Disclosure of harmful medical error to patients: a review with recommendations for pathologists.

Yael K. Heher; Suzanne M. Dintzis

Review

Disclosure of harmful medical error to patients: a review with recommendations for pathologists.

February 7, 2018

Heher YK, Dintzis SM. Adv Anat Pathol. 2018;25(2):124-130.

View more articles from the same authors.

Disclosure of medical errors is a recommended patient safety practice. However, opportunities for pathologists to improve their skill in this area are limited. This review provides recommendations to help pathologists recognize when disclosure is needed and participate in disclosure as appropriate.

PubMed citation

Available at

Related Resources From the Same Author(s)

Improving pathologists' communication skills.

September 14, 2016

Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action.

September 21, 2022

Disclosing harmful pathology errors to patients.

January 6, 2010

Surgical specimen management: a descriptive study of 648 adverse events and near misses.

October 5, 2016

Pathologists' perspectives on disclosing harmful pathology error.

May 3, 2017

Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences.

May 18, 2011

Video-based communication assessment of physician error disclosure skills by crowdsourced laypeople and patient advocates who experienced medical harm: reliability assessment with generalizability theory.

May 18, 2022

Advancing medication safety: establishing a National Action Plan for Adverse Drug Event Prevention.

August 5, 2015

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.

July 30, 2008

Managing near-miss reporting in hospitals: the dynamics between staff members’ willingness to report and management’s handling of near-miss events.

June 7, 2023

Does physician's training induce overconfidence that hampers disclosing errors?

February 10, 2016

The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff.

January 3, 2007

The doctor's new dilemma.

February 24, 2016

Drs Bramhall and Bawa-Garba and the rightful domain of the criminal law.

February 20, 2019

Patient safety: it's not just carefulness, it's a culture.

March 6, 2005

Healthcare climate: a framework for measuring and improving patient safety.

April 25, 2007

Types, prevalence, and potential clinical significance of medication administration errors in assisted living.

June 4, 2008

Ask me if I cleaned my hands.

April 25, 2012

Medication reconciliation in a community, nonteaching hospital.

November 12, 2008

Noise: a distraction, interruption, and safety hazard.

August 22, 2007

Distractions, interruptions, and patient safety.

July 25, 2007

“I’m concerned”: a multi-site assessment of emergency medicine resident speaking up behaviors.

December 21, 2022

Getting by: underuse of interpreters by resident physicians.

January 28, 2009

Between demarcation and discretion: the medical-administrative boundary as a locus of safety in high-volume organisational routines.

August 1, 2018

Reporting of hazards and near-misses in the ambulatory care setting.

October 19, 2011

Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care.

December 13, 2017

Preventing vincristine administration errors: does evidence support minibag infusions?

April 26, 2006

John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety: rewarding higher standards.

March 6, 2005

Omissions of care in nursing homes: a uniform definition for research and quality improvement.

November 18, 2020

Omissions of care in nursing home settings: a narrative review.

June 3, 2020

Engaging the patient as observer to promote hand hygiene compliance in ambulatory care.

October 7, 2009

Incident learning in radiation oncology: a review.

August 15, 2018

Improving nursing unit teamwork.

January 4, 2006

Infection control hazards and near misses reported by nursing students.

January 5, 2011

Frequency and types of patient-reported errors in electronic health record ambulatory care notes.

July 1, 2020

Intercepting wrong-patient orders in a computerized provider order entry system.

February 4, 2015

Integrating patient safety in the OMFS curriculum: survey of 4-year residency programs.

December 14, 2016

'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events.

January 25, 2012

Impact of an obstetrical hospitalist program on the safety events in a mid-sized obstetrical unit.

September 16, 2020

Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety.

February 17, 2010

Nursing perception of the impact of medication carts on patient safety and ergonomics in a teaching health care center.

August 8, 2012

Patient engagement in the inpatient setting: a systematic review.

December 18, 2013

Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs.

October 11, 2017

An electronic health record–based real-time analytics program for patient safety surveillance and improvement.

December 5, 2018

How radiation oncologists would disclose errors: results of a survey of radiation oncologists and trainees.

June 13, 2012

Dynamics of dignity and safety: a discussion.

January 24, 2018

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.

June 14, 2017

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.

November 11, 2020

Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose.

May 21, 2008

Medical errors and quality of care: from control to commitment.

June 14, 2006

Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit.

March 2, 2011

Human centered design workshops as a meta-solution to diagnostic disparities.

November 2, 2022

Incidence and causes of critical incidents in emergency departments: a comparison and root cause analysis.

June 11, 2008

Algorithmic prediction of failure modes in healthcare.

January 13, 2021

Operative team communication during simulated emergencies: too busy to respond?

December 21, 2016

Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals.

April 2, 2008

Using human error theory to explore the supply of non-prescription medicines from community pharmacies.

August 23, 2006

When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship.

June 15, 2016

Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes.

June 6, 2018

Integrating systemic accident analysis into patient safety incident investigation practices.

November 21, 2018

Potential biases in machine learning algorithms using electronic health record data.

