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Finkelstein A, Brezis M, Taub A, Arad D. Disclosure following a medical error: lessons learned from a national initiative of workshops with patients, healthcare teams, and executives. Isr J Health Policy Res 2024; 13:13. [PMID: 38462624 PMCID: PMC10926562 DOI: 10.1186/s13584-024-00599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/27/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Despite the increase in disclosures of medical errors, transparency remains a challenge. Recognized barriers include shame, fear of litigation, disciplinary actions, and loss of patient trust. In 2018, the Israeli Ministry of Health initiated a series of workshops about disclosure of medical errors. The workshops involved medical center executives, healthcare providers, patients, and family members of patients who had previously been harmed by a medical error. This study presents the lessons learned about perceived challenges in disclosure of errors in 15 such workshops. METHODS Data collection included participant observations in 15 workshops, full audio recordings of all of the workshops, and documentation of detailed field notes. Analysis was performed under thematic analysis guidelines. RESULTS We identified four main themes: "Providers agree on the value of disclosure of a medical error to the patient"; "Emotional challenges of disclosure of medical error to patients"; "The medico-legal discourse challenges transparency"; and "Providers and patients call for a change in the culture regarding disclosure of medical errors". Participant observations indicated that the presence of a patient who had experienced a tragedy in another hospital, and who was willing to share it created an intimate atmosphere that enabled an open conversation between parties. CONCLUSION The study shows the moral, human, and educational values of open discourse in a protective setting after the occurrence of a medical error. We believe that workshops like these may help foster a culture of institutional disclosure following medical errors. We recommend that the Ministry of Health extend such workshops to all healthcare facilities, establish guidelines and mandate training for skills in disclosure for all providers.
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Affiliation(s)
- Adi Finkelstein
- Department of Nursing, Faculty of Life and Health Sciences, Jerusalem College of Technology (JCT), Beit Hadfus 7 St., 9548307, Jerusalem, Israel.
| | - Mayer Brezis
- School of Public Health, Hebrew University Hadassah Medical Center, Ein-Kerem, PO Box 12000, 91120, Jerusalem, Israel
| | - Amiad Taub
- 'Ofek Back to Life' Organization, Sderot H'areches 13, 7178441, Modi'in, Israel
| | - Dana Arad
- Patient Safety Division, Ministry of Health, 39 Yeremiahu, 9101002, Jerusalem, Israel
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Strengths and weaknesses of the incident reporting system: An Italian experience. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2023. [DOI: 10.1177/25160435221150568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
One of the cornerstones for enhancing the patient safety culture is the incident reporting system (IRS). It is a process for detecting, reporting, collecting, and summarizing adverse events (AEs) and near-misses in healthcare, and so it represents a vital tool for clinical risk management. We analyzed the 5-year experience of a third-level hospital's IRSs, showing its trends and highlighting its main strengths and weaknesses. Patients’ falls and physical or verbal aggression toward the providers or between patients are the most reported events. Underreporting is the main limitation of the system, especially among nurses. Visible actions, forceful analysis of the reports, operators’ education, no-blame culture promotion, and organizational adjustments may improve operators’ adherence to IRS. Providers do not willingly inform patients’ relatives about fatal incidents. Despite that, the IRS is far from its potential, and the number of data collected has increased.
