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- Communication Improvement 2
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis
- Legal and Policy Approaches 2
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Transparency and Accountability
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Errors test openness at Beth Israel Deaconess. Disclosures will benefit hospital, president insists.
Wen P. Boston Globe. October 27, 2008.
This newspaper article reports on one hospital executive's work on transparency regarding errors and describes reactions to these efforts.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.
The Empowered Patient Coalition; 2010.
This video series uses two real cases of patients who died due to preventable errors after elective surgery to illustrate fundamental concepts in patient safety and provide lessons for patients and families in engaging in their own care. The circumstances leading to the death of Lewis Blackman, one of the patients discussed in this video series, are discussed in more detail in a separate article that analyzes his death as an example of failure to rescue.
Journal Article > Commentary
Erickson JI. J Nurs Adm. 2012;42:131-133.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
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.
Journal Article > Study
Transparency when things go wrong: physician attitudes about reporting medical errors to patients, peers, and institutions.
Bell SK, White AA, Yi JC, Yi-Frazier JP, Gallagher TH. J Patient Saf. 2017;13:243-248.
Prompt error disclosure to patients and families is the standard of care, despite varying implementation. Reporting errors to the institution and discussing incidents with peers are also recommended safety practices. In this survey study, physicians reported similar attitudes about disclosing to patients, the organization, and peers, suggesting that those who favor transparency do so across the board. Female physicians were more likely to favor transparency compared to male physicians, and academic physicians were more likely to favor transparency than those in private practice. Younger physicians were also more likely to support disclosure, suggesting that attitudes towards error reporting may improve over time. A past AHRQ WebM&M interview discussed developments in error disclosure and apologies.
Journal Article > Commentary
Moffatt-Bruce SD, Ferdinand FD, Fann JI. Ann Thorac Surg. 2016;102:358-362.
Although error disclosure is increasingly encouraged in health care, challenges to achieving transparency include liability and risk considerations, particularly for surgeons. This commentary describes the experiences of two health care systems that have implemented approaches to support transparent disclosure of medical errors.