Reporting and Disclosing Medical Errors
Archives of Pediatrics and Adolescent MedicinePublished 1 February 2007
Jane Garbutt, Dena Brownstein, Eileen J. Klein, Amy D. Waterman, Melissa J. Krauss, Edgar K. Marcuse
Citations135
Generate an AI Snapshot to get a quick, structured summary of this paper.
Study Snapshot
ObjectiveStudy objective
MethodsResearch methodology
PopulationPopulation studied
Sample sizeSample sizes
OutcomesStudy outcomes here
ResultsStudy results comes here
LimitationsResearch study limitations comes here
A concise AI-generated summary of the paper will appear here once you click Generate AI Snapshot.
TL;DR
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.
Abstract
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. Improving error reporting systems and encouraging physicians to report near misses, as well as providing training in error disclosure, could help prevent future errors and increase patient trust.
Keywords
MedicineHealth 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.
BMJCrossing the Quality Chasm: A New Health System for the 21st Century
10,744 Citations2001Alexi Baker
Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.
Mail and internet surveys : the tailored design method
9,659 Citations2007Don A. Dillman
JAMAIncidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group
2,509 Citations1995David W. Bates
Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable and prevention strategies should target both stages of the drug delivery process.
JAMAMedication Errors and Adverse Drug Events in Pediatric Inpatients
1,932 Citations2001Rainu Kaushal
Medication errors are common in pediatric inpatient settings, and further efforts are needed to reduce them.
BMJOn error management: lessons from aviation
1,313 Citations2000Robert L. Helmreich
Although operating theatres are not cockpits, medicine could learn from aviation and aviation has developed standardised methods of investigating, documenting, and disseminating errors and their lessons.
BMJReporting and preventing medical mishaps: lessons from non-medical near miss reporting systems
1,107 Citations2000Paul Barach
Focusing on data for near misses may add noticeably more value to quality improvement than a sole focus on adverse events, and an environment fostering a rich reporting culture must be created to capture accurate and detailed data about nuances of care.
JAMAPatients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors
944 Citations2003Thomas H. Gallagher, Amy D. Waterman +3 more
New England Journal of MedicineReporting of Adverse Events
834 Citations2002Lucian L. Leape
Systems for reporting adverse events can reduce medical errors by uncovering remediable problems in processes of care but are neither widely used nor highly effective.
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 Joint Commission Journal on Quality ImprovementThe Incident Reporting System Does Not Detect Adverse Drug Events: A Problem for Quality Improvement
603 Citations1995David J. Cullen, David W. Bates +4 more
The frequency with which adverse drug events result in an incident report (IR) in hospitalized patients was determined to determine and if there were differences between quality assurance administrators, nurse leaders in quality assurance, and staff nurses as to whetheran incident report should or would be filed for each adverse drug event.
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.
Archives of Disease in ChildhoodMedication errors in a paediatric teaching hospital in the UK: five years operational experience
345 Citations2000L M Ross
The overall medication error rate was low and there are clear opportunities to make system changes to reduce error rates further, but there is a need to change the culture towards recognising and acknowledging clinical errors, including drug errors.
Scientific AmericanManaging Human Error in Aviation
240 Citations1997Robert L. Helmreich
The aviation CRM model has been adapted for training surgeons and operating room staff in human factors and in automated cockpits CRM promotes the idea of automation as a crew member.
BMJ Quality & SafetyDo house officers learn from their mistakes?
226 Citations2003Albert 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.
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.
Annals of Internal MedicineEthics Manual
220 Citations2005Lois Snyder, Cathy Leffler
This fifth edition of the Ethics Manual examines emerging issues in medical ethics and revisits older issues that are still very pertinent, as well as raising ethical issues and presenting general guidelines.
Archives of Internal MedicineCommunicating With Patients About Medical Errors
218 Citations2004Kathleen M. Mazor, Steven R. Simon +1 more
Empirical research on disclosure of medical errors to patients and families has been limited, and studies have focused primarily on the decision stage of disclosure.
Medication Safety: One Organization's Approach to the Challenge
203 Citations2001John D. Rozich, Roger K. Resar
The following report discusses the rationale for differentiating ADEs from the broader spectrum of medication errors and describes a practical, resource-friendly approach to enhancing patient safety.
PEDIATRICSUse of Incident Reports by Physicians and Nurses to Document Medical Errors in Pediatric Patients
194 Citations2004James A. Taylor, Dena Brownstein +5 more
Doctors and nurses who care for pediatric patients are significantly underreported in incident report systems, particularly by physicians, and changes in the incident report system could lead to more reporting.
JAMAPhysicians' attitudes toward using deception to resolve difficult ethical problems
167 Citations1989D. H. Novack
Journal of General Internal MedicineDisclosure of medical errors
143 Citations2006Kathleen M. Mazor, George Reed +4 more
Evidence is provided that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors, and the clinical outcome also influences patients’ responses.
