AHRQ Patient Safety Network

The Collection > Patient Disclosure

PATIENT SAFETY PRIMERS
Error Disclosure

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Safety Target

•Device-related Complications (4)

•Diagnostic Errors (12)

•Identification Errors (11)

•Discontinuities, Gaps, and Hand-Off Problems (5)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (28)

•Medical Complications (15)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (21)

•Transfusion Complications (1)

•Psychological and Social Complications (47)

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•Asia (1)

•Australia and New Zealand (13)

Resource Types

•Journal Article (179)

•Legislation/Regulation (7)

•Meeting/Conference (1)

•Newspaper/Magazine Article (51)

•Special or Theme Issue (8)

•Tools/Toolkit (2)

•Web Resource (7)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (21)

•Active Errors (49)

•Latent Errors (10)

•Near Miss (6)

Approach to Improving Safety
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Patient Disclosure

Clinical Areas

Target Audience

•Health Care Providers (214)

•Health Care Executives and Administrators (191)

•Non-Health Care Professionals (107)

•Patients (53)

Setting of Care

•Hospitals (104)

•Ambulatory Care (7)

•Outpatient Surgery (3)

•Patient Transport (1)

1 - 20 of 283

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COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

STUDY

Direct reporting of laboratory test results to patients by mail to enhance patient safety.

Sung S, Forman-Hoffman V, Wilson MC, Cram P. J Gen Intern Med. 2006;21:1075-78.

STUDY

Disclosure-and-resolution programs that include generous compensation offers may prompt a complex patient response.

Murtagh L, Gallagher TH, Andrew P, Mello MM. Health Aff (Millwood). 2012;31:2681-2689.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

COMMENTARY

Anatomy of an incident disclosure: the importance of dialogue.

Iedema R, Allen S. Jt Comm J Qual Patient Saf. 2012;38:435-442.

STUDY

Disclosing harmful mammography errors to patients.

Gallagher TH, Cook AJ, Brenner RJ, et al. Radiology. 2009;253:443-452.

BOOK/REPORT classic

When Things Go Wrong: Responding to Adverse Events.

A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

STUDY

Managing the after effects of serious patient safety incidents in the NHS: an online survey study.

Pinto A, Faiz O, Vincent C. BMJ Qual Saf. 2012;21:1001-1008.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

COMMENTARY

Apology for errors: whose responsibility?

Leape LL. Front Health Serv Manage. 2012;28:3-12.

STUDY

Peer support: healthcare professionals supporting each other after adverse medical events.

van Pelt F. Qual Saf Health Care. 2008;17:249-252.

NEWSPAPER/MAGAZINE ARTICLE

Massachusetts hospitals launch patient apology program.

Gallegos A. American Medical News. May 21, 2012.

COMMENTARY

Successful remediation of patient safety incidents: a tale of two medication errors.

Helmchen LA, Richards MR, McDonald TB. Health Care Manage Rev. 2011;36:1-10.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

DATABASE/DIRECTORY

HospitalInspections.org

Columbia, MO: Association of Health Care Journalists.

COMMENTARY

Ashamed to admit it: owning up to medical error.

Ofri D. Health Aff (Millwood). 2010;29:1549-1551.

COMMENTARY

The art of apology: when and how to seek forgiveness.

Roberts RG. Fam Pract Manag. July/August 2007;14:44-49.

STUDY

Factors associated with disclosure of medical errors by housestaff.

Kronman AC, Paasche-Orlow M, Orlander JD. BMJ Qual Saf. 2012;21:271-278.

REVIEW

Narrative review: do state laws make it easier to say "I'm sorry?"

McDonnell WM, Guenther E. Ann Intern Med. 2008;149:811-815.

ORGANIZATIONAL POLICY/GUIDELINES

Disclosure of medical errors involving gametes and embryos.

Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2011;96:1312-1314.

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