Abstract
Despite our best efforts to mitigate pathology error, harmful pathology error will inevitably occur. Disclosure of error to patients is encouraged and even mandated by regulatory bodies and advocacy groups. Many pathologists are interested in participating in disclosure of serious error but are ill-equipped to do so. Error disclosure by pathologists requires not only a better understanding of how errors occur in pathology, but the relationship between pathologists and treating clinicians in reducing error, and barriers pathologists’ face when disclosing error. This chapter examines the current state of error disclosure as it pertains to pathology and provides a practical guide for who, when, and how to disclose serious pathology error to patients. The authors discuss the rationale and principles behind effective disclosure. Related topics including the management of adverse events, barriers to disclosure, and additional resources for the implementation of disclosure programs in pathology are explored.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139.
Institute of Medicine, Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington, DC: National Academies Press; 2000.
Reason J. Human error: models and management. West J Med. 2000;172:393–6.
Dekker S. Just culture: Balancing safety and accountability. Boca Raton: CRC Press; 2016.
Gallagher TH, Garbutt JM, Waterman AD, Flum DR, Larson EB, Waterman BM, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med. 2006;166:1585–93.
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.
National Academies of Sciences, Engineering, and Medicine, Institute of Medicine, Board on Health Care Services, Committee on Diagnostic Error in Health Care. Improving diagnosis in health care. Washington, DC: National Academies Press; 2016.
Etchegaray JM, Ottosen MJ, Aigbe A, Sedlock E, Sage WM, Bell SK, et al. Patients as Partners in Learning from Unexpected Events. Health Serv Res. 2016;51(Suppl 3):2600–14.
Lambert BL, Centomani NM, Smith KM, Helmchen LA, Bhaumik DK, Jalundhwala YJ, et al. The “Seven Pillars” response to patient safety incidents: effects on medical liability processes and outcomes. Health Serv Res. 2016;51(Suppl 3):2491–515.
Conway J, Federico F, Stewart K, Campbell M. Respectful management of serious clinical adverse events. IHI Innovation Series White Paper. 2nd ed. Cambridge, MA: Institute for Healthcare Improvement; 2011.
Iedema R, Allen S, Britton K, Piper D, Baker A, Grbich C, et al. Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study. BMJ. 2011;343:d4423.
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.
Mello MM, Studdert DM, Kachalia A. The medical liability climate and prospects for reform. JAMA. 2014;312:2146–55.
Snyder L, Leffler C, Ethics and Human Rights Committee, American College of Physicians. Ethics manual: fifth edition. Ann Intern Med. 2005;142:560–82.
Dintzis SM, Stetsenko GY, Sitlani CM, Gronowski AM, Astion ML, Gallagher TH. Communicating pathology and laboratory errors: anatomic pathologists’ and laboratory medical directors’ attitudes and experiences. Am J Clin Pathol. 2011;135:760–5.
Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33:467–76.
Rubin MA, Friedman DI. The ethics of disclosing another physician’s medical error. Continuum. 2015;21:1146–9.
Bell SK, White AA, Yi JC, Yi-Frazier JP, Gallagher TH. Transparency when things go wrong: physician attitudes about reporting medical errors to patients, peers, and institutions. J Patient Saf. 2017;13:243–8.
Gallagher TH, Mello MM, Levinson W, Wynia MK, Sachdeva AK, Snyder Sulmasy L, et al. Talking with patients about other clinicians’ errors. N Engl J Med. 2013;369:1752–7.
Truog RD, Browning DM, Johnson JA, Gallagher TH. Talking with Patients and Families about Medical Error: A Guide for Education and Practice. Baltimore: JHU Press; 2010.
Mello MM, Chandra A, Gawande AA, Studdert DM. National costs of the medical liability system. Health Aff. 2010;29:1569–77.
Gallagher TH, Farrell ML, Karson H, Armstrong SJ, Maldon JT, Mello MM, et al. Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot. Health Serv Res. 2016;51(Suppl 3):2569–82.
Boothman RC, Imhoff SJ, Campbell DA Jr. Nurturing a culture of patient safety and achieving lower malpractice risk through disclosure: lessons learned and future directions. Front Health Serv Manag. 2012;28:13–28.
Dintzis S. Improving pathologists’ communication skills. AMA J Ethics. 2016;18:802–8.
Dintzis SM, Clennon EK, Prouty CD, Reich LM, Elmore JG, Gallagher TH. Pathologists’ perspectives on disclosing harmful pathology error. Arch Pathol Lab Med. 2017;141:841–5.
Raab SS, Nakhleh RE, Ruby SG. Patient safety in anatomic pathology: measuring discrepancy frequencies and causes. Arch Pathol Lab Med. 2005;129:459–66.
Nakhleh RE. Error reduction and prevention in surgical pathology. New York, NY: Springer; 2015.
Zarbo RJ, Meier FA, Raab SS. Error detection in anatomic pathology. Arch Pathol Lab Med. 2005;129:1237–45.
Cooper K. Errors and error rates in surgical pathology: an Association of Directors of Anatomic and Surgical Pathology survey. Arch Pathol Lab Med. 2006;130:607–9.
Heher YK, Dintzis SM. Disclosure of harmful medical error to patients: a review with recommendations for pathologists. Adv Anat Pathol. 2018;25:124–30.
Dintzis SM, Gallagher TH. Disclosing harmful pathology errors to patients. Am J Clin Pathol. 2009;131:463–5.
Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. N Engl J Med. 2006;354:2205–8.
Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet. 1994;343:1609–13.
Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320:726–7.
Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91:1200–4.
Heher YK. A brief guide to root cause analysis. Cancer Cytopathol. 2017;125:79–82.
Foundation NPS. RCA2: improving root cause analyses and actions to prevent harm. Boston: National Patient Safety Foundation; 2016.
Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356:2713–9.
Helmchen LA, Lambert BL, TB MD. Changes in physician practice patterns after implementation of a communication-and-resolution program. Health Serv Res. 2016;51(Suppl 3):2516–36.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Mayo Foundation for Medical Education and Research
About this chapter
Cite this chapter
Dintzis, S.M., Heher, Y.K. (2019). Disclosure of Pathology Error to Treating Clinicians and Patients. In: Nakhleh, R., Volmar, K. (eds) Error Reduction and Prevention in Surgical Pathology. Springer, Cham. https://doi.org/10.1007/978-3-030-18464-3_17
Download citation
DOI: https://doi.org/10.1007/978-3-030-18464-3_17
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-18463-6
Online ISBN: 978-3-030-18464-3
eBook Packages: MedicineMedicine (R0)