Disclosure and documentation of reported unanticipated medical events or outcomes: Need for...

© 2012 American Society for Healthcare Risk Management of the American Hospital AssociationPublished online in Wiley Online Library (wileyonlinelibrary.com) • DOI: 10.1002/jhrm.21087

JOURNAL OF HEALTHCARE RISK MANAGEMENT • VOLUME 32, NUMBER 114

By Vinita Singh, MD, Christopher J. L. Cunningham, Ph.D., Mukta Panda, MD, FACP, Dale C. Hetzler, MSCM, JD, and Daniel Stanley, MD

Special Focus: Disclosure & Risk Management

Disclosure and documentation of reported unanticipated medical events or outcomes: Need for healthcare provider education

In 2001 the Joint Commission on Accreditation of Healthcare Organizations added “requirement to disclose unanticipated out-comes” to accreditation standards. Full disclosure increases patient satisfaction and trust in physicians. Though studies suggest ele-ments of complete disclosure, there are no national standards.

INTRODUCTION

“To err is human.” This is true not only for physicians, but all persons or organ-izations that provide healthcare services. What are the actions and behaviors of healthcare personnel and organizations when unintended medical events (UME) occur? According to the Webster’s Dictionary, disclosure is defined as the act of making something evident or revealing. It has been proposed that error disclo-sure can be defined as, “Communication between a healthcare provider and a patient, family members, or the patient’s proxy that acknowledges the occur-rence of an error, discusses what happened, and describes the link between the error and outcomes in a manner that is meaningful to the patient.”1(p760)

Disclosure of UME is an increasingly important topic within medical educa-tion and practice, especially when these questions are considered: Are physi-cians doing disclosure appropriately? Are there standards or policies regarding disclosure for physicians to follow and are they effective? Does full disclosure have an impact on litigation outcome or incidence? What are physicians’ atti-tudes regarding disclosure of medical errors and UME?

Disclosure standards and training are necessary to meet public expectations and promote professional responsibility following errors.2 The Accreditation Council of Graduate Medical Education (ACGME) does not address specifically how residents in training should be involved in disclosure discussions. The University of Tennessee, College of Medicine hospital system in Chattanooga, Tennessee, (UTCOMC), where this study was conducted, does not have a specific require-ment on medical error disclosure, but does address in its professionalism policy that residents are required to “adhere to ethical principles” and have “account-ability to patients.” No research to date has specifically addressed the documen-tation of UME disclosure.

JHRM21087.indd 14JHRM21087.indd 14 7/16/12 10:47:14 PM7/16/12 10:47:14 PM

DOI: 10.1002/jhrm AMERICAN SOCIETY FOR HEALTHCARE RISK MANAGEMENT • VOLUME 32, NUMBER 1 15

Documentation is a useful tool for physician communica-tion, especially with increasing frequency of handovers in patient care. It ensures better patient care and continuity, and can also provide meaningful information to guide patient safety improvements and necessary information for future root-cause analyses.3,4 However, the useful-ness of UME disclosure documentation is often limited because of a lack of details and incomplete reporting guidelines and practices.

METHODS

A team consisting of experienced members of the clinical quality improvement committee, risk management experts, and experienced physicians within UTCOMC supported the development of the present study. The purpose of this study was to examine disclosure documentation by the healthcare professionals (HCPs) in the system by retro-spective chart review, and this was considered institutional review board (IRB) exempt by the institution. After con-ducting the retrospective chart review, the study was expand-ed (following an IRB addendum) to survey HCPs regard-ing their perspectives on disclosure and documentation of

UMEs and possible reasons for the low rates of documenta-tion that had been observed in the chart review.

DATA COLLECTION

Data for this study were collected via two methods—retrospective review and on-line survey.

