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Quality Care and Patient Safety: Strategies to Disclose Medical Errors

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Advances in Human Factors and Ergonomics in Healthcare and Medical Devices (AHFE 2017)

Part of the book series: Advances in Intelligent Systems and Computing ((AISC,volume 590))

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Abstract

In any health care process, adverse events resulting from errors are inevitable. Failure to inform the patient of adverse events caused by a medical error compromises the autonomy of the patient. Disclosure of an adverse event is an important element in managing the consequences of a medical error. Physicians should seek to disclose medical errors to patients and their families on both ethical and pragmatic grounds. Effective communication between health care providers, patients and their families throughout the disclosure process is integral in sustaining and developing the physician patient relationship.

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References

  1. Brennan, T.A.: The institute of medicine report on medical errors—could it do harm? Mass Med. Soc. 342, 1123–1125 (2000)

    Google Scholar 

  2. Wilson, R., Runciman, W.B., Gibberd, R.W., Harrison, B.T., Hamilton, J.D.: Quality in Australian health care study. Med. J. Aust. 164(12), 754 (1996)

    Google Scholar 

  3. Vincent, C., Neale, G., Woloshynowych, M.: Adverse events in British hospitals: preliminary retrospective record review. BMJ 322(7285), 517–519 (2001)

    Article  Google Scholar 

  4. Kohn, L., Corrigan, J., Donaldson, M.: To err is human: building a safer health system. Natl. Acad. Sci. Inst. Med. 6 (2002)

    Google Scholar 

  5. Leape, L.L.: Error in medicine. JAMA 272(23), 1851–1857 (1994)

    Article  Google Scholar 

  6. Leape, L.L.: Reporting of adverse events. N. Engl. J. Med. 347(20), 1633 (2002)

    Article  Google Scholar 

  7. Hayward, R.A., Hofer, T.P.: Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA 286(4), 415–420 (2001)

    Article  Google Scholar 

  8. Forster, A.J., Asmis, T.R., Clark, H.D., et al.: Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. Can. Med. Assoc. J. 170(8), 1235–1240 (2004)

    Article  Google Scholar 

  9. Baker, G.R., Norton, P.G., Flintoft, V., et al.: The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Can. Med. Assoc. J. 170(11), 1678–1686 (2004)

    Article  Google Scholar 

  10. Gagnon, L.: Patient safety: medical error affects nearly 25% of Canadians. CMAJ Can. Med. Assoc. J. 171(2), 123 (2004)

    Article  Google Scholar 

  11. Kalra, J., Collard, D.: Medical error: a need for an educational program (2002)

    Google Scholar 

  12. Reason, J.: Human Error. Cambridge University Press, Cambridge (1990)

    Book  Google Scholar 

  13. Pham, J.C., Aswani, M.S., Rosen, M., et al.: Reducing medical errors and adverse events. Annu. Rev. Med. 63, 447–463 (2012)

    Article  Google Scholar 

  14. Brennan, T.A., Leape, L.L., Laird, N.M., et al.: Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N. Engl. J. Med. 324(6), 370–376 (1991)

    Article  Google Scholar 

  15. Thomas, E.J., Studdert, D.M., Burstin, H.R., et al.: Incidence and types of adverse events and negligent care in Utah and Colorado. Med. Care 38(3), 261–271 (2000)

    Article  Google Scholar 

  16. Davis, P., Lay-Yee, R., Schug, S., et al.: Adverse events regional feasibility study: indicative findings (2001)

    Google Scholar 

  17. Schiøler, T., Lipczak, H., Pedersen, B.L., et al.: Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskr. Laeger 163(39), 5370–5378 (2001)

    Google Scholar 

  18. Richardson, W.C., Berwick, D.M., Bisgard, J., Bristow, L., Buck, C., Cassel, C.: Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine, National Academy Press, Washington, DC (2001)

    Google Scholar 

  19. Helmreich, R.L.: On error management: lessons from aviation. BMJ Br. Med. J. 320(7237), 781 (2000)

    Article  Google Scholar 

  20. Satish, U., Streufert, S.: Value of a cognitive simulation in medicine: towards optimizing decision making performance of healthcare personnel. Qual. Saf. Health Care 11(2), 163–167 (2002)

    Article  Google Scholar 

  21. Kushniruk, A.W.: Analysis of complex decision-making processes in health care: cognitive approaches to health informatics. J. Biomed. Inform. 34(5), 365–376 (2001)

