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PSNet: Patient Safety Network
Journal Article

Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership.

Elwy R, Bokhour BG, Maguire EM, et al. Journal of general internal medicine. 2014;29 Suppl 4:895-903.

This interview study examined how the Veterans Affairs medical centers disclosed large-scale adverse events to stakeholders. These incidents impacted multiple patients and included system failures as well as errors by individuals. Interviews with frontline staff, local leadership, and affected patients and family members examined strengths and weakness of the current disclosure process and elicited input for improvement. All stakeholders reinforced the need for tailored, interactive, multi-modal communication rather than standard mailed letters. While staff expressed the concern that adverse event disclosure led to loss of trust, patients and families stated that despite their initial distress they supported disclosure and follow-up care associated with large-scale adverse events. These findings are consistent with prior studies of error disclosure, but demonstrate a gap in frontline staff understanding of the rationale for disclosure.