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White AA, King AM, D'Addario AE, Brigham KB, Dintzis S, Fay EE, Gallagher TH, Mazor KM. Effects of Practicing With and Obtaining Crowdsourced Feedback From the Video-Based Communication Assessment App on Resident Physicians' Adverse Event Communication Skills: Pre-post Trial. JMIR MEDICAL EDUCATION 2022; 8:e40758. [PMID: 36190751 PMCID: PMC9577713 DOI: 10.2196/40758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND US residents require practice and feedback to meet Accreditation Council for Graduate Medical Education mandates and patient expectations for effective communication after harmful errors. Current instructional approaches rely heavily on lectures, rarely provide individualized feedback to residents about communication skills, and may not assure that residents acquire the skills desired by patients. The Video-based Communication Assessment (VCA) app is a novel tool for simulating communication scenarios for practice and obtaining crowdsourced assessments and feedback on physicians' communication skills. We previously established that crowdsourced laypeople can reliably assess residents' error disclosure skills with the VCA app. However, its efficacy for error disclosure training has not been tested. OBJECTIVE We aimed to evaluate the efficacy of using VCA practice and feedback as a stand-alone intervention for the development of residents' error disclosure skills. METHODS We conducted a pre-post study in 2020 with pathology, obstetrics and gynecology, and internal medicine residents at an academic medical center in the United States. At baseline, residents each completed 2 specialty-specific VCA cases depicting medical errors. Audio responses were rated by at least 8 crowdsourced laypeople using 6 items on a 5-point scale. At 4 weeks, residents received numerical and written feedback derived from layperson ratings and then completed 2 additional cases. Residents were randomly assigned cases at baseline and after feedback assessments to avoid ordinal effects. Ratings were aggregated to create overall assessment scores for each resident at baseline and after feedback. Residents completed a survey of demographic characteristics. We used a 2×3 split-plot ANOVA to test the effects of time (pre-post) and specialty on communication ratings. RESULTS In total, 48 residents completed 2 cases at time 1, received a feedback report at 4 weeks, and completed 2 more cases. The mean ratings of residents' communication were higher at time 2 versus time 1 (3.75 vs 3.53; P<.001). Residents with prior error disclosure experience performed better at time 1 compared to those without such experience (ratings: mean 3.63 vs mean 3.46; P=.02). No differences in communication ratings based on specialty or years in training were detected. Residents' communication was rated higher for angry cases versus sad cases (mean 3.69 vs mean 3.58; P=.01). Less than half of all residents (27/62, 44%) reported prior experience with disclosing medical harm to patients; experience differed significantly among specialties (P<.001) and was lowest for pathology (1/17, 6%). CONCLUSIONS Residents at all training levels can potentially improve error disclosure skills with VCA practice and feedback. Error disclosure curricula should prepare residents for responding to various patient affects. Simulated error disclosure may particularly benefit trainees in diagnostic specialties, such as pathology, with infrequent real-life error disclosure practice opportunities. Future research should examine the effectiveness, feasibility, and acceptability of VCA within a longitudinal error disclosure curriculum.
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Affiliation(s)
- Andrew A White
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Ann M King
- National Board of Medical Examiners, Philadelphia, PA, United States
| | | | - Karen Berg Brigham
- Collaborative for Accountability and Improvement, University of Washington, Seattle, WA, United States
| | - Suzanne Dintzis
- Department of Pathology, University of Washington School of Medicine, Seattle, WA, United States
| | - Emily E Fay
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, United States
| | - Thomas H Gallagher
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Kathleen M Mazor
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, United States
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Shapiro J, Robins L, Galowitz P, Gallagher TH, Bell S. Disclosure Coaching: An Ask-Tell-Ask Model to Support Clinicians in Disclosure Conversations. J Patient Saf 2021; 17:e1364-e1370. [PMID: 29781980 DOI: 10.1097/pts.0000000000000491] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Error disclosure is a high-stakes, emotionally charged interaction for patients and families as well as clinicians. A failed disclosure can result in emotional distress, reduced patient and family trust, litigation, and lost opportunities to learn from and prevent subsequent errors. However, many clinicians have little expertise in handling these challenging interactions and can inadvertently make a bad situation worse. Even those clinicians who have had formal disclosure training may have trouble remembering what they were taught when faced with the need to actually discuss an error with patients. Providing just-in-time coaching to clinicians is recommended by national standards. However, there is scant training material to guide error disclosure coaches. Therefore, we developed an "Ask-Tell-Ask" model and materials to guide the disclosure coaching process. The Ask-Tell-Ask model is well-suited to provide clinicians with targeted interactive teaching immediately before a disclosure without overwhelming them with lecture-style facts that they are unlikely to retain. Such teaching would ideally be provided by trained disclosure coaches, available for just-in-time support of clinicians throughout the disclosure process. The Ask-Tell-Ask model can also help risk managers, department heads, clinical managers, attending physicians, service chiefs, and others who assist clinicians with error disclosure. Here, we describe a comprehensive approach to coaching developed over years of coaching experience that incorporates the model, its rationale, step-by-step coaching strategies and guidance (including sample scripts), and organizational considerations regarding implementation of a coaching program to support patient-centered transparent communication after harmful events.
