… Journal of patient safety … J Patient Saf … Based on a series of international expert …

Communication failures are a common cause of patient harm in surgical settings. This commentary reviews safety challenges in this setting and describes how models used by NASA and the FAA can be applied in health care to improve safety culture, education, and surgeon leadership.

When a patient is a victim of an error, hospitals have traditionally followed a "deny and defend" strategy, providing limited information to the patient and family and avoiding admissions of fault—or even admission that an error occurred. This approach has long been criticized for its lack of patient-centeredness, and in response some institutions have begun to implement communication-and-response strategies that emphasize early disclosure of adverse events and proactive attempts to resolve the situation. This study reviews six institutions' experiences with two types of communication-and-response strategies: early settlement programs (in which errors are fully disclosed and an offer of compensation is made, along with investigation of safety issues) and limited reimbursement programs (which provided limited compensation to patients with concerns about their care, but explicitly exclude more severe errors). Through structured interviews with key participants, the authors identify crucial regulatory, legal, and practical issues with implementing these programs. They emphasize that such programs should be viewed as part of an effort to improve safety culture and that transparency and a blame-free approach are essential to obtaining support (especially from physicians). The complex intersection between error disclosure and malpractice is explored further in an AHRQ WebM&M perspective.

Physicians are notably loath to fully disclose their own errors, but some progress is being made in this area due to institutional policies supporting error disclosure. This article is intended to foster discussion of an especially thorny issue: how clinicians should approach error disclosure when the error was committed by a colleague. As little prior literature exists regarding this dilemma, the authors emphasize a patient-centered approach that begins with a respectful peer-to-peer conversation and does not shirk the need to fully disclose the error. The importance of institutional support, particularly in establishing a just culture that promotes error disclosure, is also emphasized. The article's lead author, Dr. Thomas Gallagher, was interviewed by AHRQ WebM&M in 2009.

This study revealed a high incidence of false-positive vital sign abnormalities that meet established thresholds for triggering rapid response activation. These findings are important when considering potential automated triggering systems.

Efforts to prevent wrong-site and wrong-patient surgical errors (WSPEs) initially focused on procedural disciplines and operating room procedures. However, this analysis of WSPEs that were voluntarily reported to a Colorado malpractice insurance company database found that a significant proportion of WSPEs were committed by physicians in non-surgical fields (such as internal medicine). Root cause analysis revealed a number of contributing causes, with diagnostic errors and communication errors the primary culprits. Interestingly, the injured patients did not file a malpractice lawsuit in the vast majority of cases. This study confirms and extends prior research showing that many WSPEs actually occur outside the operating room. The authors call for strict adherence to the Joint Commission Universal Protocol in order to prevent these never events.

… journal of the American College of Medical Quality … Am J Med Qual … An orthopedic surgery department implemented a …

Five years after the publication of the Universal Protocol, the authors review the policy and assess unintended consequences, limitations, and recommendations to reduce surgical errors.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … A national campaign to save lives in the …

This study used a systematic framework for disclosing errors and adverse events to guide providers and facilitate appropriate discussions. The authors provide context to their recommended approach by discussing the scope of the problem in intensive care units, when and how to talk about errors, and the benefits of and problems with doing so. They provide a case example with a detailed dialogue between an attending physician, an intern, and a patient in disclosing news about an error that occurred during her hospitalization. The case illustrates and advocates for the approach recommended both predisclosure and during disclosure. A past study discussed patient and physician attitudes about the disclosure of medical errors.