Commentary Between a rock and a hard place: disclosing medical errors. Citation Text: Crone KG, Muraski MB, Skeel JD, et al. Between a rock and a hard place: disclosing medical errors. Clin Chem. 2006;52(9):1809-14. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL 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 Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Crone KG, Muraski MB, Skeel JD, et al. Between a rock and a hard place: disclosing medical errors. Clin Chem. 2006;52(9):1809-14. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Optimizing Pediatric Patient Safety in the Emergency Care Setting. October 19, 2022 Families as partners in hospital error and adverse event surveillance. March 8, 2017 The impact of racism on child and adolescent health. July 1, 2019 Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences. May 18, 2011 Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022 Using social and behavioural science to support COVID-19 pandemic response. June 3, 2020 The many faces of error disclosure: a common set of elements and a definition. April 4, 2007 Medication reconciliation at hospital discharge: evaluating discrepancies. October 15, 2008 Meaningful use's benefits and burdens for US family physicians. May 30, 2018 National cluster-randomized trial of duty-hour flexibility in surgical training. February 10, 2016 Defining the landscape of patient harm after osteopathic manipulative treatment: synthesis of an adverse event model. December 13, 2023 Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020 Findings of the first consensus conference on medical emergency teams. August 16, 2006 Talking with patients about other clinicians' errors. November 6, 2013 Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023 A randomized trial of a multifactorial strategy to prevent serious fall injuries. July 29, 2020 Error reduction through team leadership: applying aviation's CRM model in the OR. February 22, 2006 Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. January 28, 2015 Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? July 30, 2008 Sustaining the gains: a 7-year follow-through of a hospital-wide patient safety improvement project on hospital-wide adverse event outcomes and patient safety culture. June 10, 2020 Human factors systems approach to healthcare quality and patient safety. August 14, 2013 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 Point prevalence of surgical checklist use in Europe: relationship with hospital mortality. February 25, 2015 Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023 Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study. May 17, 2017 Comparing trainee and staff perceptions of patient safety culture. June 29, 2016 Prevalence and nature of errors and near errors reported by hospital staff nurses. March 6, 2005 Toward the development of the perfect medical team: critical components for adaptation. March 17, 2021 Readiness of US general surgery residents for independent practice. October 4, 2017 Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022 Variation in caregiver perceptions of teamwork climate in labor and delivery units. July 5, 2006 Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023 Declines in opioid prescribing after a private insurer policy change—Massachusetts, 2011–2015. November 9, 2016 Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. March 27, 2005 The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. November 12, 2014 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data. September 24, 2014 Pediatric weight errors and resultant medication dosing errors in the emergency department. November 22, 2017 Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. March 27, 2005 Standards for patient monitoring during general anesthesia at Harvard Medical School. March 6, 2005 Response of practicing chiropractors during the early phase of the COVID-19 pandemic: a descriptive report. July 8, 2020 Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma. February 20, 2013 Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. May 16, 2007 Systems analysis of adverse drug events. March 27, 2005 Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011 Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study. May 11, 2022 Towards a more patient-centered approach to medication safety. December 13, 2017 Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. December 6, 2006 Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 6, 2013 Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. April 13, 2016 Resident work hour limits and patient safety. June 8, 2005 A contemporary analysis of closed claims related to wrong site surgery. March 29, 2023 The quality, safety and content of telephone and face-to-face consultations: a comparative study. June 2, 2010 Relationship between patient complaints and surgical complications. February 15, 2006 The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose. February 14, 2018 Teamwork is associated with reduced hospital staff burnout at military treatment facilities: findings from the 2019 Department of Defense Patient Safety Culture Survey. March 22, 2023 Technological distractions—part 1 and part 2. February 14, 2018 Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. October 21, 2009 Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018 Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. November 1, 2016 Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy. July 6, 2011 SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. October 3, 2013 Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service. August 24, 2011 Communication and birth experiences among Black birthing people who experienced preterm birth. February 14, 2024 Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry. July 19, 2006 Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. March 23, 2011 An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm. April 13, 2016 Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial. January 8, 2014 Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. June 20, 2007 Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency. December 13, 2006 Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. December 2, 2020 Changes in medical errors after implementation of a handoff program. November 12, 2014 Promising roles for pharmacists in addressing the U.S. opioid crisis. February 14, 2018 Global oximetry: an international anaesthesia quality improvement project. October 21, 2009 Measures of patient safety in developing and emerging countries: a review of the literature. March 17, 2010 Implementing standardized reporting and safety checklists. June 1, 2011 Disclosing harmful mammography errors to patients. December 16, 2009 Characteristics associated with requests by pathologists for second opinions on breast biopsies. May 17, 2017 Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative. May 18, 2016 Prevalence of medication transfer errors in nephrology patients and potential risk factors. November 6, 2019 A national mixed-methods evaluation of preparedness for general surgery residency and the association with resident burnout. September 2, 2020 Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. September 2, 2020 Program director perceptions of surgical resident training and patient care under flexible duty hour requirements. September 7, 2016 Internal medicine work hours: trends, associations, and implications for the future. February 13, 2008 Diagnostic concordance among pathologists interpreting breast biopsy