Disclosing unanticipated outcomes to patients: the art and practice.

Commentary

Disclosing unanticipated outcomes to patients: the art and practice.

September 12, 2007

Gallagher TH; Denham CR; Leape LL; Amori G; Levinson W.

View more articles from the same authors.

Although medical errors remain disturbingly common, many patients are never informed about errors that occur during their care. Disclosing errors to patients was identified as a priority in the National Quality Forum's 2006 update to Safe Practices for Better Healthcare. In this commentary, the authors discuss the essential components of full disclosure, methods for overcoming barriers to error disclosure, and how an organization can improve the culture of safety through encouraging disclosure.

Available at

Related Resources From the Same Author(s)

The patient safety battles—put on your armor.

October 4, 2006

Patient safety practices: leaders can turn barriers into accelerators.

May 11, 2005

Should we disclose harmful medical errors to patients? If so, how?

October 12, 2005

Transparency and public reporting are essential for a safe health care system.

April 7, 2010

Patient Safety as an Exercise in Behavioral Change.

October 24, 2012

Talking with Patients and Families about Medical Error: A Guide for Education and Practice.

February 16, 2011

Risk Management Pearls on Disclosure of Adverse Events.

July 26, 2006

Reducing Adverse Drug Events.

March 6, 2005

Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety.

March 29, 2006

Reconciling medications at admission: safe practice recommendations and implementation strategies.

January 11, 2006

Simulation and the diagnostic process: a pilot study of trauma and rapid response teams.

December 20, 2017

Perspective: a culture of respect—part 1 and part 2.

June 20, 2012

Medication reconciliation physician order form.

December 20, 2006

Perfect is possible.

October 25, 2006

Communicating Critical Test Results.

March 6, 2005

Conversations with...Lucian Leape, MD.

July 17, 2013

U.S. to delete data on life-threatening mistakes from website.

May 15, 2013

At VA hospital, a rogue cancer unit.

July 1, 2009

The human factor.

November 5, 2014

Family matters: pharmacy mix-ups.

August 13, 2014

Do doctors understand test results?

July 23, 2014

Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies.

January 23, 2008

Apology for errors: whose responsibility?

April 18, 2012

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

November 24, 2010

Adverse Events in Hospitals: Methods for Identifying Events.

March 17, 2010

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

July 27, 2016

Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries.

January 9, 2019

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

January 18, 2012

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.

March 19, 2014

Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals.

February 11, 2015

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

February 18, 2009

Adverse Events in Hospitals: State Reporting Systems.

January 14, 2009

Adverse Events in Hospitals: Overview of Key Issues.

January 14, 2009

Making Healthcare Safe: The Story of the Patient Safety Movement.

June 9, 2021

WebM&M Cases

The Wrong Shot: Error Disclosure

June 1, 2004

Limiting resident physicians' work hours to save lives.

July 20, 2011

Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units.

March 6, 2005

Working Knowledge: How Organizations Manage What They Know.

September 14, 2005

Critical Incident Technique Bibliography—2001.

March 27, 2005

Investigation: dangers of medical recovery rooms.

February 20, 2013

Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare.

September 5, 2018

The partnership with patients: a call to action for leaders.

September 7, 2011

Radiation offers new cures, and ways to do harm.

February 3, 2010

Opioid addiction is the biggest drug epidemic in U.S. history. How'd we get here?

October 18, 2017

Using Human Factors Engineering to Improve Patient Safety, Second edition.

June 29, 2005

Preventing medical injury.

March 27, 2005

A safe practice standard for barcode technology.

June 3, 2015

Disruptive clinician behavior: a persistent threat to patient safety.

August 9, 2006

Can we use incident reports to detect hospital adverse events?

March 12, 2008

Another medical malpractice crisis?: Try something different.

October 14, 2020

Ferrari's Formula One handovers and handovers from surgery to intensive care.

September 10, 2008

Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety.

July 6, 2011

Harm to Healing - Partnering with Patients Who Have Been Harmed.

August 1, 2012

Reducing the Risk by Designing a Safer, Shame-free Health Care Environment.

September 26, 2007

Origin of Adverse Drug Events in US Hospitals, 2011.

October 9, 2013

Prevention of potential errors in resuscitation medications orders by means of a computerised physician order entry in paediatric critical care.

February 28, 2007

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.

March 27, 2005

The 2004 John M. Eisenberg Patient Safety and Quality Awards.

March 6, 2005

Impact of computerized prescriber order entry (CPOE) on clinical pharmacy practice: a hypothesis-generating study.

October 24, 2007

The Medical Apology: Making It Right When Things Go Wrong.

April 18, 2012

Preventing medication mistakes.

May 16, 2012

Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.

February 27, 2008

WebM&M Cases

Duty to Disclose Someone Else's Error?

