Disclosing errors that affect multiple patients.

Roger Chafe; Wendy Levinson; Terrence Sullivan

Commentary

Disclosing errors that affect multiple patients.

June 3, 2009

Chafe R, Levinson W, Sullivan T. CMAJ. 2009;180(11):1125-7.

View more articles from the same authors.

This commentary describes strategies for disclosing medical errors at an institutional level.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Disclosing medical errors to patients: a challenge for health care professionals and institutions.

October 21, 2009

Clinicians in quality improvement: a new career pathway in academic medicine.

February 25, 2009

Disclosing medical errors to patients: a status report in 2007.

August 15, 2007

Disclosing harmful medical errors to patients: a time for professional action.

September 21, 2005

Physicians with multiple patient complaints: ending our silence.

May 8, 2013

JAMA professionalism: disclosure of medical error.

August 24, 2016

Quality improvement in medical education: current state and future directions.

January 18, 2012

Disclosing harmful medical errors to patients.

July 11, 2007

Teaching medical error disclosure to physicians-in-training: a scoping review.

May 8, 2013

How surgeons disclose medical errors to patients: a study using standardized patients.

December 7, 2005

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

January 11, 2006

Teaching quality improvement and patient safety to trainees: a systematic review.

June 30, 2010

Factors influencing perioperative nurses' error reporting preferences.

March 28, 2007

Sustaining quality improvement and patient safety training in graduate medical education: lessons from social theory.

September 11, 2013

Patients' and physicians' attitudes regarding the disclosure of medical errors.

March 6, 2005

Recognizing quality improvement and patient safety activities in academic promotion in departments of medicine: innovative language in promotion criteria.

July 13, 2016

The role of quality improvement and patient safety in academic promotion: results of a survey of chairs of departments of internal medicine in North America.

April 20, 2011

The emotional impact of medical errors on practicing physicians in the United States and Canada.

August 1, 2007

Learning through experience: influence of formal and informal training on medical error disclosure skills in residents.

April 19, 2017

Lost opportunities: how physicians communicate about medical errors.

January 23, 2008

Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures.

September 21, 2011

US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients.

August 16, 2006

The attitudes and experiences of trainees regarding disclosing medical errors to patients.

March 19, 2008

How trainees would disclose medical errors: educational implications for training programmes.

April 13, 2011

Choosing your words carefully: how physicians would disclose harmful medical errors to patients.

August 16, 2006

Risk managers, physicians, and disclosure of harmful medical errors.

February 24, 2010

Disclosing adverse events to patients: international norms and trends.

April 30, 2014

Strategies for developing and recognizing faculty working in quality improvement and patient safety.

June 1, 2016

Talking with patients about other clinicians' errors.

November 6, 2013

The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.

December 21, 2016

Interruptions and blood transfusion checks: lessons from the simulated operating room.

February 4, 2009

A piece of my mind. Coping with fallibility.

March 6, 2005

Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals.

October 28, 2009

Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review.

March 20, 2013

The heart of darkness: the impact of perceived mistakes on physicians.

March 6, 2005

Implementing a standardized safe surgery program reduces serious reportable events.

February 4, 2015

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.

August 6, 2008

Quantification of surgical resident stress "on call".

November 30, 2005

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.

July 10, 2019

Interventions designed to improve the safety and quality of therapeutic anticoagulation in an inpatient electronic medical record.

April 22, 2020

Teaching medical students about medical errors and patient safety: evaluation of a required curriculum.

June 15, 2005

Medication errors in pediatrics—the octopus evading defeat.

March 6, 2005

Effectively leading for quality.

October 4, 2017

Health system resilience, accreditation, high-quality care, and continuous quality improvement: what is the destination and how do we get there?

July 12, 2023

Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety.

January 23, 2013

Look back and talk openly: responding to and communicating about the risk of large-scale error in pathology diagnoses.

February 15, 2012

Implementing the Safety Thermometer tool in one NHS trust.

April 16, 2014

Design and implementation of the infection prevention program into risk management: managing high level disinfection and sterilization in the outpatient setting.

June 24, 2020

How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review.

May 29, 2019

No shortcuts to safer opioid prescribing.

May 8, 2019

Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.

March 6, 2019

The effectiveness of nurse education and training for clinical alarm response and management: a systematic review.

October 4, 2017

Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs and benefits of intervention strategies.

September 2, 2009

Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults.

March 3, 2010

Personalised performance feedback reduces narcotic prescription errors in a NICU.

March 27, 2013

Physicians-in-training attitudes on patient safety: 2003 to 2008.

September 7, 2011

Factors that influence the expected length of operation: results of a prospective study.

January 4, 2012

Interruptions and miscommunications in surgery: an observational study.

May 16, 2012

The impact of a nurse led rapid response system on adverse, major adverse events and activation of the medical emergency team.

March 4, 2015

CDC guideline for prescribing opioids for chronic pain—United States, 2016.

March 30, 2016

Literature review: do rapid response systems reduce the incidence of major adverse events in the deteriorating ward patient?

November 10, 2010

Enhancing communication in surgery through team training interventions: a systematic literature review.

December 22, 2010

The impact of errors on healthcare professionals in the critical care setting.

April 24, 2019

The woman who cried pain: do sex-based disparities still exist in the experience and treatment of pain?