specimens. March 25, 2015 Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study. July 13, 2016 Utilizing improvement science methods to improve physician compliance with proper hand hygiene. March 29, 2012 Pathologists' perspectives on disclosing harmful pathology error. May 3, 2017 Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. May 13, 2009 Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. October 19, 2005 Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use? January 11, 2012 Evaluating serial strategies for preventing wrong-patient orders in the NICU. June 28, 2017 Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. April 20, 2022 Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU. December 5, 2012 A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system. December 16, 2009 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 Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. May 15, 2013 Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. February 23, 2011 The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question. June 28, 2023 Safety and diagnostic accuracy of tumor biopsies in children with cancer. June 10, 2015 View More Related Resources Redesigning Event Review with RCA2. September 10, 2024 - September 17, 2024 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 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 A review of best practices for intravenous push medication administration. December 20, 2017 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 View More See More About The Topic Health Care Providers Facility and Group Administrators Risk Managers Medicine Administration Errors View More
Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences. May 18, 2011
Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022
Defining the landscape of patient harm after osteopathic manipulative treatment: synthesis of an adverse event model. December 13, 2023
Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021
Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020
Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. January 28, 2015
Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? July 30, 2008
Sustaining the gains: a 7-year follow-through of a hospital-wide patient safety improvement project on hospital-wide adverse event outcomes and patient safety culture. June 10, 2020
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
Point prevalence of surgical checklist use in Europe: relationship with hospital mortality. February 25, 2015
Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023
Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study. May 17, 2017
Toward the development of the perfect medical team: critical components for adaptation. March 17, 2021
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023
Declines in opioid prescribing after a private insurer policy change—Massachusetts, 2011–2015. November 9, 2016
Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. March 27, 2005
The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. November 12, 2014
5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data. September 24, 2014
Pediatric weight errors and resultant medication dosing errors in the emergency department. November 22, 2017
Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. March 27, 2005
Response of practicing chiropractors during the early phase of the COVID-19 pandemic: a descriptive report. July 8, 2020
Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma. February 20, 2013
Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. May 16, 2007
Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011
Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study. May 11, 2022
Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. December 6, 2006
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 6, 2013
Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. April 13, 2016
The quality, safety and content of telephone and face-to-face consultations: a comparative study. June 2, 2010
The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose. February 14, 2018
Teamwork is associated with reduced hospital staff burnout at military treatment facilities: findings from the 2019 Department of Defense Patient Safety Culture Survey. March 22, 2023
Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. October 21, 2009
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018
Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. November 1, 2016
Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy. July 6, 2011
SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. October 3, 2013
Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service. August 24, 2011
Communication and birth experiences among Black birthing people who experienced preterm birth. February 14, 2024
Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry. July 19, 2006
Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. March 23, 2011
An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm. April 13, 2016
Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial. January 8, 2014
Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency. December 13, 2006
Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. December 2, 2020
Measures of patient safety in developing and emerging countries: a review of the literature. March 17, 2010
Characteristics associated with requests by pathologists for second opinions on breast biopsies. May 17, 2017
Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative. May 18, 2016
Prevalence of medication transfer errors in nephrology patients and potential risk factors. November 6, 2019
A national mixed-methods evaluation of preparedness for general surgery residency and the association with resident burnout. September 2, 2020
Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. September 2, 2020
Program director perceptions of surgical resident training and patient care under flexible duty hour requirements. September 7, 2016
Internal medicine work hours: trends, associations, and implications for the future. February 13, 2008
Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study. July 13, 2016
Utilizing improvement science methods to improve physician compliance with proper hand hygiene. March 29, 2012
Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. May 13, 2009
Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. October 19, 2005
Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use? January 11, 2012
Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. April 20, 2022
Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU. December 5, 2012
A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system. December 16, 2009
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
Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. May 15, 2013
Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. February 23, 2011
The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question. June 28, 2023
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
Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. May 24, 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
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
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
Organizational response to known medical errors: does peer review protection impede improvement? May 30, 2018
Qualitative content analysis of coworkers' safety reports of unprofessional behavior by physicians and advanced practice professionals. April 18, 2018
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