Retrospective review

First, a retrospective review of the medical records, includ-ing the nursing records, of the unanticipated events reported to the system in the process of risk management, falling within Categories E–I on the patient safety harm scale, within the UTCOMC hospital system between July 1, 2008 and June 30, 2009 was done. The patient safety harm scale has been adapted from the MERP medication scale by the institution’s Risk Management and Clinical Quality Improvement group for the purposes of report-ing unanticipated events and consists of various categories of UME from Category A to I, where the severity of the event gradually increases from A to I (see Table 1). In the present study, we focused on Category E–I UMEs

Table 1: Patient Safety Harm Scalea

Category Definition ExampleA Circumstances or events that have

the capacity to cause harmYou notice that 2 bottles of very different medicine have labels that are almost identical and easily mistaken for each other.

B An event occurred but did not reach the patient (near misses).

The nurse was walking down the hall with patient A’s medicine, on the way to give it to patient B. She realized it before she got to the room.

C An event occurred that reached the patient but did not cause patient harm.

Patient A got patient B’s medicine, but it didn’t harm patient A.

D An event occurred that resulted in the need for increased patient moni-toring and/or treatment or interven-tion but no patient harm.

A patient inadvertently gets twice the therapeutic dose of morphine. The patient is excessively lethargic and receives a reversal agent. He is then fine and is monitored for some time afterwards.

E An event occurred that resulted in the need for treatment or intervention and caused temporary patient harm.

A patient inadvertently receives an antibiotic to which she is known to be allergic. She has a severe allergic reaction. She is treated appro-priately, recovers, and is able to be discharged when expected

F An event occurred that resulted in initial or prolonged hospitalization and caused temporary patient harm.

A patient receives a significant overdose of product XXX, and goes into renal failure, requiring dialysis. He has a prolonged hospitaliza-tion, recovers normal renal function, and returns to his normal state of health.

G An event occurred that resulted in permanent patient harm.

A patient has the wrong leg amputated.

H An event occurred that resulted in a near-death event.

The aorta is inadvertently punctured during surgery and the patient almost hemorrhages to death. He is stabilized in ICU postoperatively.

I An event occurred that resulted in patient death.

Hoses are mislabeled in the OR and the patient receives another gas instead of oxygen. He arrests and cannot be resuscitated.

aAdapted from Medical Error Reporting and Prevention (MERP) taxonomy of medical errors by the institution.


JOURNAL OF HEALTHCARE RISK MANAGEMENT • VOLUME 32, NUMBER 1 DOI: 10.1002/jhrm16

because these were the categories that had some potential to cause harm to the patient. For example, a Category E UME would result in temporary harm to the patient and a Category I UME would result in patient mortal-ity. An evaluation team composed of a physician, a legal officer, and a clinical quality-improvement representative reviewed the existing UME disclosure records for accuracy of inclusion. Records were excluded from the study if all members of this evaluation team agreed that the particu-lar record could not be appropriately categorized or did not constitute a UME that fell into Categories E–I of the patient harm scale.

The retrospective review focused on evaluating the pres-ence and quality of disclosure documentation elements. Though there are no specific guidelines as to what con-stitutes complete disclosure, the available literature sug-gest certain necessary elements that should be in such documentation for it to be considered comprehensive.1 The research team defined complete disclosure for the purposes of this research as a UME disclosure record that included all of the elements/details mentioned in Table 2. These elements were derived from the consensus of the research team and are based on the elements of any docu-mentation in a medical record.4 Documentation was con-sidered incomplete if any of these elements was missing.

Survey

Following the retrospective record review, an anonymous survey (Appendix A) was distributed throughout the same hospital system to all HCPs, to improve the understand-ing, knowledge of, and attitudes toward UME disclosure and documentation. The hope was that this information would provide a foundation for future efforts to improve disclosure and documentation within this hospital system. The survey was distributed with the use of the Survey

Monkey Internet surveying system in March 2010 to all the university faculties, residents, nursing, and admin-istration members. It is important to note that because the records reviewed in the first part of this study were deidentified, it was not possible (nor was it an objective of the present research) to survey only those HCPs who had been involved in making and/or documenting an actual UME disclosure in the past. Indeed, one of the reasons for the survey was to understand the barriers perceived by HCPs that might prevent them from making and docu-menting UME disclosures in the first place.

