Abstract
Practitioners face many barriers to disclosing errors to patients, including embarrassment, fear of litigation, and minimal training in how to discuss them. Efforts at teaching error disclosure skills often focus on a one-on-one doctor–patient interaction and neglect the inter-professional context. This chapter describes research conducted at the University of Washington to assess whether participating in a team-based disclosure simulation training improved clinicians’ knowledge, attitudes, and skills regarding team-based disclosure of harmful errors to patients and team communication about avoiding such errors in the future. We developed two surgical and two medical error case scenarios based on real incidents. The premise of the simulations was that the members of a surgical or medical team had recently been involved in a harmful error and therefore needed to meet to discuss the event and how it happened, plan whether and how to disclose the event to the patient, and then perform the disclosure to the patient according to their plan. The nurses and physicians who participated in the simulations were experienced professionals. We trained actors from a professional troupe to perform the roles of a standardized team member and a standardized patient who had experienced a harmful error. We trained professionals from the fields of risk management and officers in patient or medication safety to become disclosure coaches who helped teams to discuss harmful errors and to plan whether and how to disclose errors to patients. Participants included 38 teams of physicians and nurses and risk managers from five different healthcare organizations in the Seattle area. Findings indicate that physicians developed an appreciation for team error disclosure. Nurses gained experience in participating as partners in conversations from which they had traditionally been excluded. Risk managers learned to participate in disclosure planning as educators, focusing on helping teams to rehearse and prepare for difficult conversations rather than dictating institutional regulations. These project outcomes are potentially transformative for the individuals and institutions involved.
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
Adelson, R., Vanloy, W. J., & Hepburn, K. (1997). Performance change in an organizational setting: A conceptual model. The Journal of Continuing Education in the Health Professions, 17, 69–80.
American Society for Healthcare Risk Management of the American Hospital Association. (2003). Disclosure of unanticipated events: The next step in better communication with patients. Chicago: American Society for Healthcare Risk Management.
Amori, G. (2006). Pearls on disclosure of adverse events. Chicago: American Society for Healthcare Risk Management.
Bell, A. (1982a). Treating students’ misconceptions. The Australian Mathematics Teacher, 2, 11–13.
Bell, A., & Purdy, D. (1985). Diagnostic teaching—Some problems of directionality. Shell Centre for Mathematical Education, University of Nottingham, England.
Bell, A. W. (1982b). Diagnosing students' misconceptions. The Australian Mathematics Teacher, 1, 6–10.
Berlinger, N. (2005). After harm: Medical error and the ethics of forgiveness. Baltimore: The Johns Hopkins University Press.
Bero, L., Grilli, R, Grimshaw, J. M., Harvey, E., Oxman, A. D., & Thomson, M. A. (1998). Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal, 317, 465–468.
Blendon, R., DesRoches, C. M, Brodie, M., Benson, J. M., Rosen, A. B., Schneider, E., et al. (2002). Views of Practicing Physicians and the public on medical errors. New England Journal of Medicine, 347, 1933–1940.
Davis, D., O’Brien, M. A., Freemantle, N., Wolf, F. M., Mazmanian, P., & Taylor-Vaisey, A. (1999). Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA, 282(9), 867–874.
Driskell, J. E. (1998). Stress exposure training. In J. Cannon-Bowers & E. Salas (Eds.), Making decisions under stress – Implications for individual and team training. Washington, DC: American Psychological Association.
Gallagher, T. H., Denham, C., Leape, L., Amori, G., & Levinson, W. (2007). Disclosing unanticipated outcomes to patients: The art and the practice. Journal of Patient Safety, 3(3), 158–165.
Gallagher, T. H., Garbutt, J. M., Waterman, A. D., Flum, D. R., Larson, E. B., Waterman, B. M., et al. (2006). Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Archives of Internal Medicine, 166(15), 1585–1593.
Gallagher, T. H., Studdert, D., & Levinson, W. (2007). Disclosing harmful medical errors to patients. New England Journal of Medicine, 356(26), 2713–2719.
Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA, 289(8), 1001–1007.
Gallagher, T. H., Waterman, A. D., Garbutt, J. M., Kapp, J. M., Chan, D. K., Dunagan, W. C., et al. (2006). US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients. Archives of Internal Medicine, 166(15), 1605–1611.
Garbutt, J., Brownstein, D. R., Klein, E. J., Waterman, A., Krauss, M. J., Marcuse, E. K., et al. (2007). Reporting and disclosing medical errors: pediatricians’ attitudes and behaviors. Archives Pediatrics and Adolescent Medicine, 161(2), 179–185.
Gibson, R., & Singh, J. P. (2003). Wall of silence: The untold story of the medical mistakes that kill and injure millions of Americans. Washington, DC: Lifeline Press.
Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Lee Gordon, D., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27(1), 10–28.
Kachalia, A., Shojania, K. G., Hofer, T. P., Piotrowski, M., & Saint, S. (2003). Does full disclosure of medical errors affect malpractice liability? The jury is still out. Joint Commission Journal on Quality and Patient Safety, 29(10), 503–511.
Kaldjian, L. C., Jones, E. W., Wu, B. J., Forman-Hoffman, V. L., Levi, B. H., & Rosenthal, G. E. (2007). Disclosing medical errors to patients: attitudes and practices of physicians and trainees. Journal of General Internal Medicine, 22(7), 988–996.
