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PSNet: Patient Safety Network
Journal Article

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

Aldrich R, Finlayson P, Hill K, et al. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2012;24:135-43.

Considerable research has provided insight on how individual clinicians should disclose errors to patients. This article explores a scenario that is perhaps less common but equally difficult to negotiate—disclosing large-scale errors to an entire population. The situation arose when a routine peer review in Australia identified one pathologist as having an unusually high rate of diagnostic errors. This prompted review of more than 7000 cases by independent pathologists who identified clinically significant errors in almost 3% of cases. The health department leadership opted for a full disclosure approach, using mass media communications to publicize the findings and providing resources and support for affected patients and families. While other organizations have publicly reported large-scale safety problems, this article provides unique insights into utilizing principles of full disclosure on a widespread basis.