DATA ANALYSIS

Data from the chart review were analyzed descriptively to identify the percentage of records within each category of UME (from E to I), and within both adult and pediatric samples, which were documented completely, incomplete-ly, or not at all. Survey data were analyzed descriptively as well, to identify response patterns for physicians and non-physicians, and more importantly, to identify disclosure-related issues needing attention.

RESULTS

Retrospective review

Two hundred thirty Category E–I UMEs were reported to the institute’s risk management system during the period reviewed for this study. Of these, 38 records were excluded for not clearly falling into 1 of the categories of patient harm; 192 charts (135 adults and 57 pediatrics) were included for the purpose of our study. Of these, only 9.89% had any level of documentation (complete and incomplete); just over 90% of these charts provided no documentation, and only 1 chart had complete disclosure documentation (see Figure 1).

Table 2: Elements of Unintended Medical Event (UME) Disclosure Documentation Reviewed in the Retrospective Study, with Examples

Elements of UME Disclosure Documentation Reviewed 1 Who made the disclosure, eg, the attending physician, resident, or the nursing staff who disclosed the facts of the UME to

the patient/guardian/family2 Who received the disclosure, eg, who all were present during the UME disclosure on patient’s behalf—the patient/guardian/

relative3 Whether the same person reported and documented disclosure, eg, whether the attending physician disclosed and

documented or the attending physician disclosed while the resident physician/nursing staff documented4 Facts relating to the event, eg, what went wrong, what has been done to fix it and5 Time from event to disclosure6 Time from disclosure to documentation7 Location of error, eg, patient’s room, pharmacy, nursing station8 Location of disclosure, eg, by the bedside, over phone, a special conference room



Table 3 summarizes overall record review results for the adult and the children’s hospitals. At Erlanger Health System, as the severity of the event increased, the percent-age of UME disclosures with some documentation also increased. Only 1 record was identified as a complete documentation of a Category E UME disclosure. At the children’s hospital, there were only 2 Category E UME disclosure records with incomplete documentation, where-as none of the records had complete disclosure. There was no documentation of UME disclosures for any other cat-egory of patient harm.

There was a great deal of variability in terms of which UME disclosure elements (described in the Methods sec-tion) were documented, whenever there was disclosure documentation. Of these documentation elements, the most frequently documented was the “facts of the event,” but even this was not documented in 100% of the UME disclosure records (see Figure 2).

Survey

Data were collected from physicians (n = 65) and non-physicians (n = 48) working within the same hospital system (total N = 113; overall response rate of 29%). Of the physician respondents, 68% were male and the aver-age age was 47.88 years (SD = 8.90). Of the nonphysician

Figure 1: Overall disclosure documentation results

(N = 192)

Table 3: Overall Results—Retrospective Review

Category Charts Reviewed Disclosure Documentation with Percent of Any DocumentationAdult Pediatric Total Adult Pediatric Total

E 108 47 155 Complete documentation 1 (0.92%) 0 (0%) 1 (0.64%)Incomplete documentation 8 (7.4%) 2 (4.25%) 10 (6.45%)

No documentation 99 (91.66%) 45 (95.74%) 144 (92.9%)F 21 7 28 Complete documentation 0 (0%) 0 (0%) 0 (0%)

Incomplete documentation 4 (19.04%) 0 (0%) 4 (14.28%)No documentation 17 (80.95%) 7 (100%) 24 (85.71%)

G 1 0 1 Complete documentation 0 (0%) 0 (0%) 0 (0%)Incomplete documentation 1(100%) 0 (0%) 1(100%)

No documentation 0 (0%) 0 (0%) 0 (0%)H 3 2 5 Complete documentation 0 (0%) 0 (0%) 0 (0%)

