Between a rock and a hard place: disclosing medical errors.

Kimberley G. Crone; Michele B. Muraski; Joy D. Skeel; Latisha Love-Gregory; Jack H. Ladenson; Ann M. Gronowski

Commentary

Between a rock and a hard place: disclosing medical errors.

September 20, 2006

Crone KG, Muraski MB, Skeel JD, et al. Clin Chem. 2006;52(9):1809-14.

View more articles from the same authors.

The authors share a case study of an inadvertent drug misadministration and discuss the fiduciary duty of clinical team members to report errors or violations in patient care.

PubMed citation

Available at

Related Resources From the Same Author(s)

Error reduction through team leadership: applying aviation's CRM model in the OR.

February 22, 2006

Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences.

May 18, 2011

Prevalence and nature of errors and near errors reported by hospital staff nurses.

March 6, 2005

Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study.

May 17, 2017

The many faces of error disclosure: a common set of elements and a definition.

April 4, 2007

Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand?

July 30, 2008

Promising roles for pharmacists in addressing the U.S. opioid crisis.

February 14, 2018

Internal medicine work hours: trends, associations, and implications for the future.

February 13, 2008

Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens.

August 17, 2016

An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm.

April 13, 2016

Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency.

December 13, 2006

How do we learn about error? A cross-sectional study of urology trainees.

June 28, 2023

Doctors debate safety of their white coats.

December 2, 2015

Pediatric weight errors and resultant medication dosing errors in the emergency department.

November 22, 2017

Human factors systems approach to healthcare quality and patient safety.

August 14, 2013

Standards for patient monitoring during general anesthesia at Harvard Medical School.

March 6, 2005

Reducing near miss medication events using an evidence-based approach.

July 27, 2022

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems.

January 28, 2015

Hand hygiene and healthcare system change within multi-modal promotion: a narrative review.

April 24, 2013

Communicating with patients about diagnostic errors in breast cancer care: providers' attitudes, experiences, and advice

January 22, 2020

Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly.

May 16, 2007

A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective.

October 23, 2013

Nurses: the patient's first—and perhaps last—line of defense.

June 24, 2009

Balancing just culture with regulatory standards.

October 22, 2008

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

August 24, 2011

Human factors in anaesthetic practice: insights from a task analysis.

March 19, 2008

Emergency physicians and disclosure of medical errors.

November 8, 2006

Antibiotic timing and errors in diagnosing pneumonia.

March 5, 2008

Ambulance stretcher adverse events.

June 17, 2009

Comparing trainee and staff perceptions of patient safety culture.

June 29, 2016

Hospital process compliance and surgical outcomes in Medicare beneficiaries.

October 27, 2010

Meaningful use's benefits and burdens for US family physicians.

May 30, 2018

Variation in caregiver perceptions of teamwork climate in labor and delivery units.

July 5, 2006

Motivational influences on anaesthetists' use of practice guidelines.

May 13, 2009

Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation.

May 15, 2013

Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France.

June 29, 2005

Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality.

April 20, 2022

Pathologists' perspectives on disclosing harmful pathology error.

May 3, 2017

Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.

June 11, 2008

An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement.

October 19, 2022

Creating complex health improvement programs as mindful organizations: from theory to action.

October 17, 2007

Potentially inappropriate prescribing for adults living with diabetes mellitus: a scoping review.

October 5, 2022

Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative.

May 18, 2016

Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses.

April 13, 2016

Bullying: a hidden threat to patient safety.

May 28, 2014

Systems analysis of adverse drug events.

March 27, 2005

Towards a more patient-centered approach to medication safety.

December 13, 2017

A contemporary analysis of closed claims related to wrong site surgery.

March 29, 2023

Voluntary electronic reporting of medical errors and adverse events.

January 18, 2006

Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review.

February 16, 2022

Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals.

March 6, 2005

The quality, safety and content of telephone and face-to-face consultations: a comparative study.

June 2, 2010

Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial.

June 20, 2007

Rapid response systems.

November 26, 2014

Controversies surrounding use of order sets for clinical decision support in computerized provider order entry.

November 29, 2006

Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses.

February 17, 2010

How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting.

March 6, 2005

Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of transfusion scheme 1996-2005.

June 25, 2008

Prevalence of medication transfer errors in nephrology patients and potential risk factors.

November 6, 2019

National Patient Safety Foundation agenda for research and development in patient safety.

March 27, 2005

Program director perceptions of surgical resident training and patient care under flexible duty hour requirements.

September 7, 2016

Ending disruptive behavior: staff nurse recommendations to nurse educators.

September 4, 2013

Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial.

January 8, 2014

A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system.

December 16, 2009

Nurses' use of computerized clinical guidelines to improve patient safety in hospitals.

