Commentary A medical error leads to tragedy: how do we inform the patient? Citation Text: Baumrucker SJ. A medical error leads to tragedy: how do we inform the patient? Am J Hosp Palliat Care. 2006;23(5):417-21. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL November 8, 2006 Baumrucker SJ. Am J Hosp Palliat Care. 2006;23(5):417-21. View more articles from the same authors. This roundtable discussion provides legal, ethical, nursing, and medical perspectives on whether to disclose a misdiagnosis to the patient and their family after cancer has metastasized and death is imminent. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Baumrucker SJ. A medical error leads to tragedy: how do we inform the patient? Am J Hosp Palliat Care. 2006;23(5):417-21. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017 Diagnostic errors in primary care pediatrics: Project RedDE. November 29, 2017 Development of a Web-based surgical booking and informed consent system to reduce the potential for error and improve communication. February 26, 2014 Primary care pediatricians' interest in diagnostic error reduction. July 20, 2016 Challenges with implementing the Centers for Disease Control and Prevention opioid guideline: a consensus panel report. April 3, 2019 The Research on Adverse Drug Events and Reports (RADAR) project. May 18, 2005 Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022 The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018 Context matters: toward a multilevel perspective on context in clinical reasoning and error. June 21, 2023 Declaring uncertainty: using quality improvement methods to change the conversation of diagnosis. March 17, 2021 Impact of COVID-19 on inpatient clinical emergencies: a single-center experience. June 9, 2021 Understanding context specificity: the effect of contextual factors on clinical reasoning. September 2, 2020 Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. July 26, 2017 A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents. May 31, 2017 Factors associated with hospital admission after outpatient surgery in the Veterans Health Administration. February 28, 2018 Patient safety perceptions of primary care providers after implementation of an electronic medical record system. September 12, 2012 The July effect: an analysis of never events in the nationwide inpatient sample. April 15, 2015 Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis. April 29, 2015 A national assessment on patient safety curricula in undergraduate medical education: results from the 2012 clerkship directors in internal medicine survey. April 8, 2020 Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors in clinical setting. April 10, 2019 Disclosure and reporting of surgical complications: a double-edged sword? August 18, 2010 Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement. February 13, 2008 "Tech-check-tech": a review of the evidence on its safety and benefits. October 5, 2011 Patient reports of preventable problems and harms in primary health care. March 6, 2005 Prescribing errors in post-COVID-19 patients: prevalence, severity, and risk factors in patients visiting a post-COVID-19 outpatient clinic. March 23, 2022 State of science: evolving perspectives on ‘human error’. March 16, 2022 Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. October 4, 2023 Racial bias in pulse oximetry measurement. December 20, 2020 Formalizing the hidden curriculum of performance enhancing errors. March 22, 2023 Inappropriate diagnosis of pneumonia among hospitalized adults. April 10, 2024 Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients. May 1, 2020 A scoping review of distributed cognition in acute care clinical decision-making. June 7, 2023 Cognitive biases in internal medicine: a scoping review. June 14, 2023 Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. April 14, 2021 The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue. November 11, 2020 Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. October 16, 2015 Clinical reasoning in the wild: premature closure during the COVID-19 pandemic. August 19, 2020 Drawing boundaries: the difficulty in defining clinical reasoning. August 15, 2018 Meaningful use's benefits and burdens for US family physicians. May 30, 2018 National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. December 7, 2016 Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. September 13, 2017 Chasing the 6-sigma: drawing lessons from the cockpit culture. March 7, 2018 Safety considerations in learning new procedures: a survey of surgeons. January 31, 2018 Transferring aviation practices into clinical medicine for the promotion of high reliability. July 26, 2017 Management reasoning: beyond the diagnosis. May 23, 2018 Prioritizing patient safety efforts in office practice settings December 18, 2019 Clinical reasoning as a core competency. October 30, 2019 Quantifying and characterizing adverse events in dermatologic surgery. May 15, 2013 The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials. February 8, 2012 On-site pharmacists in the ED improve medical errors. August 8, 2012 Medication safety in primary care practice: results from a PPRNet quality improvement intervention. July 11, 2012 Retained surgical items: a problem yet to be solved. October 31, 2012 Improving patient safety through the systematic evaluation of patient outcomes. February 13, 2013 Implementing computerized provider order entry in acute care hospitals in the United States could generate substantial savings to society. August 5, 2015 Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors. April 8, 2015 National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths. April 22, 2015 Establishing an ambulatory medicine quality and safety oversight structure: leveraging the fractal model. March 9, 2016 Impact of organizational leadership on physician burnout and satisfaction. February 3, 2016 Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. September 24, 2014 Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals. August 26, 2015 Procedural timeout compliance is improved with real-time clinical decision support. September 12, 2018 Discussing harm-causing errors with patients: an ethics primer for plastic surgeons. June 11, 2014 Are med school grads prepared to practice medicine? May 7, 2014 Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. April 