Incomplete documentation 1 (33.33%) 0 (0%) 1 (20%)No documentation 2 (66.66%) 2 (100%) 4 (80%)

I 2 1 3 Complete documentation 0 (0%) 0 (0%) 0 (0%)Incomplete documentation 2 (100%) 0 (0%) 2 (66.66%)

No documentation 0 (0%) 1 (100%) 1 (33.33%)Total charts 192 Complete documentation 1 (0.52%)

Incomplete documentation 18 (9.37%)No documentation 173 (90.1%)



Figure 2: Components of disclosure: Percentage of documentation in charts with any disclosure documentation

Table 4: Demographic Features of Survey Respondents

Male Female Total Average Age (Years)

Physician 44 (68%) 21 (32%) 65 47.88 (SD = 8.90)

Nonphysician 4 (9%) 44 (91%) 48 51.13 (SD = 6.02)

Total N 48 65 113

respondents, 91% were female and the average age was 51.13 years (SD = 6.02) (see Table 4).

Among survey respondents, 68% of physicians and 48% of nonphysicians reported an awareness of recom-mendations to disclose UME. Although physicians and nonphysicians reported learning about such disclosure recommendations from a variety of sources (e.g., lecture, literature, modeling, curriculum), 57% of physicians and 35% of nonphysicians reported not being aware/informed of policy or guidelines for UME disclosure in this particu-lar hospital system. Differences were observed between physicians and nonphysicians in terms of perceptions of when UME disclosure is necessary, but the most com-mon response in both groups was that UME disclosure is important (see Figure 3).

When asked who the best person to provide UME disclo-sure would be, both groups of survey respondents agreed that the responding physician to the event would be best

(69%), followed by the attending physician of record (65%), and the admitting physician (33%).

Regarding UME disclosure documentation, more physi-cians (91%) thought that it was important always to docu-ment disclosures in patients’ charts than nonphysicians did (71%). With respect to what elements are critical in good disclosure documentation, Figures 4 and 5 summarize the responses of survey participants. Although there was some variability in the responses of physicians and nonphysi-cians to this prompt, as these figures illustrate, both groups of individuals felt strongly that basic UME facts needed to be documented, in addition to other relevant information such as who received disclosure, the next steps, or treat-ment recommendations and the time of the event.

When asked about factors that might have hindered or prevented proper UME disclosure, the most frequent concerns for physicians were patient/family unavailability, being unsure of what needs to be disclosed, and fear of



being sued. For nonphysicians, the three most frequent issues were being unsure of how to disclose, being unsure of what needs to be disclosed, and lacking protocol/guide-lines about disclosure.

When asked about factors that might have prevented proper UME disclosure documentation, the most com-mon issues identified by physicians were time constraints, being unsure about what needs to be disclosed, and fear of being sued. For nonphysicians, the top three hindering factors were being unsure of whose responsibility it is to document, being unsure of what to document, and lack of training in documentation of a disclosure.

DISCUSSION

It was found that only 10% of UME disclosures had any level of documentation within this participating institution. Mandates from various accreditation bodies support UME disclosure among patients and healthcare providers. The ethical opinion of the American Medical Association is: “it is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients.”5 The Joint Commission added “requirement to disclose unantici-pated outcomes to accreditation standards” in 2001.6

Patients want disclosure of all harmful medical care errors. They want to know what happened, know what has been done to fix it, and receive an apology.7 Wu and his col-leagues evaluated patient views regarding medical error disclosure via a hypothetical scenario with a survey. They found that full UME disclosure increased the reported likelihood of patient satisfaction and trust with the physi-cian.8 Not only do patients and the public support UME disclosure, so do physicians in general. Responsibilities to patients, to the profession of medicine, to self, and to the medical community are factors that have been identified

Figure 3: Responses of various HCPs indicating their level

of agreement that the unanticipated events should be disclosed and documented in a

patient’s chart in different categories

Horizontal axis consists of all the categories of UMEs (see Table 1 for definitions of various categories). Vertical axis indicates the level of agreements on a 7-point scale ranging from “disagree strongly” (1) to “agree strongly” (7).