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Affiliation(s)
- Jo Shapiro
- From the Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Sigall Bell
- Beth Israel Deaconess Medical Center Harvard Medical School, Boston, Massachusetts
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Loren DL, Lyerly AD, Lipira L, Ottosen M, Namey E, Benedetti T, Dunlap BS, Thomas EJ, Prouty C, Gallagher TH. Communication regarding adverse neonatal birth events: Experiences of parents and clinicians. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2021. [DOI: 10.1177/25160435211017749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Communicating with parents about adverse birth outcomes is challenging. We sought to describe attitudes and experiences of parents and providers regarding communication about adverse newborn birth events. Methods From 2011–2012, we conducted semi-structured in-depth interviews with parents who believed they had experienced an adverse birth-related neonatal outcome and focus groups with healthcare providers who have communicated with parents about adverse newborn birth events from three geographically diverse US academic medical centers. We conducted qualitative thematic analysis to identify key themes. Results Parents and providers described unique communication challenges around adverse neonatal outcomes in six categories: 1) High expectations for a positive delivery experience and the view that birth is a life event, not a medical encounter; 2) Powerful emotions associated with birth, amplified when an adverse event occurs; 3) Rapid changes when expectations for a normal birth take a sudden negative turn; 4) Family involvement adding complexity to communication; 5) Multiple patients and providers complicating communication dynamics with inter-professional teams seeking to coordinate information and care; and, 6) Concerns about litigation surrounding the birth experience. Strategies to educate parents and enhance communication were identified by both parents and providers. Conclusion Both parents and providers experience – and may suffer as a result of – communication challenges following adverse birth events affecting the newborn. Training and resources for this care environment are needed to meet parental, extended family, and provider expectations for communication when these events occur.
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Affiliation(s)
- Davia Liba Loren
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Anne Drapkin Lyerly
- Department of Social Medicine and Center for Bioethics, University of North Carolina at Chapel Hill, NC, USA
| | - Lauren Lipira
- Department of Health Services, University of Washington School of Medicine, Seattle, WA, USA
| | - Madelene Ottosen
- University of Texas Health Science Center at Houston, UT-MH Center for Healthcare Quality and Safety, Houston, TX, USA
| | - Emily Namey
- Behavioral, Epidemiological, and Clinical Sciences, FHI 360, Durham, NC, USA
| | - Thomas Benedetti
- Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Benjamin S Dunlap
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Eric J Thomas
- McGovern Medical School, The University of Texas at Houston – Memorial Hermann Center for Healthcare Quality and Safety, Houston, TX, USA
| | - Carolyn Prouty
- Public Health and Health Sciences, The Evergreen State College, Seattle, WA, USA
| | - Thomas H Gallagher
- Department of Medicine and Department of Bioethics & Humanities, University of Washington School of Medicine, Seattle, WA, USA
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Abstract
A review of the literature related to the disclosure movement was conducted to find gaps and needs while identifying areas where needs are being met. There are several articles that address claims and other economic factors. Moreover, there are many papers that define barriers to disclosure with suggested workarounds. There is also a wealth of training content that teaches how to say "sorry." However, gaps and needs were identified. The "gap list" was developed with a focus on concepts that are novel or not mentioned in the literature as well as issues in the disclosure movement that would benefit from greater attention: (1) lack of research and disclosure training content for health care professionals beyond acute care; (2) messaging and disclosure programs, including the meaning of "apology"; (3) insufficient integration between disclosure programs and second victim support programs; (4) confidentiality clauses; (5) the National Practitioner Data Bank and state licensure boards being viewed as an impediment to disclosure; (6) understanding awareness of the disclosure movement by consumers, personal injury bar, and payors; (7) measuring what medical and nursing schools are teaching about disclosure; and (8) encouraging states to pass apology laws that support the development of disclosure programs.
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Yeung JWY. Adverse Event Disclosure Training for Nursing Students: Peer Role-Play and Simulated Patients. Int J Nurs Educ Scholarsh 2019; 16:ijnes-2019-0094. [PMID: 31863696 DOI: 10.1515/ijnes-2019-0094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/30/2019] [Indexed: 11/15/2022]
Abstract
Background Simulation has proven valuable in nursing communication training, but there are limited studies comparing the effectiveness of different training methods, especially in the area of adverse event disclosure (AED) training. Therefore, this study aimed to examine the impact of two training methods, peer role-play (PRP) and simulated patients (SP) on the self-efficacy and performance of nursing students in AED in a simulated environment. Methods Forty-four nursing students participated. Students' self-efficacy toward AED was assessed using the pre/post-test method. Also, students' performance was evaluated after the simulation encounter. Results It showed a significant difference in self-efficacy between the groups. However, no significant difference emerged between the groups in performance. Conclusion This study provides a basis for comparison of these two methods in patient communication training. Educators should consider their resources and expected learning outcomes in designing the emotionally draining adverse event disclosure training.
