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Search results for "Book/Report"
- Patient Disclosure
Clive, IA: Heartland Health Research Institute; January 7, 2018.
Patient perspectives can provide insights regarding areas in need of improvement. This survey of adults in Iowa revealed that 19% of respondents experienced a preventable medical error, either in their own care or as the loved one of a patient. The survey also found that patients support requiring clinician reporting of mistakes.
Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.
Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.
Patients and families can contribute to improvement when they are treated with respect and openness. This report explored the extent to which those characteristics are present in National Health Service (NHS) investigations regarding patient deaths and found them to be lacking, particularly in cases involving patients with mental health conditions or learning disabilities. The authors recommend a framework to guide behaviors consistently across the NHS to improve the timeliness and quality of investigations and ensure system-level learning.
London, UK: General Medical Council and the Nursing and Midwifery Council; June 29, 2015.
Open and honest discussion with patients after an error or near miss is key to effective disclosure. This guidance provides recommendations for physicians, nurses, and midwives regarding disclosure practices in the United Kingdom. A set of case studies accompanies the report, which illustrate the professional duty of candor in various practical situations.
Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015.
Health care has historically treated data as something to be safeguarded rather than openly discussed. Even in the information age it is difficult for patients to access their own medical records and for clinicians to obtain data on their own clinical performance, and efforts to encourage public reporting of safety and quality data remain controversial. This report by the Lucian Leape Institute of the National Patient Safety Foundation strongly advocates for improving transparency in health care. The authors identify four key domains of transparency and ways in which they could be enhanced: transparency between clinicians and patients (by promoting error disclosure), transparency among clinicians themselves (through peer review processes), transparency of health care organizations with one another (using collaborative approaches to improving care), and transparency with the public (by publicly reporting quality and safety data). The report includes a series of specific recommendations for clinicians, health care organizations, and governmental and nongovernmental leadership to enhance transparency. The authors acknowledge that a robust culture of safety is essential in order to overcome barriers to the free flow of information. Prior reports from the Lucian Leape Institute have addressed the role of quality and safety in health professions education and the role of information technology in patient safety.
Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.
Dalton D, Williams N. London, UK: The Royal College of Surgeons of England; March 2014.
When medical errors occur, patients desire full disclosure. This report calls for clinicians in the National Health Service to disclose errors that contribute to moderate or severe harm or death. The authors outline recommendations to help organizations establish a safety culture that requires discussion about unanticipated events and ensures that staff receive training in apologies.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
Windwick B, Aubin D, Beard P, et al; Disclosure Working Group. Edmonton, AB, Canada: Canadian Patient Safety Institute; 2011. ISBN: 9781926541389.
These national guidelines for Canadian health care providers serve as a tool for developing and implementing disclosure policies, practices, and training methods.
Truog RD, Browning DM, Johnson JA, Gallagher TH. Baltimore, MD: Johns Hopkins University Press; 2011. ISBN: 0801898048.
This publication provides guidelines for disclosure and reveals tactics for effective communication following medical error.
Wojcieszak D, Saxton JW, Finkelstein MM. Bloomington, IN: AuthorHouse; 2010. ISBN: 9781438969732.
This manual offers practical advice to providers, hospitals, medical practices, and insurers on how to build a successful disclosure program. Version 2.0 includes a chapter focusing on the patient's role in effecitve post adverse event commuinication.
Carr S. Chestnut Hill, MA: Medically Induced Trauma Support Services; 2009.
This report describes results of a multidisciplinary effort to develop programs to help clinicians cope with errors that result in patient harm.
National Quality Forum. Washington, DC: National Quality Forum; 2009.
The National Quality Forum's Safe Practices for Better Healthcare provide a blueprint for organizations to improve the quality and safety of patient care. The practices are organized into seven content areas: establishing leadership structures and systems, improving safety culture, honoring patient's wishes for informed consent and error disclosure, matching health care needs with delivery capacity, facilitating information transfer and clear communication between providers, managing medications safely, preventing health care–associated infections, and implementing safe practices for specific clinical conditions and sites of care. Since the last update in 2006, seven new practices have been added and others retired. The practices are defined so that organizations can measure the relationship between implementation of the practices and patient safety outcomes.
Thomas MO, Quinn CJ, Donohue GM. Sudbury, MA: Jones Bartlett; 2009. ISBN: 100763748560.
Written by experts in legal medicine and patient safety, this comprehensive book covers key issues surrounding medical malpractice for practicing physicians, trainees, and risk managers.
Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.
Oakbrook Terrace, IL: Joint Commission Resources; 2006. ISBN: 1599400219.
This book discusses disclosure and apology and describes methods that support their effective use.
Kaiser Family Foundation, Agency for Healthcare Research and Quality; September 2006.
This survey follows up on a prior study from 2004, asking patients about their perceptions of health care quality and medical errors. The study found minimal change since 2004 in overall impression of US health care quality, with approximately half of respondents stating they are "dissatisfied" with quality, particularly with coordination of care. More patients are aware of information comparing the quality of hospitals, health care plans, or providers, but only a small minority report using this information to make health care decisions. A large proportion of patients reported taking recommended actions to improve safety, such as bringing a list of their medications to appointments or following up on test or procedure results. As found in other studies, survey respondents overwhelmingly expressed support for full, mandatory disclosure of all preventable errors, and two-thirds felt errors should be publicly reported.
Amori G. Chicago, IL: American Society for Healthcare Risk Management; 2006.
This booklet shares scenarios and strategies for effective communication during disclosure of adverse events.
A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
Berlinger N. Baltimore, MD: Johns Hopkins University Press; 2005. ISBN: 0801881676.
The author draws from theological, ethical, religious, and cultural foundations to understand the actions that should be taken after a medical mistake.
Banja J. Sudbury, MA: Jones and Bartlett Publishers, Inc.;2005. ISBN: 0763783617.
This book chronicles the issues surrounding appropriate disclosure of medical errors by health care professionals. The author shares the personal challenges that prevent providers from engaging in these often uncomfortable conversations and offers a series of practical recommendations for doing so properly.
Woods MS, Brucker HJ. Oak Park, IL; Doctors in Touch: 2004. ISBN: 0975519603.
The author proposes a straightforward approach and practical advice on apologizing to patients, drawing on examples from medicine and other industries.