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Medical Error Disclosure - A Canadian Perspective in Improving Quality of Health Care

  • Jawahar (Jay) KalraEmail author
  • Maria Gabriela Campos-Baniak
  • Avani Saxena
  • Zoher Rafid-Hamed
Conference paper
Part of the Advances in Intelligent Systems and Computing book series (AISC, volume 957)

Abstract

Disclosure of an adverse event is an important element in managing the consequences of a medical error. The objectives of this study was to review and compare the disclosure policies implemented by individual health care authorities and hospitals in western Canada. The evaluation of the policies of individual health authorities was carried out based on the inclusion of various guidelines including avoidance of blame; support to the staff; an apology or expression of regret; avoidance of speculation; some form of patient support; and education/training to health care workers. The complexities of medical error disclosure to patients present ideal opportunities for medical educators to probe how learners are balancing the ethical complexities involved in error disclosure with other related fields. We suggest that the disclosure policies can provide framework and guidelines for appropriate disclosure that can lead to practices that are more transparent.

Keywords

Medical error Adverse event Disclosure Quality Patient safety 

References

  1. 1.
    Mensah Abrampah, N., Syed, S.B., Hirschhorn, L.R., Nambiar, B., Iqbal, U., Garcia-Elorrio, E., Chattu, V.K., Devnani, M., Kelley, E.: Quality improvement and emerging global health priorities. Int. J. Qual. Health Care 30, 5–9 (2018)CrossRefGoogle Scholar
  2. 2.
    Mitchell, P.H.: Defining Patient Safety and Quality Care. Agency for Healthcare Research and Quality (US), Rockville (2008) Google Scholar
  3. 3.
    Kapoor, P.: Why quality in healthcare. Med. J. Armed Forces India 67, 206–208 (2011)CrossRefGoogle Scholar
  4. 4.
    Gorgich, E.A.C., Barfroshan, S., Ghoreishi, G., Yaghoobi, M.: Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Glob. J. Health Sci. 8, 220–227 (2016)CrossRefGoogle Scholar
  5. 5.
    da Silva, B.A., Krishnamurthy, M.: The alarming reality of medication error: a patient case and review of Pennsylvania and National data. J. Community Hosp. Intern. Med. Perspect. 6, 31758 (2016)Google Scholar
  6. 6.
    Bari, A., Khan, R.A., Rathore, A.W.: Medical errors; causes, consequences, emotional response and resulting behavioral change. Pak. J. Med. Sci. 32, 523–528 (2016)CrossRefGoogle Scholar
  7. 7.
    Bates, D.W., Spell, N., Cullen, D.J., Burdick, E., Laird, N., Petersen, L.A., Small, S.D., Sweitzer, B.J., Leape, L.L.: The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 277, 307–311 (1997)Google Scholar
  8. 8.
    Institute of Medicine (US) Committee on Quality of Health Care in America: Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US), Washington, DC (2001)Google Scholar
  9. 9.
    Hughes, R.G.: Nurses at the “Sharp End” of Patient Care. Agency for Healthcare Research and Quality (US), Rockville (2008)Google Scholar
  10. 10.
    Carver, N., Hipskind, J.E.: Medical Error. StatPearls Publishing, Treasure Island (2018)Google Scholar
  11. 11.
    Baker, G.R., Norton, P.G., Flintoft, V., Blais, R., Brown, A., Cox, J., Etchells, E., Ghali, W.A., Hébert, P., Majumdar, S.R., O’Beirne, M., Palacios-Derflingher, L., Reid, R.J., Sheps, S., Tamblyn, R.: The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ 170, 1678–1686 (2004)CrossRefGoogle Scholar
  12. 12.
    Robbennolt, J.K.: Apologies and medical error. Clin. Orthop. Relat. Res. 467, 376–382 (2009)CrossRefGoogle Scholar
  13. 13.
    Ock, M., Lim, S.Y., Jo, M.-W., Lee, S.: Frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents: a systematic review. J. Prev. Med. Public Health 50, 68–82 (2017)CrossRefGoogle Scholar
  14. 14.
    Martin, L.R., Williams, S.L., Haskard, K.B., DiMatteo, M.R.: The challenge of patient adherence. Ther. Clin. Risk Manag. 1, 189–199 (2005)Google Scholar
  15. 15.
    Coffey, M., Espin, S., Hahmann, T., Clairman, H., Lo, L., Friedman, J.N., Matlow, A.: Parent preferences for medical error disclosure: a qualitative study. Hospital Pediatrics 7, 24–30 (2017)Google Scholar
  16. 16.
    Guillod, O.: Medical error disclosure and patient safety: legal aspects. J. Public Health Res. 2(3), e31 (2013).  https://doi.org/10.4081/jphr.2013.e31CrossRefGoogle Scholar
  17. 17.
    Hébert, P.C., Levin, A.V., Robertson, G.: Bioethics for clinicians: 23. Disclosure of medical error. CMAJ 164, 509–513 (2001)Google Scholar
  18. 18.
    Edwin, A.: Non-disclosure of medical errors an egregious violation of ethical principles. Ghana Med. J. 43, 34–39 (2009)Google Scholar
  19. 19.
    Banja, J.D.: Does medical error disclosure violate the medical malpractice insurance cooperation clause? In: Henriksen, K., Battles, J.B., Marks, E.S., et al. (eds.) Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville (MD): Agency for Healthcare Research and Quality (US), February 2005Google Scholar