May 1, 2011

Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023.

May 10, 2023

Implementation of patient safety initiatives in US hospitals.

May 24, 2006

Coronavirus strains hospitals, cancer patients face treatment delays, uncertainty.

April 15, 2020

Perspective

Workplace Safety in Health Care

January 1, 2017

Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014.

August 20, 2014

Improving Diagnosis in Medicine Act of 2022.

July 20, 2022

Improving Safety and Security for Veterans Act of 2020.

February 12, 2020

Veterans Accountability Improvement Act.

April 22, 2021

Patient Safety Improvement Act of 2020.

March 25, 2020

Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain.

March 6, 2005

No excuses: the reality that demands action.

September 1, 2005

Hospital Reporting of Deaths Related to Restraint and Seclusion.

September 27, 2006

Nursing Home Complaint Investigations.

September 20, 2006

Merry and McCall Smith's Errors, Medicine, and the Law. 2nd ed.

March 6, 2005

Improving Hand-Off Communication.

October 31, 2007

Why pay for mistakes?

September 5, 2007

Do HSMRs really measure patient safety?

August 13, 2008

Peggy Lillis Foundation.

February 7, 2018

National Patient Safety Board Act of 2022.

December 21, 2022

Improving Diagnosis in Medicine Act of 2020.

December 23, 2020

Unmet Needs: Teaching Physicians to Provide Safe Patient Care.

March 17, 2010

Health Information Technology and Patient Safety: A Dynamic Discussion.

August 17, 2011

Order from Chaos: Accelerating Care Integration.

November 7, 2012

Americans' Experiences With Medical Errors and Views on Patient Safety.

October 11, 2017

Shining a Light: Safer Health Care Through Transparency.

January 28, 2015

Ariadne Labs.

May 23, 2018

Respectful, trusting relationships are essential for patient safety, especially the surgeon-anesthesiologist dyad.

November 20, 2019

National Quality Forum.

March 6, 2005

Pediatric medication errors and reduction strategies in the perioperative period.

November 24, 2021

Noise: a Flaw in Human Judgement.

August 25, 2021

Leading a Culture of Safety: a Blueprint for Success.

May 24, 2017

Moving Measurement into Action: Global Principles for Measuring Patient Safety.

January 8, 2020

PACT Collaborative: Pathway to Accountability, Compassion and Transparency.

July 11, 2023

WebM&M Cases

Departure From Central Line Ritual

May 1, 2015

First, Do No Harm.

September 14, 2011

More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.

July 30, 2014

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Disclosure of errors in surgical procedures.

January 19, 2024

PACT Collaborative: Pathway to Accountability, Compassion and Transparency.

July 11, 2023

Disclosing medical errors: prioritising the needs of patients and families.

July 5, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence.

April 12, 2023

Getting Started with a Communication and Resolution Program (CRP) Policy or Commitment Statement to CR.

January 25, 2023

A family and hospital's journey and commitment to improving diagnostic safety.

March 9, 2022

The Good, The Bad, and The Ugly: Patient Experiences with CRPs.

October 21, 2021 - October 21, 2021

'More than words' - interpersonal communication, cognitive bias and diagnostic errors.

August 11, 2021

Enhancing a culture of safety through disclosure of adverse events.

March 10, 2021

Communication about medical errors.

February 24, 2021

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Communication with patients and families regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure.

August 12, 2020

Amid the COVID-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative.

June 24, 2020

The patient died: what about involvement in the investigation process?

June 24, 2020

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey.

February 12, 2020

Error disclosure and apology in radiology: the case for further dialogue.

September 25, 2019

Patient Safety in Obstetrics and Gynecology.

May 29, 2019

Communication and Resolution After an Adverse Health Care Incident.

May 22, 2019

Interview

In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD

April 1, 2019

Interview

In Conversation With… Timothy B. McDonald, MD, JD

April 1, 2019

Taking the blame: appropriate responses to medical error.

January 30, 2019

In support of the medical apology: the nonlegal arguments.

October 5, 2016

Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.

July 13, 2016

An experimental study of medical error explanations: do apology, empathy, corrective action, and compensation alter intentions and attitudes?

July 29, 2015

Reflection on adverse event disclosure in the postsurgical hospital context.

May 20, 2015

Should health care providers be forced to apologise after things go wrong?

January 28, 2015

Shining a Light: Safer Health Care Through Transparency.

January 28, 2015

Patient- and family-centered care: error disclosure and investigation.

October 29, 2014

See More About The Topic

Health Care Providers

Health Care Executives and Administrators

Quality and Safety Professionals

Patient Disclosure

Provider-Patient Communication

Disclosing unanticipated outcomes to patients: the art and practice.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Disclosing unanticipated outcomes to patients: the art and practice.

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