    Article  Google Scholar 

  22. Bates, D.W., Gawande, A.A.: Improving safety with information technology. N. Engl. J. Med. 348(25), 2526–2534 (2003)

    Article  Google Scholar 

  23. Hughes, E.C.: The Sociological Eye: Selected Papers. Transaction Publishers, New Brunswick (1971)

    Google Scholar 

  24. Kalra, J., Saxena, A., Mulla, A., Neufeld, H., Qureshi, M., Sander, R.: Medical error and patient safety: a model for error reduction in pathology and laboratory medicine. Clin. Invest. Med. 26, 732–733 (2003)

    Google Scholar 

  25. Saufl, N.M.: JCAHO’s patient safety standards. J. PeriAnesth. Nurs. 17(4), 265–269 (2002)

    Article  Google Scholar 

  26. Blendon, R.J., DesRoches, C.M., Brodie, M., et al.: Views of practicing physicians and the public on medical errors. N. Engl. J. Med. 347(24), 1933–1940 (2002)

    Article  Google Scholar 

  27. Hébert, P.C., Levin, A.V., Robertson, G.: Bioethics for clinicians: 23. Disclosure of medical error. Can. Med. Assoc. J. 164(4), 509–513 (2001)

    Google Scholar 

  28. Tamblyn, R., Abrahamowicz, M., Dauphinee, D., et al.: Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA 298(9), 993–1001 (2007)

    Article  Google Scholar 

  29. Donaldson, M.S., Corrigan, J.M., Kohn, L.T.: To Err is Human: Building a Safer Health System, vol 6. National Academies Press (2000)

    Google Scholar 

  30. Paterick, Z.R., Paterick, B.B., Waterhouse, B.E., Paterick, T.E.: The challenges to transparency in reporting medical errors. J. Patient Saf. 5(4), 205–209 (2009)

    Article  Google Scholar 

  31. Davis, P., Lay-Yee, R., Fitzjohn, J., Hider, P., Briant, R., Schug, S.: Compensation for medical injury in New Zealand: does “no-fault” increase the level of claims making and reduce social and clinical selectivity? J. Health Polit. Policy Law 27(5), 833–854 (2002)

    Article  Google Scholar 

  32. Dyer, C.: NHS staff should inform patients of negligent acts. BMJ Br. Med. J. 327(7405), 7 (2003)

    Article  Google Scholar 

  33. Kalra, J., Kalra, N., Baniak, N.: Medical error, disclosure and patient safety: a global view of quality care. Clin. Biochem. 46(13–14), 1161–1169 (2013)

    Article  Google Scholar 

  34. Kalra, J., Massey, K.L., Mulla, A.: Disclosure of medical error: policies and practice. J. R. Soc. Med. 98(7), 307–309 (2005)

    Article  Google Scholar 

  35. Borsellino, M.: Disclosure of harm to be standard of practice. Med. Post 39(11) (2003)

    Google Scholar 

  36. Gaulton, C.: Nova scotia public reporting-serious patient safety events? Advancing patient safety and quality? (2014)

    Google Scholar 

  37. Liang, B.A.: A system of medical error disclosure. Qual. Saf. Health Care 11(1), 64–68 (2002)

    Article  MathSciNet  Google Scholar 

  38. Gallagher, T.H., Waterman, A.D., Garbutt, J.M., et al.: US and Canadian physicians’ attitudes and experiences regarding disclosing errors to patients. Arch. Intern. Med. 166(15), 1605–1611 (2006)

    Article  Google Scholar 

  39. Waterman, A.D., Garbutt, J., Hazel, E., et al.: The emotional impact of medical errors on practicing physicians in the United States and Canada. Joint Comm. J. Qual. Patient Saf. 33(8), 467–476 (2007)

    Article  Google Scholar 

  40. Guillod, O.: Medical error disclosure and patient safety: legal aspects. J. Public Health Res. 2(3), e31 (2013)

    Article  Google Scholar 

  41. Kalra, J.: Medical error disclosure: a point of view. Pathol. Lab. Med. Open J. 1(1), e1–e3 (2016)

    Google Scholar 

  42. Wallis, K.: New Zealand’s 2005 ‘no-fault’ compensation reforms and medical professional accountability for harm (2013)

    Google Scholar 

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Correspondence to Jawahar (Jay) Kalra .

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Kalra, J.(., Kopargaonkar, A. (2018). Quality Care and Patient Safety: Strategies to Disclose Medical Errors. In: Duffy, V., Lightner, N. (eds) Advances in Human Factors and Ergonomics in Healthcare and Medical Devices. AHFE 2017. Advances in Intelligent Systems and Computing, vol 590. Springer, Cham. https://doi.org/10.1007/978-3-319-60483-1_17

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  • DOI: https://doi.org/10.1007/978-3-319-60483-1_17

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