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Who is disclosure the error to the patients

Aimee K Gardner, Gi Lim, Charles G Minard, Danielle Guffey, M Tyson Pillow
Background : Disclosure of medical errors is important to patients and physicians, but formal disclosure training during the graduate medical education curriculum is limited. Objective : We examined resident competence related to error disclosure, using standardized patient (SP) ratings of resident communication skills. Methods : All first-year residents from medicine, radiology, emergency medicine, orthopedic surgery, and neurological surgery completed a 20-minute simulated session in which they were provided background information on a medical error they had made and were asked to disclose the error to an SP acting as a family member...
August 2018: Journal of Graduate Medical Education
Jo Shapiro, Lynne Robins, Pamela Galowitz, Thomas H Gallagher, Sigall Bell
Error disclosure is a high-stakes, emotionally charged interaction for patients and families as well as clinicians. A failed disclosure can result in emotional distress, reduced patient and family trust, litigation, and lost opportunities to learn from and prevent subsequent errors. However, many clinicians have little expertise in handling these challenging interactions and can inadvertently make a bad situation worse. Even those clinicians who have had formal disclosure training may have trouble remembering what they were taught when faced with the need to actually discuss an error with patients...
May 16, 2018: Journal of Patient Safety
Yael K Heher, Suzanne M Dintzis
Harmful error is an infrequent but serious challenge in the pathology laboratory. Regulatory bodies and advocacy groups have mandated and encouraged disclosure of error to patients. Many pathologists are interested in participating in disclosure of harmful error but are ill-equipped to do so. This review of the literature with recommendations examines the current state of the patient safety movement and error disclosure as it pertains to pathology and provides a practical and explicit guide for pathologists for who, when, and how to disclose harmful pathology error to patients...
March 2018: Advances in Anatomic Pathology
Jennifer Moore, Marie Bismark, Michelle M Mello
Importance: Dissatisfaction with medical malpractice litigation has stimulated interest by health care organizations in developing alternatives to meet patients' needs after medical injury. In communication-and-resolution programs (CRPs), hospitals and liability insurers communicate with patients about adverse events, use investigation findings to improve patient safety, and offer compensation when substandard care caused harm. Despite increasing interest in this approach, little is known about patients' and family members' experiences with CRPs...
November 1, 2017: JAMA Internal Medicine
C J Cabilan, Kathryn Kynoch
BACKGROUND: Second victims are clinicians who have made adverse errors and feel traumatized by the experience. The current published literature on second victims is mainly representative of doctors, hence nurses' experiences are not fully depicted. This systematic review was necessary to understand the second victim experience for nurses, explore the support provided, and recommend appropriate support systems for nurses. OBJECTIVES: To synthesize the best available evidence on nurses' experiences as second victims, and explore their experiences of the support they receive and the support they need...
September 2017: JBI Database of Systematic Reviews and Implementation Reports
Irene Carrillo, José Joaquín Mira, Mercedes Guilabert, Susana Lorenzo
OBJECTIVE: The aim of the study was to analyze the relationships between factors that contribute to healthcare professionals informing and apologizing to a patient after an avoidable adverse event (AAE). METHODS: A secondary study based on the analysis of data collected in a cross-sectional study conducted in 2014 in Spain was performed. Health professionals from hospitals and primary care completed an online survey. RESULTS: The responses from 1087 front-line healthcare professionals were analyzed...
June 29, 2017: Journal of Patient Safety
Christian M Pettker
The critical arm of improvement and change comes after events are identified and classified. Getting and making things right when things go wrong defines a successful safety program. This article reviews the important tasks that should be familiar to any team approaching a serious event on an obstetrics unit. Root cause analysis is a critical, but often misunderstood, tool for dissecting the contributing factors leading to an adverse event. Successful root cause analyses have a standardized approach that result in meaningful action plans...
April 2017: Seminars in Perinatology
Awoke Seyoum, Principal Ndlovu, Zewotir Temesgen
BACKGROUND: Adherence and CD4 cell count change measure the progression of the disease in HIV patients after the commencement of HAART. Lack of information about associated factors on adherence to HAART and CD4 cell count reduction is a challenge for the improvement of cells in HIV positive adults. The main objective of adopting joint modeling was to compare separate and joint models of longitudinal repeated measures in identifying long-term predictors of the two longitudinal outcomes: CD4 cell count and adherence to HAART...
March 16, 2017: AIDS Research and Therapy
Charles E Cunningham, Tracy Hutchings, Jennifer Henderson, Heather Rimas, Yvonne Chen
BACKGROUND: Patients and their families play an important role in efforts to improve health service safety. OBJECTIVE: The objective of this study is to understand the safety partnership preferences of patients and their families. METHOD: We used a discrete choice conjoint experiment to model the safety partnership preferences of 1,084 patients or those such as parents acting on their behalf. Participants made choices between hypothetical safety partnerships composed by experimentally varying 15 four-level partnership design attributes...
2016: Patient Preference and Adherence
Minsu Ock, Hyun Joo Kim, Min-Woo Jo, Sang-Il Lee
BACKGROUND: Experience with open disclosure and its study are restricted to certain western countries. In addition, there are concerns that open disclosure may be less suitable in non-western countries. The present study explored and compared the in-depth perceptions of the general public and physicians regarding open disclosure in Korea. METHODS: We applied the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist to this qualitative study...
August 20, 2016: BMC Medical Ethics
Caitriona L Cox, Zoe Fritz
In modern practice, doctors who outright lie to their patients are often condemned, yet those who employ non-lying deceptions tend to be judged less critically. Some areas of non-disclosure have recently been challenged: not telling patients about resuscitation decisions; inadequately informing patients about risks of alternative procedures and withholding information about medical errors. Despite this, there remain many areas of clinical practice where non-disclosures of information are accepted, where lies about such information would not be...