Ker, J., Mole, L., & Bradley, P. (2003). Early introduction to interprofessional learning: a simulated ward environment. Medical Education, 37(3), 248–255.
Kim, S., Brock, D., Prouty, C., Odegard, P., Shannon, S., Robins, L., et al. (2011). A web-based team-oriented medical error communication assessment tool: Development, preliminary reliability, validity, and user ratings. Teaching and Learning in Medicine, 23(1), 68–77.
Knowles, M., et al. (1984). Andragogy in action: applying modern principles of adult learning. San Francisco: Jossey-Bass.
Kolb, D. (1984). Experiential learning. Englewood Cliffs, NJ: Prentice Hall.
Loren, D., Klein, E. J., Garbutt, J., Krauss, M. J., Fraser, V., Dunagain, W. C., et al. (2008). Medical Error disclosure among pediatricians: choosing carefully what we might say to parents. Archives Pediatrics and Adolescent Medicine, 162, 922–927.
Mann, K. V., McFetridge-Durdle, J., Martin-Misener, R., Clovis, J., Rowe, R., Beanlands, H., et al. (2009). Interprofessional education for students of the health professions: the “Seamless Care” model. Journal of Interprofessional Care, 23(3), 224–233.
Marinopoulos, S. S., Dorman, T., Ratanawongsa N, Wilson LM, Ashar BH, Magaziner JL, et al. (2007). Effectiveness of continuing medical education. Evidence Report/Technology Assessment No. 149 (Prepared by the Johns Hopkins Evidence-based Practice Center, under Contract No. 290-02-0018.) AHRQ Publication No. 07-E006. Rockville, MD: Agency for Healthcare Research and Quality.
Mazor, K. M., Haley, H. L., Sullivan, K., & Quirk, M. E. (2007). The video-based test of communication skills: description, development, and preliminary findings. Teaching and Learning in Medicine, 19(2), 162–167.
Mazor, K. M., Reed, G. W., Yood, R. A., Fischer, M. A., Baril, J., & Gurwitz, J. H. (2006). Disclosure of medical errors: what factors influence how patients respond? Journal of General Internal Medicine, 21(7), 704–710.
Morey, J., Simon, R., Jay, G. D., Wears, R. L., Salisbury, M., Dukes, K. A., et al. (2002). Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Services Research, 37(6), 1553–1581.
Schoen, C., Osborn, R., Huynh, P. T., Doty, M., Zapert, K., Peugh, J., et al. (2005). Taking the pulse of health care systems: experiences of patients with health problems in six countries. Health Aff (Millwood), Suppl Web Exclusives, W5-509–525.
Shannon, S., Foglia, M., Hardy, M., & Gallagher, T. (2009). Disclosing errors to patients: Perspectives of registered nurses. Joint Commission Journal of Quality and Patient Safety, 35(1), 5–12.
Shapiro, E. (2008). Disclosing medical errors: Best practices from the “leading edge”. Retrieved January 22, 2009, from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Literature/DisclosingMedicalErrorsBestPracticesLeadingEdge.htm
Sharpe, V. (2004). Accountability: Patient safety and policy reform. Washington, DC: Georgetown University Press.
Showers, B. (1982). Transfer of training: The contribution of coaching. Eugene, Oregon: Center for Educational Policy and Management.
The Full Disclosure Working Group. (2006). When things go wrong: responding to adverse events. A consensus statement of the Harvard Hospitals. Boston: Massachusetts Coalition for the Prevention of Medical Errors.
The Joint Commission. (2007). Hospital Accreditation Standards, 2007. Oakbrook Terrace, IL: Joint Commission Resources.
The Kaiser Family Foundation/Agency for Healthcare Research & Quality/Harvard School of Public Health. (November 2004). National survey on consumers’ experiences with patient safety and quality information. Retrieved October 6, 2005, from http://www.kff.org/kaiserpolls/upload/National-Survey-on-Consumers-Experiences-With-Patient-Safety-and-Quality-Information-Survey-Summary-and-Chartpack.pdf.
Waterman, A. D., Garbutt, J., Hazel, E., Dunagan, W. C., Levinson, W., Fraser, V. J., et al. (2007). The emotional impact of medical errors on practicing physicians in the United States and Canada. Joint Commission Journal of Quality and Patient Safety, 33(8), 467–476.
White, A., Waterman, A., McCotter, P., Boyle, D., & Gallagher, T. (2008). Supporting healthcare workers after medical errors: Considerations for health care leaders. Journal of Clinical Outcomes Management, 15(5), 240–247.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2012 Springer Science+Business Media B.V.
About this chapter
Cite this chapter
Robins, L. et al. (2012). Using Simulation and Coaching as a Catalyst for Introducing Team-Based Medical Error Disclosure. In: Mc Kee, A., Eraut, M. (eds) Learning Trajectories, Innovation and Identity for Professional Development. Innovation and Change in Professional Education, vol 7. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-1724-4_4
Download citation
DOI: https://doi.org/10.1007/978-94-007-1724-4_4
Published:
Publisher Name: Springer, Dordrecht
Print ISBN: 978-94-007-1723-7
Online ISBN: 978-94-007-1724-4
eBook Packages: Humanities, Social Sciences and LawEducation (R0)