Figure 4: Percentage of physician and nonphysician

respondents indicating “moderately important” or “very important” to document ratings for

“what and who” disclosure elements

Figure 5: Percentage of physician and nonphysician

respondents indicating “moderately important” or “very important” to document ratings for

“where and when” disclosure elements



that compel the physician to provide adequate disclosure of medical errors.9 This was reflected in the current sur-vey, in which the majority of both physicians and non-physician providers responded that disclosure of unantici-pated events is important.

An important question raised by the present findings is why the level of documentation observed in this study was so low despite wide acceptance of the need for UME disclosure practices that are comprehensive (see Figure 3). The present survey identified several impedi-ments to the provision of complete and detailed disclo-sure, including patient/family unavailability, uncertainty of what needs to be disclosed, fear of being sued, and lack of protocol/guidelines. Studies at other medical institutions have identified similar barriers that prevent adequate disclosure from occurring.9 Factors that impede disclosure of errors include attitudinal barriers, help-lessness, uncertainties, fear, and anxiety.10 Professional repercussions, legal liability, and blame have also been identified as impediments to disclosure.11 Impediments to UME disclosure documentation identified by the sur-vey were similar and included time constraints, uncer-tainty about what needs to be disclosed, fear of being sued, and lack of training. The first of these barriers may be reduced by improving or creating a process of institutional administrative assistance. The impediments of patient/family unavailability and time constraints may be remedied by a process of education, account-ability measures, and institutional administrative assist-ance in assembling interested parties in the discussion of unanticipated events. The lack of knowledge expressed regarding the process and content required for disclosure was common to both physician and nonphysician pro-viders. An element of process of disclosure may include the identification of an unanticipated adverse event, which might require a formal documented disclosure. A process of evaluation of an adverse event based on stand-ard definition may increase and improve disclosure. For instance, it has been proposed that an adverse outcome meet 1 of 2 criteria to be considered unanticipated: (1) It would not be included in a reasonable informed con-sent process for treatment of the patient’s condition(s) and/or would not be expected during the usual course of treatment; and (2) it may have been caused by human or systemic error—that is, it is not immediately possible to rule out error clearly and decisively.12

The fear of litigation as an impediment identified in this study may be due to lack of training in proper UME disclosure and a potential misunderstanding of the effects that such disclosure may have on potential litigators. Contrary to HCP fears and concerns, after the Lexington, Kentucky Veterans Administration instituted a policy of “extreme honesty” in 1987, the resulting studies at their facility discovered that litigation payouts have decreased.13 More recent work at the University of Michigan Hospitals provides an even more dramatic account of the economics

of UME disclosure, showing that cost of litigation may be reduced by more than 60% when timely disclosure is an integral part of a claims resolution process.14 Wu et al. found that full disclosure increased the reported likeli-hood of patient satisfaction and trust with the physician.8 If these findings were more widely understood, fear of liti-gation might become a motivator rather than an impedi-ment to proper disclosure.

Impediments to disclosure and its documentation among nonphysicians focused not only on content and process of disclosure but also on locus of responsibility. This may be addressed through education and implementation of institutional protocols that assign responsibility to caregiv-ers to initiate a process and facilitate the process when a suspected unanticipated adverse event has occurred.

Based on these data, improvement in UME disclosure may occur with implementation of policies regarding process and content while addressing fears of litigation and locus of responsibility. Even after implementation of policies, this may not be of significant impact unless there is a process for education and monitoring for sustained improvement. In the study institutions a policy for dis-closure of adverse events had been adopted shortly before conducting the survey. As part of the adoption process, the policy was reviewed and approved by a joint commit-tee of administrators and physician leaders, the Medical Executive Committee, and the Joint Conference and Accreditation Committee of the Board of Trustees. Once approved, the policy was distributed to the professional staff of the institution by the medical staff office, while general communication of the policy occurred in the same manner as other new policies relating to the medical staff; however 57% of physicians and 35% of nonphysicians reported not being aware or informed of policy or guide-lines for disclosure in this particular hospital system. This reported lack of awareness points out the need to look at the effectiveness of existing methods of communication to professional staff and how best to address the implementa-tion of a new policy on disclosure.