29, 2020 Americans' growing exposure to clinician quality information: insights and implications. March 20, 2019 Clinical reasoning assessment methods: a scoping review and practical guidance. June 26, 2019 Using computerized virtual cases to explore diagnostic error in practicing physicians. February 13, 2019 Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). June 26, 2019 Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days. June 17, 2020 Predictors of adverse events and medical errors among adult inpatients of psychiatric units of acute care general hospitals. January 30, 2019 Using prospective clinical surveillance to identify adverse events in hospital. March 30, 2011 Patient safety in emergency medical services: a systematic review of the literature. December 21, 2011 Failure to notify reportable test results: significance in medical malpractice. December 21, 2011 Electronic health record-based surveillance of diagnostic errors in primary care. November 2, 2011 Agreement between patient-reported symptoms and their documentation in the medical record. August 27, 2008 Patient care, square-rigger sailing, and safety. October 22, 2008 Older patients' perceptions of "unnecessary" tests and referrals: a national survey of Medicare beneficiaries. September 24, 2008 Practice advisory for the prevention and management of operating room fires. May 7, 2008 Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices. April 23, 2008 How safe is my intensive care unit? Methods for monitoring and measurement. November 21, 2007 Academic detailing to improve laboratory testing among outpatient medication users. October 17, 2007 Is the availability of hospital IT applications associated with a hospital's risk adjusted incidence rate for patient safety indicators: results from 66 Georgia hospitals. October 10, 2007 Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation. August 22, 2007 Crisis checklists for the operating room: development and pilot testing. January 30, 2005 Automated identification of postoperative complications within an electronic medical record using natural language processing. August 31, 2011 Missed opportunities in the primary care management of early acute ischemic heart disease. November 29, 2006 Morbidity and mortality conference, grand rounds, and the ACGME's core competencies. October 25, 2006 Ambiguity and workarounds as contributors to medical error. April 27, 2005 Exploring barriers and facilitators to the use of computerized clinical reminders. April 21, 2005 Patient safety: mindful, meaningful, and fulfilling. October 19, 2005 New York-Presbyterian Hospital: translating innovation into practice. October 12, 2005 Fixing healthcare from the inside, today. September 28, 2005 Operational failures and interruptions in hospital nursing. June 14, 2006 Detecting adverse events in dermatologic surgery. January 6, 2010 Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. December 2, 2009 Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. March 31, 2010 Systematic root cause analysis of adverse drug events in a tertiary referral hospital. March 27, 2005 Driving improvement in patient care: lessons from Toyota. March 6, 2005 Health plan members' views about disclosure of medical errors. March 6, 2005 Effect of reducing interns' weekly work hours on sleep and attentional failures. March 27, 2005 View More Related Resources A proposed approach to allegations of sexual boundary violation in health care. December 13, 2023 Interview In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Perspectives on Safety The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Disclosing medical errors: prioritising the needs of patients and families. July 5, 2023 Support for healthcare workers and patients after medical error through mutual healing: another step towards patient safety. January 18, 2023 Administering High-Strength Insulin from a Pen Device in Hospital. September 14, 2022 Health care quality and safety in a correctional system: creating goals and performance measures for improvement. August 17, 2022 Criminal liability for nursing and medical harm. August 3, 2022 Who killed patient safety? July 20, 2022 Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS. May 4, 2022 Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors. November 10, 2021 The role of apology laws in medical malpractice. July 7, 2021 Missing diagnoses during the COVID-19 pandemic: a year in review. June 23, 2021 How U.S. teams advanced communication and resolution program adoption at local, state and national levels. January 13, 2021 Nurses' perceptions of open disclosure processes in cancer care: a cross-sectional study. December 16, 2020 Making communication and resolution programmes mission critical in healthcare organisations. November 11, 2020 To err is human, unless you are a healthcare provider. August 3, 2020 Apology laws and malpractice liability: what have we learned? July 8, 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 Communicating with patients about diagnostic errors in breast cancer care: providers' attitudes, experiences, and advice January 22, 2020 What is an ethically informed approach to managing patient safety risk during discharge planning? January 20, 2020 Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. September 25, 2019 Hospital image repair strategies, organizational apology, and medical errors: an analysis of the CoxHealth brain over-radiation case. September 18, 2019 Communication and Resolution After an Adverse Health Care Incident. May 22, 2019 When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer? April 17, 2019 Interview In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD April 1, 2019 Use of a public health law framework to improve medication safety by anesthesia providers. March 20, 2019 Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. February 27, 2019 Reversing the rise in maternal mortality. January 16, 2019 View More See More About The Topic Health Care Providers Health Care Executives and Administrators Medical Oncology Nurse Care Legal and Policy Approaches View More
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017
Development of a Web-based surgical booking and informed consent system to reduce the potential for error and improve communication. February 26, 2014
