Patient Safety pp 329-340 | Cite as

Error Disclosure



Promoting patient safety using systems assessments and analysis has shown promise in improving healthcare operations and delivery system resiliency to medical error occurrence. However, promoting patient safety through error disclosure and the creation of a transparent safety culture has not yet been rigorously assessed or implemented. We illustrate how the traditional, “deny and defend, shut up and fight” adversarial model is ineffective in addressing and identifying key safety concerns in health delivery systems, and then contrast this traditional method with an alternative, systems-focused approach to medical error disclosure and assessment. We also review some of the potential legal issues associated with apology and its use in disclosure systems. Finally, we provide some suggestions to integrate these processes into the delivery system culture to promote patient safety.


Patient Safety Medical Error General Counsel Disclosure Event Patient Safety Incident 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: Institute of Medicine, National Academy Press; 1999.Google Scholar
  2. 2.
    Liang BA, Hamman W, Riley W, Beaubien J, Rutherford W. In situ simulation: using aviation principles to identify relevant teamwork and systems issues to promote patient safety. Int J Saf High Consequences Ind. 2011;1(1):53–64.Google Scholar
  3. 3.
    Carayon P, Wood KE. Patient safety – the role of human factors and systems engineering. Stud Health Technol Inform. 2010;153:23–46.PubMedGoogle Scholar
  4. 4.
    Liang BA, Mackey T. Quality and safety in medical care: what does the future hold? Arch Pathol Lab Med. 2011;135:1425–31.PubMedCrossRefGoogle Scholar
  5. 5.
    Kachalia A, Kaufman SR, Boothman R, Anderson S, Welch K, Saint S, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153:213–21.PubMedCrossRefGoogle Scholar
  6. 6.
    Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356:2713–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Levinson W, Gallagher TH. Disclosing medical errors to patients: a status report in 2007. CMAJ. 2007;177:265–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. N Engl J Med. 2006;354:2205–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Snyder L, Leffler C, Ethics and Human Rights Committee, American College of Physicians. Ethics manual: fifth edition. Ann Intern Med. 2005;142:560–82.PubMedCrossRefGoogle Scholar
  10. 10.
    Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, et al. Health plan members’ views on forgiving medical errors. Am J Manag Care. 2005;11:49–52.PubMedGoogle Scholar
  11. 11.
    Liang BA. A policy of system safety: shifting the medical and legal paradigms to effectively address error in medicine. Harvard Health Policy Rev. 2004;5(1):6–13.Google Scholar
  12. 12.
    Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933–40.PubMedCrossRefGoogle Scholar
  13. 13.
    Loren DJ, Klein EJ, Garbutt J, Krauss MJ, Fraser V, Dunagan WC, et al. Medical error disclosure among pediatricians: choosing carefully what we might say to parents. Arch Pediatr Adolesc Med. 2008;162:922–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Gallagher TH, Waterman AD, Garbutt JM, Kapp JM, Chan DK, Dunagan WC, et al. US and Canadian physicians’ attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006;166:1605–11.PubMedCrossRefGoogle Scholar
  15. 15.
    Weissman JS, Annas CL, Epstein AM, Schneider EC, Clarridge B, Kirle L, et al. Error reporting and disclosure systems: views from hospital leaders. JAMA. 2005;293:1359–66.PubMedCrossRefGoogle Scholar
  16. 16.
    Lamb RM, Studdert DM, Bohmer RM, Berwick DM, Brennan TA. Hospital disclosure practices: results of a national survey. Health Aff (Millwood). 2003;22:73–83.CrossRefGoogle Scholar
  17. 17.
    Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Liang BA. A system of medical error disclosure. Qual Saf Health Care. 2002;11:64–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Liang BA. Dr. Arthur W. Grayson distinguished lecture in law & medicine: promoting patient safety through reducing medical error: a paradigm of cooperation between patient, physician, and attorney. South Ill Univ Law J. 2000;24:541–68.Google Scholar
  20. 20.
    Liang BA. The adverse event of unaddressed medical error. J Law Med Ethics. 2001;29:346–68.PubMedCrossRefGoogle Scholar
  21. 21.
    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;166:1585–93.PubMedCrossRefGoogle Scholar
  22. 22.
    Fein SP, Hilborne LH, Spiritus EM, et al. J Gen Intern Med. 2007;22:755–61.PubMedCrossRefGoogle Scholar
  23. 23.
    Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Error or “Act of God”? A study of patients’ and operating room team members’ perception of error definition, reporting, and disclosure. Surgery. 2006;139(1):6–14.PubMedCrossRefGoogle Scholar
  24. 24.
    Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors. Arch Intern Med. 2004;164:1690–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Pelt JL, Faldmo LP. Physician error and disclosure. Clin Obstet Gynecol. 2008;51(4):700–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Studdert DM, Mello MM, Gawande AA, Brennan TA, Wang YC. Disclosure of medical injury to patients: an improbably risk management strategy. Health Aff (Milwood). 2007;26(1):215–26.CrossRefGoogle Scholar