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Affiliation(s)
- Joanna Wing Yan Yeung
- Department of Health and Nursing Sciences, School of Nursing, Tung Wah College, Kowloon, Hong Kong
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McLennan S, Moore J. New Zealand District Health Boards' Open Disclosure Policies: A Qualitative Review. JOURNAL OF BIOETHICAL INQUIRY 2019; 16:35-44. [PMID: 30617731 DOI: 10.1007/s11673-018-9894-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 12/13/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND New Zealand health and disability providers are expected to have local open disclosure policies in place, however, empirical analysis of these policies has not been undertaken. AIM This study aims to (1) examine the scope and content of open disclosure policies in New Zealand (2) compare open disclosure policies in New Zealand, and (3) provide baseline results for future research. METHODS Open disclosure policies were requested from all twenty New Zealand District Health Boards in June 2016. A total of twenty-one policies were received, with nineteen policies included in the review. The data were analysed using conventional content analysis. Areas of identified guidance were categorised categorized under the headings: 1) identification of an adverse event, 2) actions before disclosure, 3) disclosure of harm, and 4) actions after disclosure. RESULTS A total of forty-six distinct areas of guidance could be categorized under the different phases of the open disclosure life-cycle. CONCLUSION This review has identified significant unwarranted heterogeneity and important gaps in open disclosure documents in New Zealand which urgently needs to be addressed. Open disclosure policies which are both flexible and specific should enhance the likelihood that injured patients' needs will be met.
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Affiliation(s)
- Stuart McLennan
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
| | - Jennifer Moore
- Faculty of Law, University of New South Wales, The Law Building, Union Road, UNSW Kensington Campus, Sydney, New South Wales, 2052, Australia
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Moore J, Bismark M, Mello MM. Patients' Experiences With Communication-and-Resolution Programs After Medical Injury. JAMA Intern Med 2017; 177:1595-1603. [PMID: 29052704 PMCID: PMC5710270 DOI: 10.1001/jamainternmed.2017.4002] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
IMPORTANCE Dissatisfaction with medical malpractice litigation has stimulated interest by health care organizations in developing alternatives to meet patients' needs after medical injury. In communication-and-resolution programs (CRPs), hospitals and liability insurers communicate with patients about adverse events, use investigation findings to improve patient safety, and offer compensation when substandard care caused harm. Despite increasing interest in this approach, little is known about patients' and family members' experiences with CRPs. OBJECTIVE To explore the experiences of patients and family members with medical injuries and CRPs to understand different aspects of institutional responses to injury that promoted and impeded reconciliation. DESIGN, SETTING, AND PARTICIPANTS From January 6 through June 30, 2016, semistructured interviews were conducted with patients (n = 27), family members (n = 3), and staff (n = 10) at 3 US hospitals that operate CRPs. Patients and families were eligible for participation if they experienced a CRP, spoke English, and could no longer file a malpractice claim because they had accepted a settlement or the statute of limitations had expired. The CRP administrators identified hospital and insurer staff who had been involved in a CRP event and had a close relationship with the injured patient and/or family. They identified patients and families by applying the inclusion criteria to their CRP databases. Of 66 possible participants, 40 interviews (61%) were completed, including 30 of 50 invited patients and families (60%) and 10 of 16 invited staff (63%). MAIN OUTCOMES AND MEASURES Patients' reported satisfaction with disclosure and reconciliation efforts made by hospitals. RESULTS A total of 40 participants completed interviews (15 men and 25 women; mean [range] age, 46 [18-67] years). Among the 30 patients and family members interviewed, 27 patients experienced injuries attributed to error and received compensation. The CRP experience was positive overall for 18 of the 30 patients and family members, and 18 patients continued to receive care at the hospital. Satisfaction was highest when communications were empathetic and nonadversarial, including compensation negotiations. Patients and families expressed a strong need to be heard and expected the attending physician to listen without interrupting during conversations about the event. Thirty-five of the 40 respondents believed that including plaintiffs' attorneys in these discussions was helpful. Sixteen of the 30 patients and family members deemed their compensation to be adequate but 17 reported that the offer was not sufficiently proactive. Patients and families strongly desired to know what the hospital did to prevent recurrences of the event, but 24 of 30 reported receiving no information about safety improvement efforts. CONCLUSIONS AND RELEVANCE As hospitals strive to provide more patient-centered care, opportunities exist to improve institutional responses to injuries and promote reconciliation.
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Affiliation(s)
- Jennifer Moore
- Faculty of Law, University of New South Wales, Sydney, Australia
| | - Marie Bismark
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Michelle M Mello
- Stanford Law School, Stanford University, Stanford, California.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
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Card AJ. Risks without walls. J Healthc Risk Manag 2017; 36:4-5. [PMID: 28099793 DOI: 10.1002/jhrm.21264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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