Abstract
Since the Institute of Medicine report, “To Err is Human,” there has been a great focus on medical errors and the creation of systems to prevent the occurrence of these errors. Error disclosure is critical to managing medical errors in order to uphold the ethical principles of autonomy and truth-telling, both integral to the physician-patient relationship. Surgeons feel responsible for their patients’ outcomes and report that errors should be disclosed though the surgeon may not have the proper training in disclosure. Institutional support, both for the emotional disruption that physicians face and for disclosure training programs, is important to advance patient-centered communication and high-quality health care.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Kohn L, Corrigan J, Donaldson M. To err is human: building a safer healthcare system. 1st ed. Washington, DC: Institute of Medicine, National Academy Press; 2000.
Gallagher TH, Garbutt JM, Waterman AD, Flum DR, Larson EB, Watern BM, et al. Choosing your words carefully. Arch Intern Med. 2006;166:1585–93.
Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13:330–4.
Pinkus R. Learning to keep a cautious tongue: the reporting of mistakes in neurosurgery, 1890 to 1930. In: Rubin SB, Zoloth L, editors. Margin error: the ethics of mistakes in the practice of medicine. 1st ed. Hagerstown: University Publishing Group; 2000. p. 131–52.
Dunn EJ, McKinney KM, Martin ME. Empathic disclosure of adverse events to patients. Fed Pract. 2014;31(5):18–21.
Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131:963–7.
Hamm GM, Kraman SS. New standards, new dilemmas: reflections on managing medical mistakes. Bioethics Forum. 2001;17(2):19–25.
Joint Commission on Accreditation of Health Care Organizations. Revisions to Joint Commission standards in support of patient safety and medical health care error reduction: effective July 1, 2001. Oakbrook Terrace: JCAHO; 2001.
Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356:2713–9.
National Quality Forum (NQF). Safe practices for better healthcare-2010 update: a consensus report. Washington, DC: NQF; 2010.
Council on Ethical and Judicial Affairs. Code of Medical Ethics of the American Medical Association. 2014–2015th ed. Chicago: AMA; 2014.
Iezzoni LI, Rao SR, DesRoches CM, Vogeli C, Campbell EG. Survey shows that at least some physicians are not always open or honest with patients. Health Aff. 2012;31(2):383–91.
Griffen FD. The impact of transparency on patient safety and liability. Bull Am Coll Surg. 2008;93(3):19–23.
Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. N Engl J Med. 2006;354(21):2205–8.
Griffen FD. ACS Closed Claims Study reveals critical failures to communicate. Bull Am Coll Surg. 2007;92(1):11–6.
Delbanco T, Bell SK. Guilty, afraid, and alone – struggling with medical error. N Engl J Med. 2007;357(17):1682–3.
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.
Marcus L, Dorn B, McNulty E. Renegotiating health care: resolving conflict to build collaboration. 2nd ed. San Francisco: Jossey-Bass; 2011.
Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med. 2004;140:409–18.
Gawande A. Complications: a surgeon’s notes on an imperfect science. 1st ed. New York: Picador; 2002.
American Medical Association (AMA). Medical liability reform. 2015. http://www.ama-assn.org/ama/pub/advocacy/topics/medical-liability-reform.page?. Accessed 10 May 2015.
Harrison R, Lawton R, Perlo J, Gardner P, Armitage G, Shapiro J. Emotion and coping in the aftermath of medical error: a cross-country exploration. J Patient Saf. 2015;11:28–35.
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(8):467–76.
Banja J. Medical errors and medical narcissism. 1st ed. Sudbury: Jones and Bartlett Publishers; 2005.
Namm JP, Siegler M, Brander C, Kim TY, Lowe C, Angelos P. History and evolution of surgical ethics: John Gregory to the twenty-first century. World J Surg. 2014;38:1568–73.
Bosk CL. Forgive and remember: managing medical failure. 2nd ed. Chicago: The University of Chicago Press; 1979.
Sokol DK, Wilson J. What is a surgical complication? World J Surg. 2008;32(6):942–4.
Angelos P. Complications, errors, and surgical ethics. World J Surg. 2009;33:609–11.
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. 2015. doi:10.1097/PTS.0000000000000153.
Chan DK, Gallagher TH, Reznick R, Levinson W. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery. 2005;138:851–8.
Pichert J, Hickson G, Trotter T. Malpractice and communication skills for difficult situations. Amb Child Health. 1998;4:213–21.
White AA, Bell SK, Krauss MJ, Garbutt J, Dunagan WC, Fraser VJ, et al. How trainees would disclose medical errors: educational implications for training programmes. Med Educ. 2011;45:372–80.
Accreditation Council for Graduate Medical Education. ACGME common program requirements. 2013. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Accessed 11 May 2015.
Gore DC. National survey of surgical morbidity and mortality conferences. Am J Surg. 2006;191(5):708–14.
Raper SE, Resnick AS, Morris JB. Simulated disclosure of a medical error by residents: development of a course in specific communication skills. J Surg Educ. 2014;71(6):e116–26.
Robbennolt JK. Apologies and medical error. Clin Orthop Relat Res. 2009;467:376–82.
Acknowledgment
Edward Dunn, MD for providing expertise on error disclosure and the development of the disclosure training program at the Lexington VAMC.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2015 Springer International Publishing Switzerland
About this chapter
Cite this chapter
Singh, P., Shakhsheer, B.A., Milner, R. (2015). Honesty in the Perioperative Setting: Error and Communication. In: Jericho, B. (eds) Ethical Issues in Anesthesiology and Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-15949-2_12
Download citation
DOI: https://doi.org/10.1007/978-3-319-15949-2_12
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-15948-5
Online ISBN: 978-3-319-15949-2
eBook Packages: MedicineMedicine (R0)