Challenges with implementing the Centers for Disease Control and Prevention opioid guideline: a consensus panel report. April 3, 2019
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018
Context matters: toward a multilevel perspective on context in clinical reasoning and error. June 21, 2023
Declaring uncertainty: using quality improvement methods to change the conversation of diagnosis. March 17, 2021
Understanding context specificity: the effect of contextual factors on clinical reasoning. September 2, 2020
Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. July 26, 2017
A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents. May 31, 2017
Factors associated with hospital admission after outpatient surgery in the Veterans Health Administration. February 28, 2018
Patient safety perceptions of primary care providers after implementation of an electronic medical record system. September 12, 2012
Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis. April 29, 2015
A national assessment on patient safety curricula in undergraduate medical education: results from the 2012 clerkship directors in internal medicine survey. April 8, 2020
Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors in clinical setting. April 10, 2019
Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement. February 13, 2008
Prescribing errors in post-COVID-19 patients: prevalence, severity, and risk factors in patients visiting a post-COVID-19 outpatient clinic. March 23, 2022
Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. October 4, 2023
Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients. May 1, 2020
Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. April 14, 2021
The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue. November 11, 2020
Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. October 16, 2015
National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. December 7, 2016
Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. September 13, 2017
Transferring aviation practices into clinical medicine for the promotion of high reliability. July 26, 2017
The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials. February 8, 2012
Medication safety in primary care practice: results from a PPRNet quality improvement intervention. July 11, 2012
Implementing computerized provider order entry in acute care hospitals in the United States could generate substantial savings to society. August 5, 2015
Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors. April 8, 2015
National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths. April 22, 2015
Establishing an ambulatory medicine quality and safety oversight structure: leveraging the fractal model. March 9, 2016
Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. September 24, 2014
Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals. August 26, 2015
Procedural timeout compliance is improved with real-time clinical decision support. September 12, 2018
Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. April 29, 2020
Americans' growing exposure to clinician quality information: insights and implications. March 20, 2019
Using computerized virtual cases to explore diagnostic error in practicing physicians. February 13, 2019
Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). June 26, 2019
Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days. June 17, 2020
Predictors of adverse events and medical errors among adult inpatients of psychiatric units of acute care general hospitals. January 30, 2019
Patient safety in emergency medical services: a systematic review of the literature. December 21, 2011
Agreement between patient-reported symptoms and their documentation in the medical record. August 27, 2008
Older patients' perceptions of "unnecessary" tests and referrals: a national survey of Medicare beneficiaries. September 24, 2008
Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices. April 23, 2008
Is the availability of hospital IT applications associated with a hospital's risk adjusted incidence rate for patient safety indicators: results from 66 Georgia hospitals. October 10, 2007
Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation. August 22, 2007
Automated identification of postoperative complications within an electronic medical record using natural language processing. August 31, 2011
Missed opportunities in the primary care management of early acute ischemic heart disease. November 29, 2006
Morbidity and mortality conference, grand rounds, and the ACGME's core competencies. October 25, 2006
Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. December 2, 2009
Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. March 31, 2010
Systematic root cause analysis of adverse drug events in a tertiary referral hospital. March 27, 2005
Interview In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023
Perspectives on Safety The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023
Support for healthcare workers and patients after medical error through mutual healing: another step towards patient safety. January 18, 2023
Health care quality and safety in a correctional system: creating goals and performance measures for improvement. August 17, 2022
Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors. November 10, 2021
How U.S. teams advanced communication and resolution program adoption at local, state and national levels. January 13, 2021
Nurses' perceptions of open disclosure processes in cancer care: a cross-sectional study. December 16, 2020
Making communication and resolution programmes mission critical in healthcare organisations. November 11, 2020
Amid the COVID-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative. June 24, 2020
Communicating with patients about diagnostic errors in breast cancer care: providers' attitudes, experiences, and advice January 22, 2020
What is an ethically informed approach to managing patient safety risk during discharge planning? January 20, 2020
Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. September 25, 2019
Hospital image repair strategies, organizational apology, and medical errors: an analysis of the CoxHealth brain over-radiation case. September 18, 2019
Use of a public health law framework to improve medication safety by anesthesia providers. March 20, 2019
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. February 27, 2019