Disclosure of medical errors

Amongst the lay and media population there is a perception that pregnancy, labour and delivery is always physiological, morbidity and mortality should be "never events" and that error is the only cause of adverse events. Those working in maternity care know that it is an imperfect art, where adverse outcomes and errors will occur. When errors do occur, there is a domino effect with three groups being involved - the patient (first victim), the staff (second victims) and the organization (third victims). If the perceived expectation of patients on all clinicians is that of perfection, then clinicians may suffer the consequences of adverse outcomes in isolation and silence...

CONTEXT: The ability to carry out prompt and effective error disclosure has been described in the literature as an essential skill among physicians that can lead to improved patient satisfaction, staff well-being and hospital outcomes. However, few studies have addressed the social psychology principles that may influence physician behaviour. METHODS: The authors provide an overview of recent administrative measures designed to encourage physicians to disclose error, but note that deliberate practice, buttressed with lessons from social psychology, is needed to implement further productive behavioural changes...

OBJECTIVE: To test whether an educational model involving patients and family members (P/F) in medical error disclosure training for interprofessional clinicians can narrow existing gaps between clinician and P/F views about disclosure. METHOD: Parallel presurveys/postsurveys using Likert scale questions for clinicians and P/F. RESULTS: Baseline surveys were completed by 91% (50/55) of clinicians who attended the workshops and 74% (65/88) of P/F from a hospital patient and family advisory council...

AIM: To collect empirical data on the attitudes of dental professionals and dental auxiliaries in Riyadh, Saudi Arabia, regarding the disclosure of medical errors. METHODS: A cross-sectional study was conducted, involving the administration of a questionnaire to a sample of 586 participants recruited from over 10 government and private dental institutions in Riyadh between August 2015 and January 2016. The questionnaire collected information regarding participant opinions on (a) personal beliefs, norms, and practices regarding medical errors, (b) the nature of errors that should be disclosed, and (c) who should disclose errors...

The question is no longer whether to disclose an error to a patient. Many studies have established that medical errors are co-owned by providers and patients and thus must be disclosed. However, little evidence is available on the concrete communication skills and contextual features that contribute to patients' perceptions of "competent disclosures" as a key predictor of objective disclosure outcomes. This study operationalises a communication science model to empirically characterise what messages, behaviours and contextual factors Swiss patients commonly consider "competent" during medical error disclosures, and what symptoms and behaviours they experience in response to competent and incompetent disclosures...

CONTEXT: - Medical errors are unfortunately common. The US Institute of Medicine proposed guidelines for mitigating and disclosing errors. Implementing these recommendations in pathology will require a better understanding of how errors occur in pathology, the relationship between pathologists and treating clinicians in reducing error, and pathologists' experiences with and attitudes toward disclosure of medical error. OBJECTIVE: - To understand pathologists' attitudes toward disclosing pathology error to treating clinicians and patients...

BACKGROUND : Residents' attitudes toward error disclosure have improved over time. It is unclear whether this has been accompanied by improvements in disclosure skills. OBJECTIVE : To measure the disclosure skills of internal medicine (IM), paediatrics, and orthopaedic surgery residents, and to explore resident perceptions of formal versus informal training in preparing them for disclosure in real-world practice. METHODS : We assessed residents' error disclosure skills using a structured role play with a standardized patient in 2012-2013...

BACKGROUND: Although physicians believe that medical errors should be disclosed to patients and their families, they often hesitate to do so. In this study, we assessed the effectiveness of an education program for medical error disclosure. METHODS: In 2015, six medical interns and 79 fourth-year medical students participated in this study. The education program included practice of error disclosure using a standardized patient scenario, feedback, and short didactic sessions...

BACKGROUND: In this study, medical errors are defined as unintentional patient harm caused by a doctor's mistake. This topic, due to limited research, is poorly understood in Malaysia. The objective of this study was to determine the proportion of doctors intending to disclose medical errors, and their attitudes/perception pertaining to medical errors. METHODS: This cross-sectional study was conducted at a tertiary public hospital from July- December 2015 among 276 randomly selected doctors...

National guidelines call for health care organizations to provide around-the-clock coaching for medical error disclosure. However, frontline clinicians may not always seek risk managers for coaching. As part of a demonstration project designed to improve patient safety and reduce malpractice liability, we trained multidisciplinary disclosure coaches at 8 health care organizations in Washington State. The training was highly rated by participants, although not all emerged confident in their coaching skill. This multisite intervention can serve as a model for other organizations looking to enhance existing disclosure capabilities...

