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Journal Article > Study
Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness.
Cleopas A, Villaveces A, Charvet A, Bovier PA, Kolly V, Perneger TV. Qual Saf Health Care. 2006;15:136-141.
This study presented a medication error scenario to a group of recently discharged patients and discovered that patients viewed the error less favorably in association with a slow hospital response, a lack of disclosure, and the presence of serious health effects. Using a mailed questionnaire, investigators achieved a 70% response rate from eligible patients, providing more than 1200 evaluations of the scenario. The three primary findings noted above appeared additive and, in particular, the finding that slow and ineffective handling of the error by health care staff produced a more negative response independent of disclosure. A past study similarly discussed patient and physician attitudes regarding the disclosure of medical errors.
Talaga T, Cribb R. Toronto Star. March 19, 2007.
This article discusses disclosure of medical errors and shares stories from several Canadian hospitals on their policies for disclosing adverse events.
Journal Article > Study
Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.
Web Resource > Multi-use Website
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The 2018 results are the sixth generation of the scores, which now include a medication error score. A related report from the Armstrong Institute examines avoidable death associated with grading hospitals.
Journal Article > Study
Pinto A, Faiz O, Vincent C. BMJ Qual Saf. 2012;21:1001-1008.
This study explored current practices related to the National Health Services' being open policy for communicating unintentional harm with patients and families.
Web Resource > Database/Directory
Columbia, MO: Association of Health Care Journalists.
This Web site provides access to federal hospital inspection reports that detail deficiencies cited from complaint inspections at acute care and critical access hospitals.
Babcock CR. Bloomberg News. May 1, 2013.
Consumer Reports. September 2013;78:31-41.
This report analyzed Medicare claims data on 27 types of procedures to develop surgical safety ratings of hospitals by state.
Hertz BT. Med Econ. 2015;92:40-44.
Communication and response strategies have been shown to improve how organizations, clinicians, and patients and their families recover from adverse incidents. This news article discusses apology laws which protect certain statements regarding disclosure from being admissible in court and highlights how sensitivity to patients and transparent communication about the failure can be beneficial for both clinicians and patients after a medical error.
Rice S. Modern Healthc. August 15, 2015.
Landro L. Wall Street Journal. February 1, 2016.
Communication and resolution strategies that emphasize early disclosure after a medical error can enhance patient safety. This newspaper article reports on communication and resolution programs, how they can provide support for patients, elements that contribute to their success, and efforts to guide hospitals in developing such programs.
Abelson J, Staltzman J. Boston Globe. April 13, 2016.
Although scheduling overlapping surgeries may improve operating room efficiency, the practice can diminish patient safety. This newspaper article reports on new standards issued by the American College of Surgeons to reduce risks associated with concurrent surgeries, reviews a previous news investigation into the practice, and includes reactions from clinicians.
Miller N. The Pathologist. June 2016(20):18-29; July 2016(21):18-33.
In light of the growing focus on diagnostic errors, this magazine series reports on unique challenges that pathologists face when they discover potential errors. The first article in the series discusses how pathologists may experience barriers to disclosure including feeling shame in disclosing their own error, discomfort with raising concerns about a colleague who has misdiagnosed a patient, and lack of direct relationships with patients. The second article expands the discussion to focus on how industry support of open transparency can enable pathologists to participate in reporting and disclosure activities.
Tozzi J. Bloomberg News Service. June 10, 2016.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.