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Perspectives on Safety > Interview
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
Brody H. Am Fam Physician. 2006;73:1272, 1274.
This article presents a case scenario of an unacknowledged misdiagnosis discovered through a patient's request for a second opinion. The author discusses how the colleague who discovered the mistake should address the first physician's denial of error.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
This article reports on a wrong-side surgery that was immediately disclosed to the patient along with an apology. Hospital administrators also disclosed the error to staff.
Journal Article > Study
Improving the patient, family, and clinician experience after harmful events: the "When Things Go Wrong" curriculum.
Bell SK, Moorman DW, Delbanco T. Acad Med. 2010;85:1010-1017.
Medical errors have a lasting effect on patients and their families but can also leave providers—the "second victim"—with a similar emotional toll. Error disclosure is increasingly viewed as an essential skill for physicians just as training curriculums and guidelines continue to emerge. This study describes an interactive educational curriculum for trainees and faculty physicians that teaches error disclosure, apology, and explores the human impact of error. Among the participants, 62% of trainees and 88% of faculty reported making a medical error, while 62% and 78% of them, respectively, did not apologize, citing the lack of training to do so. The authors share the development of their curriculum, its evaluation, and also provide a tool to address practical issues related to communication and professionalism following an adverse event. Past AHRQ WebM&M perspectives have discussed error disclosure and new developments in the field.