This study was conceived as a pilot program to determine the need to implement a UME disclosure policy and educate the HCPs regarding the importance and pro-cess for disclosure and proper documentation of UME. The results indicate that such a need exists; it appears that such efforts will need to be tailored to address the challenges and unique experiences of physician and non-physician interactions with patients and their families. An evaluation of the quality of documentation of disclosures that occur after such implementation will need to be done to give additional insight into how effective the efforts at implementation and education might be when carried out at the institutional level.

Development of institutional disclosure policies and pro-cedures may be hindered by a lack of national standards



of disclosure policies. A study by Gallagher et al. discov-ered that there is much variability in the process of dis-closure among physicians.2 Other studies have observed that this variability in physician attitude is not only limited to physicians, but extends to medical students as well.15 This implies that experience may not be the only or even a major influence in how physicians develop atti-tude of disclosure. Because physicians vary widely in how they disclose errors to patients, and because of the lack of effective documentation, disclosure standards and train-ing are necessary to meet public expectations, to promote professional responsibility, and, most importantly, to support patient safety and quality improvement follow-ing unintended outcomes or errors. This will require education of healthcare providers regarding disclosure, documentation, and follow-up after unintended medical outcomes.

The researchers faced several practical limitations in designing and conducting this research. Because we could only identify UME that was officially reported in the risk management process, we were necessarily limited in the study design to retrospective reviewing of UME. There may be additional UMEs that occurred in the institution, but were not reported to risk management and therefore not identifiable for the purposes of the present study. As such, these estimates may be considered conservative estimates of the scope of the problem of incomplete and undocumented UME.

Lack of associated documentation with UME disclosure could again have several causes, such as a lack of stan-dardization of complete documentation of the unintended outcome of patient care and follow-up, for example, after hospital discharge and others as identified in the survey. As mentioned earlier, because the records in the retrospec-tive review were deidentified, the authors were unable to survey specifically the HCPs involved in management and process of disclosure, if any, of the UME reviewed retrospectively. However, as the survey was conducted in the same institute as the retrospective review, it is reason-able to assume that the HCPs involved in the manage-ment and disclosure of the UME reviewed retrospectively represent a sample of the HCPs surveyed. Unfortunately, because of the low N, the researchers were unable to do any power analysis, but this study provides a general pic-ture about the reality and perception and attitude of the HCPs toward UME disclosure. As there have been no studies like this, this is a good first step. Future prospec-tive studies, with larger samples and multiple institutions, need to be conducted to help provide the basis for nation-al guidelines and policies on proper UME disclosure and documentation.

At the study institution there is a guideline on disclosure and communication of unanticipated events in the medi-cal staff manual. Following is what the guideline says on documentation of disclosure of UMEs:

1. Documentation of each discussion that includes dis-closure of an unanticipated outcome or event will be made by the disclosing physician.

2. The documentation in the medical record should include:

A brief, objective statement of the facts relating to the • occurrence, outcome, and event necessary to provide caregivers with the information needed for continuity of care.