February 8, 2023

Implementing bedside handover: strategies for change management.

October 27, 2010

Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose.

May 21, 2008

Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events.

June 6, 2007

E-prescribing, efficiency, quality: lessons from the computerization of UK family practice.

September 20, 2006

Findings of a naloxone database and its utilization to improve safety and education in a tertiary care medical center.

February 1, 2017

Cognitive engineering to improve patient safety and outcomes in cardiothoracic surgery

December 4, 2019

The effects of hospital safety scores, total price, out-of-pocket cost, and household income on consumers' self-reported choice of hospitals.

November 29, 2017

How to avoid the 'seven deadly sins of surgery.'

March 14, 2012

Why isn't 'time out' being implemented? An exploratory study.

March 31, 2010

The impact of organisational and individual factors on team communication in surgery: a qualitative study.

December 16, 2009

Effect of a weight-based prescribing method within an electronic health record on prescribing errors.

November 25, 2009

Applying the high reliability health care maturity model to assess hospital performance: a VA case study.

August 31, 2016

Medication reconciliation in the acute care setting: opportunity and challenge for nursing.

May 4, 2005

Systematic review of the impact of physician work schedules on patient safety with meta-analyses of mortality risk.

August 16, 2023

Patient safety and suicide prevention in mental health services: time for a new paradigm?

February 19, 2020

Patient preferences for participation in patient care and safety activities in hospitals.

December 20, 2017

How reliable are patient-completed medication reconciliation forms compared with pharmacy lists?

November 21, 2012

Quality improvement and patient safety activities in academic departments of medicine.

October 31, 2012

A multidisciplinary approach to adverse drug events in pediatric trauma patients in an adult trauma center.

July 15, 2009

Older patients' engagement in hospital medication safety behaviours.

June 16, 2021

Clinical handover of patients arriving by ambulance to the emergency department: a literature review.

October 13, 2010

Predictors of adverse events in patients after discharge from the intensive care unit.

May 28, 2008

Nearing zero...reducing grade C medication errors.

July 23, 2014

The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.

December 22, 2010

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

Analysis of iatrogenic and in-hospital medication errors reported to United States poison centers: a retrospective observational study.

June 24, 2020

What causes adverse events in prehospital care? A human-factors approach.

September 19, 2012

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system.

August 6, 2014

Effect of emergency medicine pharmacists on medication-error reporting in an emergency department.

November 17, 2010

Patient characteristics and the occurrence of never events.

February 24, 2010

Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit.

April 2, 2008

Agreement between patient-reported symptoms and their documentation in the medical record.

August 27, 2008

Early prognostic value of the medical emergency team calling criteria in patients admitted to intensive care from the emergency department.

February 6, 2008

A trigger tool to identify adverse events in the intensive care unit.

October 4, 2006

Increasing adoption of computerized provider order entry, and persistent regional disparities, in US emergency departments.

August 31, 2011

Improving the discharge process by embedding a discharge facilitator in a resident team.

November 16, 2011

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Interview

In conversation with Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

December 14, 2022

Perspective

Resilient Healthcare and the Safety-I and Safety-II Frameworks

December 14, 2022

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

November 9, 2022

LeDeR - Learning from Lives and Deaths.

January 19, 2022

The Life and Death of Elizabeth Dixon: A Catalyst for Change.

December 9, 2020

COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected.

August 19, 2020

Global oncology pharmacy response to COVID-19 pandemic: medication access and safety.

June 10, 2020

Canada continues to lag behind other OECD countries on measures of patient safety

December 4, 2019

Deprescribing Guidelines: Special Section on Symposium Results.

June 26, 2019

Doctors were alarmed: would I have my children have surgery here?

June 12, 2019

Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.

March 13, 2019

How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals.

March 13, 2019

JAMA professionalism: disclosure of medical error.

August 24, 2016

Safety of the Manchester Triage System to detect critically ill children at the emergency department.

August 17, 2016

Patient safety: disclosure of medical errors and risk mitigation.

August 3, 2016

Do physicians clean their hands? Insights from a covert observational study.

July 27, 2016

Innovations to improve patient safety.

June 1, 2016

Breaking the silence of the switch—increasing transparency about trainee participation in surgery.

July 29, 2015

Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study.

November 26, 2014

Communicating doses of pediatric liquid medicines to parents/caregivers: a comparison of written dosing directions on prescriptions with labels applied by dispensed pharmacy.

May 21, 2014

An interprofessional qualitative study of barriers and potential solutions for the safe use of insulin in the hospital setting.

April 23, 2014

Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study.

April 9, 2014

To disclose or not to disclose radiologic errors: should "patient-first" supersede radiologist self-interest?

September 11, 2013

Anatomy of an incident disclosure: the importance of dialogue.

October 3, 2012

2012 ISMP International Medication Safety Self Assessment for Oncology.

April 18, 2012

Patients count on it: an initiative to reduce incorrect counts and prevent retained surgical items.

January 18, 2012

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.

September 28, 2011

What prevents incident disclosure, and what can be done to promote it?

August 31, 2011

Revealing their medical errors: why three doctors went public.

August 24, 2011

See More About The Topic

Health Care Providers

Health Care Executives and Administrators

Audit and Feedback

Practice Guidelines

Public Reporting

Disclosing errors that affect multiple patients.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Disclosing errors that affect multiple patients.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

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