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- Communication Improvement 9
- Culture of Safety 1
Education and Training
- Students 1
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches 11
- Policies and Operations 1
- Quality Improvement Strategies 5
- Transparency and Accountability 4
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Failure to rescue 1
- Identification Errors 2
- Medical Complications 1
- Medication Safety 1
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 2
- Surgical Complications 6
- Family Members and Caregivers 7
- Health Care Executives and Administrators 10
- Health Care Providers 11
- Non-Health Care Professionals 7
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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.
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.
"The Early Show." CBS News Video. February 7, 2007.
This news video discusses the impact of apology on potential malpractice lawsuits and features a patient and her anesthesiologist discussing how apology helped them to overcome the psychological distress of medical 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.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
Shelton DL. Chicago Tribune. October 7, 2011.
Reporting on a fatal medical error, this article describes how the family became involved with patient safety, serving on an advisory council at the hospital where it occurred.
Sanghavi D. Boston Globe Magazine. January 27, 2013.
Jain M. Washington Post. May 27, 2013.
Journal Article > Commentary
Petronio S, Torke A, Bosslet G, Isenberg S, Wocial L, Helft PR. Perm J. 2013;17:73-79.
This piece describes a two-step model to help physicians disclose medical errors to patients and families.
Saul S. New York Times. July 19, 2010;A1.
This newspaper article investigates diagnostic errors in breast cancer through the story of a patient who was misdiagnosed. Concern about the accuracy of pathology for early stages of disease and ductal carcinoma in situ has experts debating the best mechanisms to ensure competency and reliability in this field.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
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.
Journal Article > Commentary
Helmchen LA, Richards MR, McDonald TB. Health Care Manage Rev. 2011;36:1-10.
This commentary compares two cases of preventable medical errors and suggests disclosure and remediation as tactics to establish post–adverse event trust with families and patients.
Khullar D. New York Times. May 15, 2014.
Kowalczyk L. Boston Globe. August 31, 2014.
Reporting on an incident involving administration of an inappropriate dye which led to a patient's death, this newspaper article reveals how cognitive biases may have played a role and steps the hospital took to prevent similar errors. Six Massachusetts hospitals have launched a pilot program for early apology and resolution in an effort to enhance patient satisfaction and safety.
Gubar S. New York Times. October 30, 2014.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Journal Article > Study
Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.
Langer T, Martinez W, Browning DM, Varrin P, Sarnoff Lee B, Bell SK. BMJ Qual Saf. 2016;25:615-625.
Health systems struggle with how to effectively involve patients in safety efforts without placing undue responsibility or blame on them. Greater patient–clinician collaboration is particularly important for error disclosure because of the well-documented gaps in clinician and patient perspectives. In this study, investigators developed an intervention to have patients or family members teach error disclosure and prevention to interprofessional clinician learners, including physicians, nurses, and social workers. Their pre–post evaluation showed that the majority of patient and clinician participants reported improved communication and found the intervention valuable. Patient and clinician participation was voluntary. Although these results show promise for involving patients and families as teachers for error disclosure and prevention training, further work is needed to determine whether this approach will be effective among broader health care teams, as opposed to interested clinicians who volunteer. A related editorial discusses the challenges of including patients in safety efforts.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.