May 6, 2015

Making residents part of the safety culture: improving error reporting and reducing harms.

February 15, 2017

Relationship between patient complaints and surgical complications.

February 15, 2006

High 5s initiative: implementation of medication reconciliation in France a 5 years experimentation.

June 21, 2017

Incidence of medication errors and adverse drug events in the ICU: a systematic review.

September 15, 2010

Medication-prescribing errors in a teaching hospital: a 9-year experience.

March 6, 2005

Development of an expert system for classification of medical errors.

June 15, 2005

Neurologic patient safety: an in-depth study of malpractice claims.

November 9, 2005

Declines in opioid prescribing after a private insurer policy change—Massachusetts, 2011–2015.

November 9, 2016

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.

January 23, 2008

How can the principles of complexity science be applied to improve the coordination of care for complex pediatric patients?

April 19, 2006

Measuring and managing quality of surgery. Statistical vs incidental approaches.

March 6, 2005

Medication reconciliation at hospital discharge: evaluating discrepancies.

October 15, 2008

Incidence of adverse drug events and potential adverse drug events: implications for prevention.

March 27, 2005

The second victim: a review.

June 28, 2017

Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies.

December 7, 2011

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

October 21, 2009

National cluster-randomized trial of duty-hour flexibility in surgical training.

February 10, 2016

Patient falls in the operating room setting: an analysis of reported safety events.

May 11, 2022

Responding to patient safety incidents: the "seven pillars."

April 7, 2010

Negligent care and malpractice claiming behavior in Utah and Colorado.

March 27, 2005

The role of cognitive bias in breast radiology diagnostic and judgment errors.

May 27, 2020

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

October 19, 2005

Defining attributes of patient safety through a concept analysis.

July 15, 2015

On the trail of quality and safety in health care.

January 23, 2008

Reduction in pediatric identification band errors: a quality collaborative.

August 22, 2012

Safety standards: implementing fall prevention interventions and sustaining lower fall rates by promoting the culture of safety on an inpatient rehabilitation unit.

December 9, 2015

Patient safety in after-hours telephone medicine.

June 20, 2007

Review of alternatives to root cause analysis: developing a robust system for incident report analysis.

September 18, 2019

'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene.

November 14, 2007

Safety issues in combined gynecologic and plastic surgical procedures.

August 15, 2007

Board of pharmacy practices related to medication errors and their potential impact on patient safety.

August 1, 2018

A review of best practices for intravenous push medication administration.

December 20, 2017

What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.

May 5, 2010

Preventable errors in organ transplantation: an emerging patient safety issue?

July 11, 2012

Resident work hour limits and patient safety.

June 8, 2005

Related Resources

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

November 29, 2023

Redesigning Event Review with RCA2.

March 12, 2024 - April 23, 2024

Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries.

May 24, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Patient Safety Innovations

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

March 15, 2023

Exploring nurses' attitudes, skills, and beliefs of medication safety practices.

August 24, 2022

Pump up the volume: tips for increasing error reporting and decreasing patient harm.

September 8, 2021

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

Implementing a human factors approach to RCA(2) : tools, processes and strategies.

March 10, 2021

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.

July 22, 2020

Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt.

November 13, 2019

Standardized Competencies for Parenteral Nutrition Administration: the ASPEN Model.

June 20, 2018

Organizational response to known medical errors: does peer review protection impede improvement?

May 30, 2018

Physician burnout in the electronic health record era: are we ignoring the real cause?

May 9, 2018

A framework for operationalizing risk: a practical approach to patient safety.

May 2, 2018

Qualitative content analysis of coworkers' safety reports of unprofessional behavior by physicians and advanced practice professionals.

April 18, 2018

Insulin dosing error in a patient with severe hyperkalemia.

January 17, 2018

Where should patient safety be installed?

November 29, 2017

Using fault trees to advance understanding of diagnostic errors.

November 1, 2017

The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program.

June 14, 2017

Root cause analysis of adverse events in an outpatient anticoagulation management consortium.

May 31, 2017

Root-cause analysis: swatting at mosquitoes versus draining the swamp.

March 22, 2017

Perspective

Errors and Near Misses: What Health Care Could Learn From Aviation

December 1, 2016

Interview

In Conversation With... James P. Bagian, MD, PE

December 1, 2016

How to Improve Electronic Health Record Usability and Patient Safety.

October 5, 2016

Performing the wrong procedure.

September 28, 2016

The problem with the '5 whys.'

September 14, 2016

Unit-based incident reporting and root cause analysis: variation at three hospital unit types.

August 17, 2016

See More About The Topic

Health Care Providers

Facility and Group Administrators

Risk Managers

Medicine

Administration Errors

Between a rock and a hard place: disclosing medical errors.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Between a rock and a hard place: disclosing medical errors.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site