Disclosure of Medical Errors

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From the course by Johns Hopkins University

Setting the Stage for Success: An Eye on Safety Culture and Teamwork (Patient Safety II)

100 ratings

Johns Hopkins University

Setting the Stage for Success: An Eye on Safety Culture and Teamwork (Patient Safety II)

100 ratings

Course 2 of 7 in the Specialization Patient Safety

Safety culture is a facet of organizational culture that captures attitudes, beliefs, perceptions, and values about safety. A culture of safety is essential in high reliability organizations and is a critical mechanism for the delivery of safe and high-quality care. It requires a strong commitment from leadership and staff. In this course, a safe culture is promoted through the use of identifying and reporting patient safety hazards, accountability and transparency, involvement with patients and families, and effective teamwork.

From the lesson

Event Reporting and Second Victims

Patient safety event reports are a critical data source for identifying and mitigating harm in high reliability organizations; yet, many healthcare organizations do not take full advantage of this data. At the conclusion of this module, learners will understand how event reports should be used to design safer care systems and how organizations can provide support to staff involved in medical errors.

How to Submit an Event Report9:25

Journey of an Event Report3:04

Event Reporting and High Reliability3:28

Using Event Reports to Improve Safety and Culture3:09

Reporting Culture4:04

Using Event Reports to Design Safer Systems: Part I2:34

Using Event Reports to Design Safer Systems: Part II5:01

A Sample Event Review Meeting12:34

Introduction to the Learning from Defects Tool12:50

Disclosure of Medical Errors2:49

Second Victims7:30

Peer Support: Making a Difference for Second Victims8:48

Meet the Instructors

Eileen Kasda

In this video we're going to talk about disclosing medical errors.

For a second, ask yourself,

do you think you will make a medical error that harms a patient during your career?

Do you think you will make a medical error that contributes to a patient's death?

In an anonymous house officer survey,

house officers were asked about their worst mistake.

90% of officers reported having been involved in a serious adverse outcome.

Of those 31% involved the patient dying and of the

90% only 24% actually told the patient or family about the serious event.

When a medical error happens,

there's an ethical duty to disclose to the patient

and their family about the medical error.

The American College of Physicians said that physicians should disclose to patients

information about procedural and judgment errors made in the course of care,

if such information significantly affects the care of the patient.

In addition, many regulatory agencies also

have statements about what should be disclosed.

When trying to identify what should be disclosed to a patient,

it's important to consider the following questions.

Who should do the actual disclosure of an error?

It's important that you refer to your organization's policy

but it should be someone who can explain to the patient or family member what occurred.

When thinking about when the event should

be disclosed to the patient and family member as

soon as possible but at a time that is reasonable given their care plan.

Where should the event be disclosed.

It's important that events be disclosed in the privacy,

in a place where a patient or family member can have a private conversation.

And what should be told to the patient?

It's important that you only share what is known at the time of

the event and that you actually stick with the facts.

Provide just the facts,

answer questions, admit when you don't know something.

Outline a follow up plan and consider surroundings and emotions.

It's important to make sure that you're not having

these conversations in a waiting room but that they're in a private place.

What patients want when something bad happens?

They want the facts,

they want to know that responsibility is taken,

they would like an apology,

and most importantly they want to know that actions are being

taken to prevent the same thing from happening to someone else.

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