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PSNet: Patient Safety Network
Journal Article

Anatomy of an incident disclosure: the importance of dialogue.

Iedema R, Allen S. Joint Commission journal on quality and patient safety. 2012;38:435-42.

Physician organizations wholeheartedly support full disclosure following medical errors, and The Joint Commission requires that hospitals disclose unanticipated outcomes of care. This detailed case study discusses a unique incident disclosure process that involved prolonged dialogue between a patient's family and hospital staff over the course of multiple telephone calls and meetings. The initial basis for disclosure was a fatal medication error, but these discussions uncovered other serious errors in this case including flawed communication and delayed recognition of clinical deterioration. Using direct quotations from the patient's wife, this report reinforces the important role that patients and their families can play in quality improvement and patient safety. Medical error disclosure is discussed by Dr. Allen Kachalia in an AHRQ WebM&M perspective.