BACKGROUND: The death notification process can affect family grief and bereavement. It can also affect the well-being of involved physicians. There is no standardized process for making death notification phone calls. We assumed that residents are likely to be unprepared before and troubled after. OBJECTIVE: We investigated current death notification practices to develop an evidence-based template for standardizing this process. DESIGN: We used results of a literature review and open-ended interviews with faculty, residents, and widows to develop a survey regarding resident training and experience in death notification by phone...

BACKGROUND: Little is known about the views of faculty members who train medical students concerning open disclosure. OBJECTIVES: The objectives of this study were to determine the views of faculty in a medical school on: 1 what constitutes a medical error and the severity of such an error in relation to medication use or diagnosis; 2 information giving following such an adverse event, based on severity; and 3 acknowledgement of responsibility, remedial action, compensation, disciplinary action, legal action, and reporting to a higher body in relation to such adverse event...

Since the publication of the Institute of Medicine’s report “To Err is Human: Building a Safer Health System” awareness of the importance of medical errors has increased. These are a major cause of morbidity and mortality and recent studies suggest that they can be the third leading cause of death in the United States. Difficulties have been identified by health personnel to prevent, detect and disclose to patients the occurrence of a medical error, an also to report them to the appropriate authorities. Although human error cannot be eliminated, it is possible to design safety systems to mitigate their frequency and consequences...

INTRODUCTION: Treatment planning systems (TPS) are a cornerstone of modern radiation therapy. Errors in their commissioning or use can have a devastating impact on many patients. To support safe and high quality care, medical physicists must conduct efficient and proper commissioning, good clinical integration, and ongoing quality assurance (QA) of the TPS. AAPM Task Group 53 and related publications have served as seminal benchmarks for TPS commissioning and QA over the past two decades...

INTRODUCTION: Treatment planning systems (TPS) are a cornerstone of modern radiation therapy. Errors in their commissioning or use can have a devastating impact on many patients. To support safe and high quality care, medical physicists must conduct efficient and proper commissioning, good clinical integration, and ongoing quality assurance (QA) of the TPS. AAPM Task Group 53 and related publications have served as seminal benchmarks for TPS commissioning and QA over the past two decades...

PURPOSE: Extremity cone-beam CT (CBCT) with an amorphous silicon (aSi) flat-panel detector (FPD) provides low-dose volumetric imaging with high spatial resolution. We investigate the performance of the newer complementary metal-oxide semiconductor (CMOS) detectors to enhance resolution of extremities CBCT to ∼0.1 mm, enabling morphological analysis of trabecular bone. Quantitative in-vivo imaging of bone microarchitecture could present an important advance for osteoporosis and osteoarthritis diagnosis and therapy assessment...

INTRODUCTION: Treatment planning systems (TPS) are a cornerstone of modern radiation therapy. Errors in their commissioning or use can have a devastating impact on many patients. To support safe and high quality care, medical physicists must conduct efficient and proper commissioning, good clinical integration, and ongoing quality assurance (QA) of the TPS. AAPM Task Group 53 and related publications have served as seminal benchmarks for TPS commissioning and QA over the past two decades...

INTRODUCTION: Treatment planning systems (TPS) are a cornerstone of modern radiation therapy. Errors in their commissioning or use can have a devastating impact on many patients. To support safe and high quality care, medical physicists must conduct efficient and proper commissioning, good clinical integration, and ongoing quality assurance (QA) of the TPS. AAPM Task Group 53 and related publications have served as seminal benchmarks for TPS commissioning and QA over the past two decades...

OBJECTIVE: According to disclosure guidelines, patients experiencing adverse events due to medical errors should be offered full disclosure, whereas disclosure of near misses is not traditionally expected. This may conflict with parental expectations; surveys reveal most parents expect full disclosure whether errors resulted in harm or not. Protocols regarding whether to include children in these discussions have not been established. This study explores parent preferences around disclosure and views on including children...

Despite increasing attention to issues of patient safety, preventable adverse events (AEs) continue to occur, causing direct and consequential injuries to patients, families, and health care providers. Pediatricians generally agree that there is an ethical obligation to inform patients and families about preventable AEs and medical errors. Nonetheless, barriers, such as fear of liability, interfere with disclosure regarding preventable AEs. Changes to the legal system, improved communications skills, and carefully developed disclosure policies and programs can improve the quality and frequency of appropriate AE disclosure communications...