on narratives and intervention and towards research in primary health care.
Annals of Internal MedicineHealth Plan Members' Views about Disclosure of Medical Errors
295 Citations2004Kathleen M. Mazor, Steven R. Simon +5 more
Assessment of patients' views of disclosure of medical errors and the relationship of the error, severity of clinical outcome, and the level of disclosure to 5 dependent variables found that full disclosure improved trust, satisfaction, and emotional response.
Archives of Internal MedicineChoosing Your Words Carefully
258 Citations2006Thomas H. Gallagher, Jane Garbutt +7 more
Physicians vary widely in how they would disclose errors to patients, and disclosure standards and training are necessary to meet public expectations and promote professional responsibility following errors.
Archives of Internal MedicineResidents Report on Adverse Events and Their Causes
235 Citations2005Reshma Jagsi, Barrett T. Kitch +4 more
Findings support the perception that AEs are commonly encountered by physicians and often associated with errors, and causes of errors in teaching hospitals appear to be multifactorial.
Archives of Internal MedicineUS and Canadian Physicians' Attitudes and Experiences Regarding Disclosing Errors to Patients
222 Citations2006Thomas H. Gallagher, Amy D. Waterman +6 more
US and Canadian physicians' error disclosure attitudes and experiences are similar despite different malpractice environments, and reveal mixed feelings about disclosing errors to patients.
Academic MedicineResidents?? Responses to Medical Error: Coping, Learning, and Change
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Medical mishaps have a profound impact on resident physicians by eliciting intense emotional responses and it is critical that resident training programs recognize the personal and professional significance of these experiences for young physicians.
Archives of Internal MedicineHow Do Patients Want Physicians to Handle Mistakes?
185 Citations1996Amy B. Witman
Patients desire an acknowledgment from their physicians of even minor errors, and doing so may actually reduce the risk of punitive actions, which reinforces the importance of open communication between patients and physicians.
Swiss Medical WeeklyThe emotional impact of medical error involvement on physicians: A call for leadership and organizational accountability
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There appears to be a gap between physicians’ attitudes and practices regarding error disclosure, and willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation.
New England Journal of MedicineGuilty, Afraid, and Alone — Struggling with Medical Error
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How can the human dimensions of medical error be characterized and addressed so that patients, families, and clinicians may reach some degree of closure and move toward forgiveness?
Health AffairsHospital Disclosure Practices: Results Of A National Survey
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Survey of risk managers at a nationally representative sample of hospitals found that the vast majority reported that their hospital's practice was to disclose harm at least some of the time, although only one-third of hospitals actually had board-approved policies in place.
Adverse Events in New Zealand Public Hospitals: Principal Findings from a National Survey
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The study provides the base parameters necessary to inform the understanding of patient safety and the quality of care in New Zealand public hospitals and points to the importance of similar research on the sources and characteristics of adverse events outside public hospitals.
Academic MedicineThe Attitudes and Experiences of Trainees Regarding Disclosing Medical Errors to Patients
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Although many trainees had disclosed errors to patients, only a minority had been formally prepared to do so, and formal disclosure curricula are necessary to prepare trainees to independently disclose errors to Patients by the end of their training.
JAMAThe Journal of Clinical Ethics
141 Citations1993Carson Strong
This publication germinated from a perceived need for a journal aimed at front-line health care providers that applies medical ethics to clinical practice and pursues the goal of "advancing the field" by publishing up-to-date reviews, case reports and analyses, research reports, and discussions of ethical theory as it relates to practice.
Archives of Pediatrics and Adolescent MedicineReporting and Disclosing Medical Errors
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Pediatricians are willing to report errors to hospitals and disclose errors to patients' families but believe current reporting systems are inadequate and struggle with error disclosure, and improving error reporting systems and encouraging physicians to report near misses could help prevent future errors and increase patient trust.
PubMedA better approach to medical malpractice claims? The University of Michigan experience.
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The case example illustrates how an honest, principle-driven approach to claims is better for all those involved-the patient, the healthcare providers, the institution, future patients, and even the lawyers.
International Journal for Quality in Health CarePatient perspectives of patient–provider communication after adverse events
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International Journal for Quality in Health CareWhat makes an error unacceptable? A factorial survey on the disclosure of medical errors
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In errors with a severe outcome, an honest, empathic, and accountable approach to the error decreases the probability of participants' support for strong sanctions against the physician involved by 59%.
JAMAError Reporting and Disclosure Systems
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While hospital leaders generally favor disclosure of patient safety incidents to involved patients, fewer would disclose incidents involving moderate or minor injury to state reporting systems.
Canadian Medical Association JournalAccountability sought by patients following adverse events from medical care: the New Zealand experience
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Health AffairsDisclosure Of Medical Injury To Patients: An Improbable Risk Management Strategy
123 Citations2007David M. Studdert, Michelle M. Mello +3 more
This theory that disclosure will actually reduce providers' liability exposure was tested by modeling the litigation consequences of disclosure and found that forecasts of reduced litigation volume or cost do not withstand close scrutiny.
BMJPatients' and doctors' attitudes to amount of information given after unintended injury during treatment: cross sectional, questionnaire survey
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Patients' and doctors' attitudes to the provision of information to patients after a hypothetical adverse event in cataract surgery are surveyed.
Archives of Internal MedicinePhysician and Public Opinions on Quality of Health Care and the Problem of Medical Errors
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The results suggest that physicians see several barriers to successful error reduction including difficulty defining errors, the need for more training in handling errors, and fear of malpractice litigation.
Academic Emergency MedicineMedical Errors—What and When: What Do Patients Want to Know?
