Improving disclosure and management of medical error—an opportunity to transform the surgeons of tomorrow.

Ruth Tevlin; Eva Doherty; Oscar Traynor

Review

Improving disclosure and management of medical error—an opportunity to transform the surgeons of tomorrow.

October 2, 2013

Tevlin R, Doherty E, Traynor O. Surgeon. 2013;11(6):338-43.

View more articles from the same authors.

This review recommends educating surgical trainees about error disclosure, teamwork, and non-technical skills to augment their ability to cope and learn from medical errors.

PubMed citation

Available at

Related Resources From the Same Author(s)

What about doctors? The impact of medical errors.

August 20, 2014

What about doctors? The impact of medical errors.

January 14, 2015

Is the skillset obtained in surgical simulation transferable to the operating theatre?

February 19, 2014

Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure.

June 22, 2011

Safety culture includes "good catches."

September 30, 2015

Economic impact of medication error: a systematic review.

May 17, 2017

Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review.

May 16, 2012

Tenfold medication errors: 5 years' experience at a university-affiliated pediatric hospital.

July 18, 2012

Elective surgical patients' narratives of hospitalization: the co-construction of safety.

March 5, 2014

Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting system.

December 18, 2019

Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project.

January 22, 2014

Transition planning for the senior surgeon: guidance and recommendations from the Society of Surgical Chairs.

May 29, 2019

Principles supporting dynamic clinical care teams: an American College of Physicians position paper.

September 25, 2013

Employee silence in health care: charting new avenues for leadership and management.

August 3, 2022

Clinical diagnoses and autopsy findings: discrepancies in critically ill patients.

April 11, 2012

The effect of a rapid response team on major clinical outcome measures in a community hospital.

September 5, 2007

Dementia and risk of adverse warfarin-related events in the nursing home setting.

November 21, 2012

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

February 23, 2011

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

November 17, 2010

Multisource evaluation of surgeon behavior is associated with malpractice claims.

April 11, 2018

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.

November 11, 2020

Diagnostic errors in pediatric echocardiography: development of taxonomy and identification of risk factors.

June 18, 2008

Information technology interventions to improve medication safety in primary care: a systematic review.

July 10, 2013

Noise in the operating room—what do we know? A review of the literature.

December 22, 2010

Positive deviance: a new tool for infection prevention and patient safety.

October 16, 2013

A piece of my mind. Mistakes.

September 27, 2006

Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care or different patient cohorts? A population-based study.

November 20, 2013

Monitoring during sedation given by non-anaesthetic doctors.

March 19, 2008

Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.

June 16, 2021

Avoiding a second wave of medical errors: the importance of human factors in the context of a pandemic.

August 26, 2020

Managing alarm systems for quality and safety in the hospital setting.

November 14, 2018

Perceptions of providing safe care for frail older people at home: a qualitative study based on focus group interviews with home care staff.

November 10, 2021

Interdisciplinary clinicians' attitudes, challenges, and success strategies in providing care to transgender people: a qualitative descriptive study.

October 19, 2022

A process for analysis of sentinel events due to health care–associated infection.

November 28, 2007

Design of an evidence-based "second victim" curriculum for nurse anesthetists.

June 1, 2016

Setting priorities for patient safety: ethics, accountability, and public engagement.

September 2, 2009

Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards.

January 20, 2010

Psychological safety during the test of new work processes in an emergency department.

April 6, 2022

The effect of a program to shorten the decision-to-delivery interval for emergent cesarean section on maternal and neonatal outcome.

May 25, 2016

Hospital implementation of computerized provider order entry systems: results from the 2003 Leapfrog Group quality and safety survey.

November 16, 2005

When bad things happen: training medical students to anticipate the aftermath of medical errors.

September 2, 2020

Implementing a nurse-shadowing program for first-year medical students to improve interprofessional collaborations on health care teams.

August 22, 2012

Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital.

February 4, 2009

Communication matters when it comes to adverse events: associations of adverse events during implant treatment with patients' communication quality and trust assessments.

March 15, 2023

Enhancing patient safety by integrating ethical dimensions to critical incident reporting systems.

April 28, 2021

Use of quality indicators to compare point-of-care testing errors in a neonatal unit and errors in a STAT central laboratory.

February 25, 2015

Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients.

October 3, 2012

Speaking up during the COVID-19 pandemic: nurses' experiences of organizational disregard and silence.

February 1, 2023

Identifying high-risk medication: a systematic literature review.

August 13, 2014

The role of purple pens in learning to prescribe.

February 13, 2019

Implementing safety hotlines: Stamford Health's experience and future opportunities.

September 19, 2018

Alcoholism and American healthcare: the case for a patient safety approach.

August 17, 2022

Rules, safety and the narrativisation of identity: a hospital operating theatre case study.

March 15, 2006

'Balancing risk, that is my life': The politics of risk in a hospital operating theatre department.

January 18, 2006

Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults.

September 23, 2009

The effect of medication reconciliation in elderly patients at hospital discharge.

January 30, 2005

Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.

September 21, 2016

Dealing honestly with an honest mistake.

January 20, 2010

The $17.1 billion problem: the annual cost of measurable medical errors.

April 20, 2011

Identifying adverse events in patients hospitalized in isolation or quarantine due to COVID-19.

May 10, 2023

Strategies to reduce errors associated with 2-component vaccines.

December 2, 2020

A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people.