A list of all who attended the disclosure meeting•

The medically significant facts disclosed•

Next steps or changes in treatment that were discussed.•

A complete medical record should include the “who, what, when, where, and how” details regarding a patient’s treatment and healthcare experiences.4 In addition, because disclosure of UME presents an opportunity for healthcare providers to understand mistakes and issues that arise in the provision of healthcare clearly and deci-sively, a comprehensive and well-documented disclosure presents a very important opportunity for improving the provision of healthcare so that similar UMEs do not occur in the future. Therefore for the completeness of medical records and as an important component to a comprehen-sive disclosure process, the authors recommend that in addition to the above elements, documentation of UME disclosures should also include:

Who disclosed and documented (ideally should be the • same person)

Time of event, disclosure, and documentation•

Location of event and disclosure•

CONCLUSION

Despite mandates from various accreditation bodies and the general perception that UME disclosure and docu-mentation is important, there is paucity of disclosure documentation due to various reasons. There is an incom-plete understanding of how to disclose and document UMEs appropriately. Developing explicit policies and adoption of disclosure templates coupled with multisource education and training of healthcare providers will assist in improving and promoting professional responsibility. In addition, such training should begin as early as pos-sible in the process of medical training, for example, in medical school for physicians. In addition, a more formal approach will meet public expectations, help reduce costs incurred in resolving questions about the unintended outcome of care when combined with other elements of a progressive claims-resolution process, and most impor-tantly, support patient safety and quality improvement following unintended outcomes or errors.



REFERENCES

1. Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements and a definition. J Gen Intern Med. 2007;22(6):755–761.

2. Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: How physicians would disclose harmful medical errors to patients. Arch Intern Med. 2006;166(15):1585–1593.

3. Roach WH. Medical records and the law. 4th ed. American Health Information Management Association. Burlington, MA: Jones & Bartlett Learning; 2006.

4. Guidelines for Medical Record and Clinical Documentation, WHO-SEARO coding workshop 2007.

5. AMA Ethical Opinion E-8.12. www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion812.page?. Accessed September, 2011.

6. The Joint Commission. CAMH 2004 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. The Joint Commission on Accreditation of Healthcare Organizations; September 2003. ISBN: 978-0866888226.

7. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001–1007.

8. Wu AW, Huang IC, Stokes S, Pronovost PJ. Disclosing medical errors to patients: It’s not what you say, it’s what they hear. J Gen Intern Med.2009;24(9):1012–1017.

9. Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: A review of the literature. Arch Intern Med. 2004;164(15):1690–1697.

10. Kaldjian LC, Jones EW, Rosenthal GE. Facilitating and impeding factors for physicians’ error disclosure: A structured literature review. Jt Comm J Qual Patient Saf. 2006;32(4):188–198.

11. NCC MERP Taxonomy of Medication Errors. http://www.nccmerp.org/pdf/taxo2001-07-31.pdf. Accessed September, 2011.

12. Barron WM, Kuczewski MG. Unanticipated harm to patients: Deciding when to disclose outcomes. Jt Comm J Qual Saf. 2003;29(10):551–555.

13. Kraman SS, Hamm G. Risk management: Extreme honesty may be the best policy. Ann Intern Med. 1999;131(12):963–967.

14. Kaldjian LC, Jones EW, Rosenthal GE, Tripp-Reimer T, Hillis SL. An empirically derived taxonomy of fac-tors affecting physicians’ willingness to disclose medi-cal errors. J Gen Intern Med. 2006;21(9):942–948.

15. White AA, Gallagher TH, Krauss MJ, et al. The attitudes and experiences of trainees regarding disclosing medical errors to patients. Acad Med. 2008;83(3):250–256.

ABOUT THE AUTHORS

Vinita Singh, MD, Department of Anesthesia at Indiana University and the Department of Internal Medicine at The University of Tennessee College of Medicine-Chattanooga; Christopher J. L. Cunningham, PhD, Department of Internal Medicine at The University of Tennessee College of Medicine-Chattanooga and Department of Psychology at The University of Tennessee at Chattanooga; Mukta Panda, MD, FACP, Department of Internal Medicine at The University of Tennessee College of Medicine-Chattanooga; Dale C. Hetzler, MSCM, JD, Erlanger Health System, Chattanooga, Tennessee; Daniel Stanley, MD, Department of Surgery, The University of Tennessee College of Medicine-Chattanooga.


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