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Intensive Care MedicineInformation in the ICU: are we being honest with our patients? The results of a European questionnaire
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International Journal for Quality in Health CarePatients' and family members' experiences of open disclosure following adverse events
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PEDIATRICSParental Preferences for Error Disclosure, Reporting, and Legal Action After Medical Error in the Care of Their Children
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PubMedHow house officers cope with their mistakes.
104 Citations1993Albert W. Wu, Susan Folkman +2 more
For house officers who have made a mistake, medical educators are suggested to provide specific advice about preventing a recurrence of the mistake, provide emotional support, and help them understand that distress is an expected concomitant of learning from the experience.
Journal of General Internal MedicineDisclosing Medical Errors to Patients: It’s Not What You Say, It’s What They Hear
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Spatients will probably respond more favorably to physicians who apologize and accept responsibility for medical errors than those who do not apologize or give ambiguous responses.
The LaryngoscopeOtolaryngologists' Responses to Errors and Adverse Events
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Medical EducationLearning not to take it seriously: junior doctors’ accounts of error
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SurgeryError or “act of God”? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure
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A strong culture of individualism pervades nurses' perception of error reporting, suggesting that interventions are needed to foster collective responsibility and a constructive approach to error identification.
The Joint Commission Journal on Quality and SafetyDoes Full Disclosure of Medical Errors Affect Malpractice Liability? The Jury Is Still Out
94 Citations2003Allen Kachalia, Kaveh G Shojania +3 more
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Journal of Medical EthicsSubtracting insult from injury: addressing cultural expectations in the disclosure of medical error
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It is recommended that learning how to disclose errors, apologise to injured patients, ensure that these patients’ needs are met, and confront the emotional dimensions of one’s own mistakes should be part of medical education and reinforced by the conduct of senior physicians.
Annals of Emergency MedicineDealing with failure: The aftermath of errors and adverse events
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The Joint Commission Journal on Quality and Patient SafetyDisclosing Errors to Patients: Perspectives of Registered Nurses
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BMJ Quality & SafetyResponding to patient safety incidents: the "seven pillars"
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The Joint Commission Journal on Quality and Patient SafetyPatients’ Concerns About Medical Errors During Hospitalization
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Journal of General Internal MedicineThe Many Faces of Error Disclosure: A Common Set of Elements and a Definition
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The Joint Commission Journal on Quality and Patient SafetyFacilitating and Impeding Factors for Physicians’ Error Disclosure: A Structured Literature Review
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BMJ Quality & SafetyMeasures of patient safety in developing and emerging countries: a review of the literature
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Investigation of patient safety in developing and emerging countries has been infrequent and limited in scope, and establishing fundamental safe patient practices and integrating those processes into routine health services delivery and developing patients' expectations that such processes be present are necessary prerequisites to measuring and monitoring progress towards safe patient care.
Academic Emergency MedicineMedical Error Identification, Disclosure, and Reporting: Do Emergency Medicine Provider Groups Differ?
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If the three types of emergency medicine providers--physicians, nurses, and out-of-hospital providers (emergency medical technicians [EMTs])--differ in their identification, disclosure, and reporting of medical error is investigated.
American Journal of Medical QualityAttitudes About Patient Safety: A Survey of Physicians-in-Training
53 Citations2005Rachel Sorokin, Jeff M. Riggio +1 more
Trainees believe adverse events are preventable and are poised to respond to many components of the patient safety movement, including improved teamwork, procedural training, and improved sign-out.
Canadian Medical Association JournalDisclosing medical errors to patients: a status report in 2007
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In the past decade, evidence has shown that adverse events, including errors, occur frequently in health care.
BMC Public HealthConsumer perceptions of safety in hospitals
49 Citations2006Sue Evans, Jesia G. Berry +2 more
The Medical Journal of AustraliaThe National Open Disclosure Pilot: evaluation of a policy implementation initiative
47 Citations2008Rick Iedema, Nadine A. Mallock +11 more
To determine which aspects of open disclosure “work” for patients and health care staff, based on an evaluation of the National Open Disclosure Pilot.
The Joint Commission Journal on Quality and Patient SafetyRisk Managers, Physicians, and Disclosure of Harmful Medical Errors
45 Citations2010David J. Loren, Jane Garbutt +8 more
Risk managers have more favorable attitudes about disclosing errors to patients compared with physicians but are less supportive of providing a full apology, which may create conflicts between risk managers and physicians regarding disclosure.
Prehospital Emergency CareDo EMS Personnel Identify, Report, andDisclose Medical Errors?
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Self-reports of prehospital providers' error frequency, disclosure, andreporting in their actual practice and in hypothetical scenarios demonstrate the capacity to identify, report, and, to a lesser extent, disclose errors in hypothetic scenarios but may not apply these skills uniformly in their own practices.
Academic Emergency MedicineResident Perceptions of Medical Errors in the Emergency Department
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Patient Education and CounselingDisclosing medical errors to patients: A challenge for health care professionals and institutions
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Journal of Health Services Research & PolicyHealth care professionals’ views of implementing a policy of open disclosure of errors
32 Citations2008Ros Sorensen, Rick Iedema +4 more
Health services must develop organizing capabilities if open disclosure is to be implemented as intended and activities should identify and address factors that impede implementation and enable workforce and system competencies to develop.
Journal of Communications In HealthcareUnderstanding patients' perceptions of medical errors
30 Citations2009Kathleen M. Mazor, Sarah L. Goff +2 more
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Journal of Healthcare Risk ManagementNational survey: Risk managers' attitudes and experiences regarding patient safety and error disclosure
19 Citations2006Thomas H. Gallagher, Geneva Brundage +6 more
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