April 10, 2019

The safety of emergency medicine.

November 25, 2015

What methods are used to apply positive deviance within healthcare organisations? A systematic review.

March 2, 2016

The safe day call: reducing silos in health care through frontline risk assessment.

September 24, 2014

'The ABC of Handover': impact on shift handover in the emergency department.

February 8, 2012

Development and validation of a tool to assess emergency physicians' nontechnical skills.

April 18, 2012

Identifying nontechnical skills associated with safety in the emergency department: a scoping review of the literature.

April 18, 2012

'Even now it makes me angry': health care students' professionalism dilemma narratives.

August 6, 2014

Communication patterns in a UK emergency department.

October 10, 2007

Risk of COVID-19-related bullying, harassment and stigma among healthcare workers: an analytical cross-sectional global study.

January 27, 2021

Incidence and severity of prescribing errors in parenteral nutrition for pediatric inpatients at a neonatal and pediatric intensive care unit.

October 4, 2017

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement.

June 1, 2022

Taking aim at infusion confusion.

April 12, 2006

Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients.

April 11, 2012

Case study research: the view from complexity science.

May 4, 2005

Development of a trigger tool to identify adverse drug events in elderly patients with multimorbidity.

August 30, 2017

Fostering a just culture in healthcare organizations: experiences in practice.

August 31, 2022

Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care.

August 10, 2022

At risk care plans: a way to reduce readmissions and adverse events.

January 21, 2015

Developing an intervention to reduce harm in hospitalized patients: patients and families in research.

December 5, 2018

Perspectives on patient and family engagement with reduction in harm: the forgotten voice.

August 15, 2018

Variation in 17 obstetric care pathways: potential danger for health professionals and patient safety?

April 25, 2012

Teams under pressure in the emergency department: an interview study.

January 25, 2012

Sensemaking and the co-production of safety: a qualitative study of primary medical care patients.

January 27, 2016

What do patients and their carers do to support the safety of cancer treatment and care? A scoping review.

December 14, 2022

Making patients safer: nurses' responses to patient safety alerts.

September 24, 2008

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

December 9, 2020

An improved patient safety reporting system increases reports of disruptive behavior in the perioperative setting.

February 5, 2020

An official Critical Care Societies Collaborative statement: burnout syndrome in critical care healthcare professionals: a call for action.

July 27, 2016

Developing critical thinking skills for delivering optimal care

July 28, 2021

Incident reporting in one UK accident and emergency department.

December 21, 2005

Intervention study for the reduction of medication errors in elderly trauma patients.

September 2, 2020

Rapid response team implementation and in-hospital mortality.

August 27, 2014

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

August 17, 2022

The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.

March 16, 2011

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

December 8, 2010

Human factors and quality improvement in the emergency department: reducing potential errors in blood collection.

March 30, 2016

John M. Eisenberg Patient Safety Awards. The LVHHN patient safety video: patients as partners in safe care delivery.

March 6, 2005

Related Resources

Formalizing the hidden curriculum of performance enhancing errors.

March 22, 2023

Bad things can happen: are medical students aware of patient centered care and safety?

January 25, 2023

To err is human, but what happens when surgeons err?

September 28, 2022

Disclosure of errors in surgical procedures.

February 2, 2022

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety.

December 9, 2020

A national mixed-methods evaluation of preparedness for general surgery residency and the association with resident burnout.

September 2, 2020

Surgical errors happen, but are learners trained to recover from them? A survey of North American surgical residents and fellows.

August 26, 2020

Use of error management theory to quantify and characterize residents' error recovery strategies.

January 15, 2020

The SECOND Trial

November 13, 2019

Analysis of human performance deficiencies associated with surgical adverse events.

August 14, 2019

Impact of critical event checklists on anaesthetist performance in simulated operating theatre emergencies.

July 31, 2019

Allowing failure for educational purposes in postgraduate clinical training: a narrative review.

July 24, 2019

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.

July 10, 2019

Exposure to incivility hinders clinical performance in a simulated operative crisis.

June 26, 2019

Impact of the World Health Organization surgical safety checklist on patient safety.

June 12, 2019

Knowledge retention after simulated crisis: importance of independent practice and simulated mortality.

June 5, 2019

Understanding the clinical implications of resident involvement in uncommon operations.

May 1, 2019

Potential consequences of patient complications for surgeon well-being: a systematic review.

April 17, 2019

Closing the disclosure gap: medical errors in pediatrics.

March 27, 2019

Identification of warning signs during selection of surgical trainees.

January 16, 2019

Simulation-based clinical rehearsals as a method for improving patient safety.

October 31, 2018

Evaluation of reasons why surgical residents exceeded 2011 duty hour requirements when offered flexibility.

June 20, 2018

Fake it 'til you make it: pressures to measure up in surgical training.

June 13, 2018

Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training.

May 16, 2018

Effect of sleep deprivation after a night shift duty on simulated crisis management by residents in anaesthesia. A randomised crossover study.

October 18, 2017

Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training.

June 7, 2017

Comparison of appendectomy outcomes between senior general surgeons and general surgery residents.

May 3, 2017

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

April 19, 2017

Performance of vascular exposure and fasciotomy among surgical residents before and after training compared with experts.

March 22, 2017

Improving disclosure and management of medical error—an opportunity to transform the surgeons of tomorrow.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Improving disclosure and management of medical error—an opportunity to transform the surgeons of tomorrow.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

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