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1 - 20 of 83
Maher V, Cwiek M. Hosp Top. 2022;Epub Jul 20.
Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.
Ibrahim SA, Reynolds KA, Poon E, et al. BMJ. 2022;377:e063064.
Accreditation programs such as The Joint Commission are intended to improve patient safety and quality. Investigators evaluated the evidence base for 20 actionable standards issued by The Joint Commission. Standards were classified by the extent to which they were supported by evidence, evidence quality ratings, and the strength of the recommendation.
Lin M, Horwitz LI, Gross RS, et al. J Patient Saf. 2022;18:e470-e476.
Error disclosure is an essential activity to addressing harm and establishing trust between clinicians and patients. Trainees in pediatric specialties at one urban medical center were provided with clinical vignettes depicting an error resulting in a safety event or near-miss and surveyed about error classification and disclosure. Participants agreed with disclosing serious and minor safety events, but only 7% agreed with disclosing a near miss event. Trainees’ decisions regarding disclosure considered the type of harm, parental preferences, ethical principles, and anticipatory guidance to address the consequences of the error.
Wyner D, Wyner F, Brumbaugh D, et al. Pediatrics. 2021;148:e2021053091.
The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias  contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55.
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17:e529-e533.
While prior research has shown patients want disclosure of adverse events, healthcare providers may still be hesitant to disclose and apologize. Factors that influence providers’ willingness to disclose errors and apologize include organizational support, experience in communicating errors, and expectations surrounding patient response. A culture of safety and a clear legal framework may increase providers’ willingness to disclose errors and apologize.
Elwy AR, Maguire EM, McCullough M, et al. Healthc (Amst). 2021;8:100496.
Disclosure of medical errors is supported by both patients and providers. Following the implementation of the Veterans Health Administration’s policy on disclosing medical errors to patients and their families, it was necessary to determine the effects of implementation (or not) of this policy. This article describes the development, implementation, and sustainment of an error disclosure toolkit for use across the VA system.

Ross NE, Newman WJ. J Am Acad Psychiatry Law. Epub 2021 May 21.

Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians frequently cite fear of malpractice lawsuits as a reason to avoid apologizing for an error. This commentary summarizes the relationship between apologies and malpractice, the emergency of apology laws in the United States, and research exploring the impact of apology laws on malpractice claims and patient outcomes.
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  
LeCraw FR, Stearns SC, McCoy MJ. J Patient Saf Risk Manag. 2021;26:34-40.
Healthcare systems have implemented communication-and-resolution programs (CRPs) to respond and disclose serious errors and adverse events. This article describes methods used by nine teams of CRP advocates to encourage adoption and endorsement by hospitals and national medical societies at the national, state, and local levels.  

Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.

The recognition that humans err and the situation of response to error in a constructive and nonpunitive light are central to achieving safe patient care. This article discusses how implementation of just culture principles can assign accountability appropriately while encouraging disclosure and improvement when mistakes occur. 
Busch IM, Saxena A, Wu AW. J Patient Saf. 2021;17:358-362.
In this literature review, the authors identified patient-, clinician-, and institutional-level barriers to patient involvement in patient safety investigations. Potential strategies for overcoming barriers are also discussed, such as adopting a blame-free climate and enhancing clinician training in error disclosure and communication.
Chuang E, Cuartas PA, Powell T, et al. AJOB Empir Bioeth. 2020;11:148-159.
Before the emergence of COVID-19, the National Academy of Medicine had provided guidance on the reallocation of scarce medical resources – including ventilators – during extreme situations. Based on focus groups and key informant interviews conducted in 2018, this study sought to understand potential barriers arising from ethical conflicts to the implementation of these guidelines for ventilator allocation in the event of resource scarcity. Participants anticipated challenges reconciling this protocol with their roles and identities as health care providers, as well as concerns about emotional consequences, and fear of legal repercussions. These concerns raise questions about the performance of such a protocol in disaster scenarios and highlight the need for disaster preparedness drills and training.
Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.
Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.
Hart WM, Doerr P, Qian Y, et al. AMA J Ethics. 2020;22:E298-E304.
Communication has become a foci of improvement efforts across the spectrum of patient safety. This article discusses a surgical complication incident that illustrates the importance of transparency, disclosure and collaboration as elements of a successful approach to communication that can successfully manage the impact of an adverse incident.
Kisely S, Warren N, McMahon L, et al. BMJ. 2020;369:m1642.
This meta-analysis examined the psychological effects of viral outbreaks on clinicians and effective strategies to manage stress and psychological distress. The review included 59 studies involving severe acute respiratory syndrome (SARS), COVID-19, Middle East respiratory syndrome (MERS), Ebola and influence. Compared with clinicians at lower risk, those in contact with affected patients had greater levels of both acute and post-traumatic stress, as well as psychological distress. Clinicians were at increased risk for psychological distress if they were younger, more junior, had dependent children, or had an infected family member. Identified interventions to mitigate stress and psychological distress included clear communication, infectious disease training and education, enforcement of infection control procedures, adequate supply of personal protective equipment (PPE) and access to psychological support.