October 2016: Journal of Medical Ethics
Margaret Plews-Ogan, Natalie May, Justine Owens, Monika Ardelt, Jo Shapiro, Sigall K Bell
PURPOSE: Confronting medical error openly is critical to organizational learning, but less is known about what helps individual clinicians learn and adapt positively after making a harmful mistake. Understanding what factors help doctors gain wisdom can inform educational and peer support programs, and may facilitate the development of specific tools to assist doctors after harmful errors occur. METHOD: Using "posttraumatic growth" as a model, the authors conducted semistructured interviews (2009-2011) with 61 physicians who had made a serious medical error...
February 2016: Academic Medicine: Journal of the Association of American Medical Colleges
Priscila Giraldo, Isabel Trespaderne, Cristina Díaz, María Dolores Bardallo
OBJECTIVES: To describe the approach to the communication and blame of an adverse by nursing students. METHOD: A descriptive study on disclosure and apologies for adverse events by nursing students in the academic years 2011-12 and 2012-13. The study included group discussion and drafting a written communication to the injured patient about adverse events during hospitalization. An ad hoc checklist was used and an analysis was performed on items related to the disclosure and apologies issues...
September 2015: Enfermería Clínica
Sigall K Bell, Andrew A White, Jean C Yi, Joyce P Yi-Frazier, Thomas H Gallagher
OBJECTIVES: Transparent communication after medical error includes disclosing the mistake to the patient, discussing the event with colleagues, and reporting to the institution. Little is known about whether attitudes about these transparency practices are related. Understanding these relationships could inform educational and organizational strategies to promote transparency. METHODS: We analyzed responses of 3038 US and Canadian physicians to a medical error communication survey...
December 2017: Journal of Patient Safety
Steven E Raper, Andrew S Resnick, Jon B Morris
OBJECTIVES: Surgery residents are expected to demonstrate the ability to communicate with patients, families, and the public in a wide array of settings on a wide variety of issues. One important setting in which residents may be required to communicate with patients is in the disclosure of medical error. This article details one approach to developing a course in the disclosure of medical errors by residents. DESIGN: Before the development of this course, residents had no education in the skills necessary to disclose medical errors to patients...
November 2014: Journal of Surgical Education
Carolyn D Prouty, Mary Beth Foglia, Thomas H Gallagher
BACKGROUND: Hospitals face a disclosure dilemma when large-scale adverse events affect multiple patients and the chance of harm is extremely low. Understanding the perspectives of patients who have received disclosures following such events could help institutions develop communication plans that are commensurate with the perceived or real harm and scale of the event. METHODS: A mailed survey was conducted in 2008 of 266 University of Washington Medical Center (UWMC) patients who received written disclosure in 2004 about a large-scale, low-harm/low-risk adverse event involving an incomplete endoscope cleaning process...
2013: Journal of Clinical Ethics
Aimee G Russell, Lei Chen, Kelli Jones, Alan N Peiris
Diabetes mellitus is increasing in frequency and is associated with disabling acute and chronic complications. There is evidence to indicate that excellent glucose control may retard the development and/or progression of these complications. In order to optimize diabetic control, patients are encouraged to monitor their glucose frequently We describe a patient who provided inaccurate glucose monitoring results, delaying effective management of his progressively increasing glycosylated hemoglobin level. The diagnostic clue to his erroneous glucose monitoring results was the lack of intra-day variation in this patient on insulin therapy...
January 2014: Tennessee Medicine: Journal of the Tennessee Medical Association
Jason M Etchegaray, Madelene J Ottosen, Landrus Burress, William M Sage, Sigall K Bell, Thomas H Gallagher, Eric J Thomas
The study of adverse event disclosure has typically focused on the words that are said to the patient and family members after an event. But there is also growing interest in determining how patients and their families can be involved in the analysis of the adverse events that harmed them. We conducted a two-phase study to understand whether patients and families who have experienced an adverse event should be involved in the postevent analysis following the disclosure of a medical error. We first conducted twenty-eight interviews with patients, family members, clinicians, and administrators to determine the extent to which patients and family members are included in event analysis processes and to learn how their experiences might be improved...
January 2014: Health Affairs
Ann Hendrich, Christine Kocot McCoy, Jane Gale, Lora Sparkman, Palmira Santos
Communicating openly and honestly with patients and families about unexpected medical events-a policy known as full disclosure-improves outcomes for patients and providers. Although many certification and licensing organizations have declared full disclosure to be imperative, the adoption of and adherence to a full disclosure protocol is not common practice in most clinical settings. We conducted a case study of Ascension Health's implementation of a full disclosure protocol at five labor and delivery demonstration sites...
January 2014: Health Affairs
M C Martín-Delgado, M Fernández-Maillo, J Bañeres-Amella, C Campillo-Artero, L Cabré-Pericas, R Anglés-Coll, R Gutiérrez-Fernández, J M Aranaz-Andrés, A Pardo-Hernández, A Wu
OBJECTIVE: To develop recommendations regarding «Information about adverse events to patients and their families», through the implementation of a consensus conference. MATERIAL AND METHODS: A literature review was conducted to identify all relevant articles, the major policies and international guidelines, and the specific legislation developed in some countries on this process. The literature review was the basis for responding to a series of questions posed in a public session...
November 2013: Revista de Calidad Asistencial: Organo de la Sociedad Española de Calidad Asistencial
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