August 29, 2018

Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center.

January 8, 2014

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.

January 12, 2022

Has the Leapfrog Group had an impact on the health care market?

April 15, 2005

SBAR improves nurse–physician communication and reduces unexpected death: a pre and post intervention study.

October 23, 2013

Overestimation of clinical diagnostic performance caused by low necropsy rates.

December 14, 2005

Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis.

October 12, 2016

Hospital governance and the quality of care.

November 18, 2009

Group urges going metric to head off dosing mistakes.

June 18, 2014

Documentation of drug allergy on drug chart in patients presenting for surgery.

July 9, 2008

Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System.

April 2, 2008

Fatigue among clinicians and the safety of patients.

March 6, 2005

Teamwork on inpatient medical units: assessing attitudes and barriers.

May 5, 2010

Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey.

October 14, 2015

Interprofessional learning for medication safety.

July 9, 2014

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety.

December 19, 2007

Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies.

September 5, 2018

Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia.

March 8, 2023

Morning handover of on-call issues: opportunities for improvement.

August 6, 2014

Use of maternal early warning trigger tool reduces maternal morbidity.

April 6, 2016

Overcoming human barriers to safety event reporting in radiology.

March 6, 2019

Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

March 13, 2013

Electronic health record adoption by children's hospitals in the United States.

December 15, 2010

Legal and policy interventions to improve patient safety.

March 2, 2016

What near misses tell us about risk and safety in mental health care.

November 30, 2011

Effects of a communication-and-resolution program on hospitals' malpractice claims and costs.

December 19, 2018

November 4, 2009

Impact of system-level activities and reporting design on the number of incident reports for patient safety.

April 21, 2010

Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal.

January 30, 2005

Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns using a new observation system.

July 30, 2008

Defining and classifying medical error: lessons for patient safety reporting systems.

March 6, 2005

Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England.

February 27, 2019

Development and implementation of a suicide prevention checklist to create a safe environment.

March 4, 2020

Nurses' perceptions of error communication and reporting in the intensive care unit.

August 13, 2008

Understanding the informal aspects of medication processes to maintain patient safety in hospitals: a sociotechnical ethnographic study in paediatric units.

April 17, 2024

Patient risk factors for medical injury: a case–control study.

January 26, 2011

Moving toward improved teamwork in cancer care: the role of psychological safety in team communication.

December 14, 2016

Engaging hospital patients in the medication reconciliation process using tablet computers.

September 26, 2018

Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery.

January 17, 2018

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

December 7, 2022

Related Resources

Blood and blood products transfusion errors: what can we do to improve patient safety.

May 10, 2023

Preferences and perceptions of medical error disclosure among marginalized populations: a narrative review.

August 10, 2022

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

January 11, 2022

How Veterans Affairs failed to stop a pathologist who misdiagnosed 3,000 cases.

September 11, 2019

A team disclosure of error educational activity: objective outcomes.

June 5, 2019

Reducing diagnostic errors worldwide through diagnostic management teams.

April 3, 2019

Closing the disclosure gap: medical errors in pediatrics.

March 27, 2019

Electronic patient identification for sample labeling reduces wrong blood in tube errors.

March 20, 2019

Diagnostic error as a result of drug-laboratory test interactions.

March 6, 2019

Transfusion safety: the nature and outcomes of errors in patient registration.

February 20, 2019

Impact of interactions between drugs and laboratory test results on diagnostic test interpretation—a systematic review.

November 21, 2018

Direct oral anticoagulants: a review of common medication errors.

November 21, 2018

Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review.

March 14, 2018

Improving medication-related clinical decision support.

March 7, 2018

A systematic review of interventions to follow-up test results pending at discharge.

February 7, 2018

WebM&M Cases

Delayed Diagnosis of Endocrinologic Emergencies

November 1, 2017

Clinician perspectives on the management of abnormal subcritical tests in an urban academic safety-net health care system.

October 4, 2017

Mistakes were made (by me).

September 13, 2017

Risk factors of missed colorectal lesions after colonoscopy.

September 6, 2017

Kind World #42: The Patient.

August 23, 2017

Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use.

August 16, 2017

The impact of incident disclosure behaviors on medical malpractice claims.

July 19, 2017

Assigning responsibility to close the loop on radiology test results.

July 12, 2017

Pediatric radiology malpractice claims—characteristics and comparison to adult radiology claims.

July 12, 2017

WebM&M Cases

Delayed Recognition of a Positive Blood Culture

July 1, 2017

Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.

June 7, 2017

Pathologists' perspectives on disclosing harmful pathology error.

May 3, 2017

Managing the patient identification crisis in healthcare and laboratory medicine.

March 22, 2017

Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study.

March 15, 2017

Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record.

March 8, 2017

See More About The Topic

Hospitals

Health Care Providers

Pathology and Laboratory Medicine

Medication Errors/Preventable Adverse Drug Events

Active Errors

Disclosure of harmful medical error to patients: a review with recommendations for pathologists.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Disclosure of harmful medical error to patients: a review with recommendations for pathologists.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site