  27. 27.
    Little P, Everitt H, Williamson I, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ. 2001;323:908–11.PubMedCrossRefGoogle Scholar
  28. 28.
    Rogers AE, Addington-Hall JM, Abery AJ, et al. Knowledge and communication difficulties for patients with chronic heart failure: qualitative study. BMJ. 2000;321:605–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Lefevre FV, Waters TM, Budetti PP. A survey of physician training programs in risk management and communication skills for malpractice prevention. J Law Med Ethics. 2000;28:258–65.PubMedCrossRefGoogle Scholar
  30. 30.
    Allen J, Brock S. Health care communication using personality type: patients are different! London: Routledge; 2000.Google Scholar
  31. 31.
    Edwards A, Elwyn G, Gwyn R. General practice registrar responses to use of different risk communication tools in simulated consultations: a focus group study. BMJ. 1999;319:749–52.PubMedCrossRefGoogle Scholar
  32. 32.
    Coiera E, Tombs V. Communication behaviours in a hospital setting: an observational study. BMJ. 1998;316:673–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Buckman R. How to break bad news: a guide for healthcare professionals. Baltimore, MD: Johns Hopkins Press; 1992.Google Scholar
  34. 34.
    Wayman KI, Yaeger KA, Sharek PJ, Trotter S, Wise L, Flora JA, et al. Simulation-based medical error disclosure training for pediatric healthcare professionals. J Healthc Qual. 2007;29(4):12–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med. 2003;78(8):783–8.PubMedCrossRefGoogle Scholar
  36. 36.
    The Patient Safety and Quality Improvement Act of 2005. Pub. L. 109–41; 2005.Google Scholar
  37. 37.
    Wu AW. A major medical error. Am Fam Physician. 2001;63:985–8.PubMedGoogle Scholar
  38. 38.
    Brazeau C. Disclosing the truth about a medical error. Am Fam Physician. 2000;62:315.Google Scholar
  39. 39.
    Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7:424–31.PubMedCrossRefGoogle Scholar
  40. 40.
    Leape LL, Swankin DS, Yessian MR. A conversation on medical injury. Public Health Rep. 1999;114:302–17.PubMedCrossRefGoogle Scholar
  41. 41.
    Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131:963–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Liang BA. Alternative dispute resolution. In: Liang BA, editor. Health law & policy. Boston, MA: Butterworth-Heinemann; 2000. p. 257–70.Google Scholar
  43. 43.
    Liang BA. Themes for a system of medical error disclosure: promoting patient safety using a partnership of provider and patient. In: Davies HTO, Tavakoli M, editors. Health care policy, performance, and finance: strategic issues in healthcare management. Aldershot: Ashgate; 2004. p. 92–105.Google Scholar
  44. 44.
    Liang BA. The perils of law and medicine: avoiding litigation to promote patient safety. Prev Law Rep. 2001;19:10–2.Google Scholar
  45. 45.
    Goldberg SB, Sanders FA, Rodgers NH, Cole SR. Dispute resolution: negotiation, mediation, and other processes. New York, NY: Aspen Press; 2007.Google Scholar
  46. 46.
    Dauer EA, Becker DW. Conflict management in managed care. In: Dauer EA, Kovach KK, Liang BA, et al., editors. Health care dispute resolution manual: techniques for avoiding litigation. Gaitherburg, MD: Apsen Publishers; 2000. p. 1:1–1:68.Google Scholar
  47. 47.
    Lazare A. Apology in medical practice. JAMA. 2006;296(11):1401–4.PubMedCrossRefGoogle Scholar
  48. 48.
    Leape LL. Full disclosure and apology—an idea whose time has come. Physician Exec. 2006;32:16–8.PubMedGoogle Scholar
  49. 49.
    Campaigne C, Costantino J, Guarino G, et al. Evidence; particular types of evidence; admissions and declarations; person making or affected by statement; agents and employees. In: American jurisprudence. Evidence. 2nd ed. Rochester, NY: Lawyers Co-operative Publishing Co; 2000.Google Scholar
  50. 50.
    Liang BA. Error disclosure for quality improvement: authenticating a team of patients and providers to promote patient safety. In: Sharpe VA, editor. Accountability: patient safety and policy reform. Washington, DC: Georgetown University Press; 2004. p. 59–82.Google Scholar
  51. 51.
    O’Rourke PT, Hershey KM. The power of “Sorry”: know how state statutes work before ­apologizing for an error. Hospitalist. 2007;17.Google Scholar
  52. 52.
    Lopez L, Weissman JS, Schneider EC, Weingart SN, Cohen AP, Epsein AM. Disclosure of hospital adverse events and its association with patients’ rating of the quality of care. Arch Intern Med. 2009;169(20):1888–94.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2014

Authors and Affiliations

  1. 1.Institute of Health Law Studies, California Western School of LawSan DiegoUSA
  2. 2.Department of Anesthesiology, San Diego Center for Patient SafetyUniversity of California, San Diego School of MedicineSan DiegoUSA
  3. 3.Department of Family MedicineSouthern California Permanente Medical GroupEl CajonUSA

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