PEDIATRICSPatient Safety Events During Pediatric Hospitalizations
134 Citations2003Marlene R. Miller, Anne Elixhauser +1 more
The prevalence of birth trauma and other potential patient safety events for hospitalized children is high and comparable to hospitalized adults, and these events are associated with increased length of stay, in-hospital mortality, and total charges.
SurgeryHow surgeons disclose medical errors to patients: A study using standardized patients
124 Citations2005David Chan, Thomas H. Gallagher +2 more
Significant gaps exist between how surgeons disclose errors and patient preferences, and programs should be developed to teach surgeons how to communicate more effectively with patients about errors.
TransfusionReporting of near‐miss events for transfusion medicine: improving transfusion safety
123 Citations2001Jeannie Callum, Harold S. Kaplan +6 more
A no‐fault medical‐event reporting system for transfusion medicine (MERS‐TM) was developed to capture and analyze both near‐miss and actual transfusion‐related errors.
BMJPatients' and doctors' attitudes to amount of information given after unintended injury during treatment: cross sectional, questionnaire survey
122 Citations1999Mohan Hingorani, Tina Wong +1 more
Patients' and doctors' attitudes to the provision of information to patients after a hypothetical adverse event in cataract surgery are surveyed.
The Joint Commission Journal on Quality and SafetyUsing Focus Groups to Understand Physicians’ and Nurses’ Perspectives on Error Reporting in Hospitals
119 Citations2004Donna B. Jeffe, William Claiborne Dunagan +7 more
A culture characterized by anonymous reporting, freedom from repercussions, and feedback about error reports should promote error reporting.
Intensive Care MedicineInformation in the ICU: are we being honest with our patients? The results of a European questionnaire
113 Citations1998Jean‐Louis Vincent
Doctors are often not completely honest with their patients regarding their diagnosis or prognosis, or in the event of an iatrogenic incident, however, most doctors will respect a patient's right to refuse treatment.
PEDIATRICSParental Preferences for Error Disclosure, Reporting, and Legal Action After Medical Error in the Care of Their Children
108 Citations2005Cherri Hobgood, Joshua H. Tamayo‐Sarver +2 more
Academic MedicineThe Influence of the Causes and Contexts of Medical Errors on Emergency Medicine Residents??? Responses to Their Errors: An Exploration
100 Citations2005Cherri Hobgood, Armando Hevia +3 more
Emotional and behavioral responses to medical errors committed by emergency medicine residents often resulted in negative emotions, limited constructive system-based improvements, and inadequate disclosure.
Archives of Internal MedicineDisclosing Harmful Medical Errors to Patients
95 Citations2005Thomas H. Gallagher, Wendy Levinson
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
Despite extensive literature on the impact of disclosure on malpractice liability, few well-designed studies have focused on the real-world impact on the volume and cost of suits following implementation of a full disclosure policy.
European Journal of PediatricsDoes critical incident reporting contribute to medication error prevention?
87 Citations2002Bernhard Frey, V. Buettiker +6 more
Most of the system changes were based on minor critical incidents which were often detected only after a longer period of time, showing the value of the "low-threshold" critical incident monitoring.
BMJ Quality & SafetyPatients' experience of surgical accidents.
87 Citations1993Charles Vincent, Tamar Pincus +1 more
Surgical accidents have a major adverse psychological impact on patients, and poor communication after the accident may increase patients' distress.
American Journal of Health-System PharmacyRe-engineering the medication error-reporting process: Removing the blame and improving the system
74 Citations2000Lisa Stump
A hospital's change from a traditional, multitiered incident-reporting system for medication errors to a standardized, nonpunitive medication-use variance process is described, serving as a trigger for quality improvement efforts and a measure of their effectiveness.
Academic Emergency MedicineError Identification, Disclosure, and Reporting: Practice Patterns of Three Emergency Medicine Provider Types
72 Citations2004Cherri Hobgood, Jipan Xie +2 more
This study suggests that provider-specific education and enhanced teamwork training will be required to further the transformation of the ED into a high-reliability organization.
The American Journal of MedicineIatrogenic events resulting in intensive care admission: Frequency, cause, and disclosure to patients and institutions
68 Citations2005Lisa Soleymani Lehmann, Ann Louise Puopolo +2 more
The frequency of iatrogenic medical events resulting in admission to intensive care units is lower than previous studies have reported and a considerable percentage of i atrogenic events may be preventable.
PEDIATRICSPrinciples of Patient Safety in Pediatrics
68 Citations2001National Initiative for Children's Health Care Quality Project Advisory Committee
The American Academy of Pediatrics and its members are committed to improving the health care system to provide the best and safest health care for infants, children, adolescents, and young adults.
Annals of Emergency MedicineMedical error during residency
39 Citations2003Armando Hevia, Cherri Hobgood
The Journal of PediatricsAchieving closure through disclosure:
17 Citations2004Anne Matlow, Polly Stevens +2 more
Ambulatory PediatricsPediatric Resident Education About Medical Errors
16 Citations2004Kathleen E. Walsh, Marlene R. Miller +2 more
The amount and type of training that pediatric residents have about medical errors and the ability to deal with a medical error are determined to assess pediatric chief resident knowledge aboutMedical errors.