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Thomas H. Gallagher, MD; May 2011
Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.
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.
Journal Article > Study
McDonald TB, Helmchen LA, Smith KM, et al. Qual Saf Health Care. 2010;19:e11.
This article describes one institution's principles for reporting, investigating, analyzing, and disclosing adverse events.