  20. 20.
    O’Connor, E., Coates, H.M., Yardley, I.E., Wu, A.W.: Disclosure of patient safety incidents: a comprehensive review. Int. J. Qual. Health Care 22, 371–379 (2010)CrossRefGoogle Scholar
  21. 21.
    Gallagher, T.H., Waterman, A.D., Ebers, A.G., Fraser, V.J., Levinson, W.: Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 289, 1001–1007 (2003)CrossRefGoogle Scholar
  22. 22.
    Heilig, S.: Honest mistakes: from the physician father of a young patient. Camb. Q. Healthc. Ethics 3, 636–638 (1994)CrossRefGoogle Scholar
  23. 23.
    Turillazzi, E., Neri, M.: Medical error disclosure: from the therapeutic alliance to risk management: the vision of the new Italian code of medical ethics. BMC Med. Ethics 15, 57 (2014)Google Scholar
  24. 24.
    Kiguba, R., Waako, P., Ndagije, H.B., Karamagi, C.: Medication error disclosure and attitudes to reporting by healthcare professionals in a sub-Saharan African setting: a survey in Uganda. Drugs - Real World Outcomes 2, 273–287 (2015)CrossRefGoogle Scholar
  25. 25.
    Shanks, L., Bil, K., Fernhout, J.: Learning without borders: a review of the implementation of medical error reporting in Médecins Sans Frontières. PLoS One 10, e0137158 (2015)CrossRefGoogle Scholar
  26. 26.
    Paradise, A.: Why the Joint Commission on Accreditation of Healthcare Organizations should add new regulations regarding libraries. J. Med. Libr. Assoc. 92, 166–168 (2004)Google Scholar
  27. 27.
    Australian Council for Safety and Quality in Health Care, Australian Health Ministers’ Conference: Safety and quality and the health reform agenda. Standards Australia, XX 1234-220, Draft v5.2 (2003)Google Scholar
  28. 28.
    Dyer, C.: NHS staff should inform patients of negligent acts. BMJ 327, 7 (2003)CrossRefGoogle Scholar
  29. 29.
    Bismark, M., Dauer, E., Paterson, R., Studdert, D.: Accountability sought by patients following adverse events from medical care: the New Zealand experience. CMAJ 175, 889–894 (2006)CrossRefGoogle Scholar
  30. 30.
    Davies, J.M., Hebert, P.C., Hoffman, C.: Canadian Patient Safety Institute, Royal College of Physicians and Surgeons of Canada: The Canadian patient safety dictionary. Canadian Patient Safety Institute, Royal College of Physicians and Surgeons of Canada, Edmonton, Ottawa (2003)Google Scholar
  31. 31.
    Kalra, J., Massey, K.L., Mulla, A.: Disclosure of medical error: policies and practice. J. R. Soc. Med. 98, 307–309 (2005)CrossRefGoogle Scholar
  32. 32.
  33. 33.
  34. 34.
    Kalra, J., Kalra, N., Baniak, N.: Medical error, disclosure and patient safety: a global view of quality care. Clin. Biochem. 46, 1161–1169 (2013)CrossRefGoogle Scholar
  35. 35.
    Kalra, J., Saxena, A., Mulla, A., Neufeld, H., Massey, K.L.: Medical error: a clinical approach in enhancing quality care. Clin. Biochem. 37, 732–733 (2004)Google Scholar
  36. 36.
    Kalra, J., Mulla, A., Qureshi, M., Massey, K.L.: The ‘no fault’ model: a clinical laboratory initiative in enhancing quality care and medical error reduction. Clin. Chem. 51(A127), A41 (2005)Google Scholar
  37. 37.
    Disclosure Working Group: Canadian Disclosure Guidelines: Being Open and Honest with Patients and Families. Canadian Patient Safety Institute, Edmonton, AB (2011)Google Scholar
  38. 38.
    White, A.A., Brock, D., McCotter, P.I., Hofeldt, R., Edrees, H.H., Wu, A.W., Shannon, S., Gallagher, T.H.: Risk managers’ descriptions of programs to support second victims after adverse events. J. Healthc. Risk Manag. 34, 30–40 (2015)CrossRefGoogle Scholar
  39. 39.
    Koinis, A., Giannou, V., Drantaki, V., Angelaina, S., Stratou, E., Saridi, M.: The impact of healthcare workers job environment on their mental-emotional health. Coping strategies: the case of a local general hospital. Health. Psychol. Res. 3(1), 1984 (2015).  https://doi.org/10.4081/hpr.2015.1984CrossRefGoogle Scholar
  40. 40.
    Wu, A.W., Huang, I.-C., Stokes, S., Pronovost, P.J.: Disclosing medical errors to patients: it’s not what you say, it’s what they hear. J. Gen. Intern. Med. 24, 1012–1017 (2009)CrossRefGoogle Scholar
  41. 41.
    Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., Zarvani, A.: Ethical and legal aspects of patient’s safety: a clinical case report. J. Med. Ethics Hist. Med. 10, 15 (2017)Google Scholar
  42. 42.
    Genovese, U., Del Sordo, S., Pravettoni, G., Akulin, I.M., Zoja, R., Casali, M.: A new paradigm on health care accountability to improve the quality of the system: four parameters to achieve individual and collective accountability. J. Glob. Health. 7, 010301 (2017)Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Jawahar (Jay) Kalra
    • 1
    • 2
    Email author
  • Maria Gabriela Campos-Baniak
    • 2
  • Avani Saxena
    • 1
  • Zoher Rafid-Hamed
    • 1
  1. 1.Department of Pathology and Laboratory Medicine, College of MedicineUniversity of SaskatchewanSaskatoonCanada
  2. 2.Royal University Hospital, Saskatoon Health RegionSaskatoonCanada

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