J Korean Med Assoc.  2017 May;60(5):417-427. 10.5124/jkma.2017.60.5.417.

Disclosure of patient safety incidents: implications from ethical and quality of care perspectives

• Ock M
• Lee SI

• KMID: 2378974
• DOI: http://doi.org/10.5124/jkma.2017.60.5.417

Abstract

In order to improve patient safety, it is important to manage and respond to patient safety incidents that have already occurred. Disclosure of patient safety incidents (DPSI) can be regarded as a prudent strategy, as it has the potential to decrease the number of medical disputes in advance. DPSI is defined as follows: "When a patient safety incident occurs, medical professionals preemptively explain the incident to the patients and their caregivers, express sympathy and regret for the incident, deliver apology and compensation appropriately if needed, and promise to prevent recurrence." Although DPSI is known to be effective for reducing the number of medical lawsuits, it can be also viewed as reflecting important ethical and quality of care issues. In particular, medical professionals have an ethical imperative to conduct DPSI with the patient, if patient safety incidents have occurred. In this paper, we review the necessity of DPSI from ethical and quality of care perspectives. The ethical basis of DPSI includes autonomy, transparency, trust, and professional standards. Furthermore, DPSI will become inevitable as society comes to emphasize safer and more patient-centered care. In order to make DPSI a routine practice in South Korea, various efforts, such as the development of DPSI guidelines and educational programs, as well as the introduction of an apology law, will be required.

Keyword

Disclosure of patient safety incidents; Patient safety; Patient safety incident; Communication

MeSH Terms

Caregivers
Compensation and Redress
Disclosure*
Dissent and Disputes
Humans
Jurisprudence
Korea
Patient Safety*
Patient-Centered Care

Figure

• 

  Figure 1 Significance of disclosure of patient safety incidents in terms of ethicality.

Reference

1. Ock M, Kim HJ, Jo MW, Lee SI. Perceptions of the general public and physicians regarding open disclosure in Korea: a qualitative study. BMC Med Ethics. 2016; 17:50.

2. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003; 289:1001–1007.

3. Gallagher TH, Waterman AD, Garbutt JM, Kapp JM, Chan DK, Dunagan WC, Fraser VJ, Levinson W. US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006; 166:1605–1611.

4. Renkema E, Broekhuis M, Ahaus K. Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety. BMC Health Serv Res. 2014; 14:38.

5. Mazor KM, Greene SM, Roblin D, Lemay CA, Firneno CL, Calvi J, Prouty CD, Horner K, Gallagher TH. More than words: patients' views on apology and disclosure when things go wrong in cancer care. Patient Educ Couns. 2013; 90:341–346.

6. Ock M, Kim JH, Lee SI. A legal framework for improving patient safety in Korea. Health Policy Manag. 2015; 25:174–184.

7. Ock M. Evaluating the feasibility of introducing open disclosure of patient safety incidents [dissertation]. Ulsan: University of Ulsan;2016.

8. Ock M, Lim SY, Jo MW, Lee SI. Frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents: a systematic review. J Prev Med Public Health. 2017; 50:68–82.

9. Kachalia A, Kaufman SR, Boothman R, Anderson S, Welch K, Saint S, Rogers MA. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010; 153:213–221.

10. Adams MA, Elmunzer BJ, Scheiman JM. Effect of a health system's medical error disclosure program on gastroenterology-related claims rates and costs. Am J Gastroenterol. 2014; 109:460–464.

11. Accreditation Canada. Required organizational practices handbook 2016 [Internet]. Ottawa: Accreditation Canada;2016. cited 2017 Feb 18. Available from: https://accreditation.ca/sites/default/files/rop-handbook-2016-en.pdf.

12. Joint Commission Resources. Comprehensive accreditation manual for hospitals: the official handbook [Internet]. Oak Brook: Joint Commission Resources;2010. cited 2017 Feb 18. Available from: http://www.jointcommission.org/assets/1/6/2010_CAMH_Update_2.pdf.

13. Canadian Patient Safety Institute. Canadian disclosure guidelines: being open and honest with patients and families [Internet]. Ottawa: Canadian Patient Safety Institute;2011. cited 2017 Feb 18. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/disclosure/Pages/default.aspx.

14. Australian Commission on Safety and Quality in Health Care. Australian open disclosure framework [Internet]. Sydney: Australian Commission on Safety and Quality in Health Care;2014. cited 2017 Feb 18. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2013/03/Australian-Open-Disclosure-Framework-Feb-2014.pdf.

15. Runciman WB. Shared meanings: preferred terms and definitions for safety and quality concepts. Med J Aust. 2006; 184:10 Suppl. S41–S43.

16. McLennan S, Beitat K, Lauterberg J, Vollmann J. Regulating open disclosure: a German perspective. Int J Qual Health Care. 2012; 24:23–27.

17. National Institute of Korean Language. Korean standard unabri-dged dictionary [Internet]. Seoul: National Institute of Korean Language;cited 2017 Feb 18. Available from: http://stdweb2.korean.go.kr.

18. McLennan S, Walker S, Rich LE. Should health care providers be forced to apologise after things go wrong? J Bioeth Inq. 2014; 11:431–435.

19. Australian Commission on Safety and Quality in Health Care. Open disclosure standard review report[internet]. Sydney: Australian Commission on Safety and Quality in Health Care;2012. cited 2017 Feb 18. Available from: https://www.safetyandquality.gov.au/wp-content/uploads/2013/05/Open-Disclosure-Standard-Review-Report-Final-Jun-2012.pdf.

20. Saitta N, Hodge SD Jr. Efficacy of a physician's words of empathy: an overview of state apology laws. J Am Osteopath Assoc. 2012; 112:302–306.

21. Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, Gurwitz JH. Health plan members' views about disclosure of medical errors. Ann Intern Med. 2004; 140:409–418.

22. Wu AW, Boyle DJ, Wallace G, Mazor KM. Disclosure of adverse events in the United States and Canada: an update, and a proposed framework for improvement. J Public Health Res. 2013; 2:e32.

23. Shekar V, Singh M, Shekar K, Brennan P. Clinical negligence and duty of candour. Br J Oral Maxillofac Surg. 2011; 49:593–596.

24. Wojcieszak D, Banja J, Houk C. The Sorry Works! Coalition: making the case for full disclosure. Jt Comm J Qual Patient Saf. 2006; 32:344–350.

25. Um YR. Disclosure of unanticipated outcome information as a strategy of patient safety. Korean Bioethics Assoc. 2005; 6:11–29.

26. Han H. A qualitative study on medical error disclosure program in Korea [dissertation]. Seoul: Yonsei University;2012.

27. Lee SH, Shin YH, Kim SS. Comparing attitudes toward disclosing medical errors between medical students and interns. Korean J Med Educ. 2012; 24:247–258.

28. Lee SH, Kim HA, Han HS, Kim SS. The attitudes of college students regarding doctors' disclosing medical errors. Korean J Med Ethics. 2011; 14:320–334.

29. Wolf ZR, Hughes RG. Error reporting and disclosure. In : Hughes RG, editor. Patient safety and quality: an evidence-based handbook for nurses. Rockville: Agency for Healthcare Research and Quality;2008. p. 339–343.

30. Straumanis JP. Disclosure of medical error: is it worth the risk? Pediatr Crit Care Med. 2007; 8:2 Suppl. S38–S43.

31. Lipira LE, Gallagher TH. Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement. World J Surg. 2014; 38:1614–1621.

32. Kachalia A. Improving patient safety through transparency. N Engl J Med. 2013; 369:1677–1679.

33. Perez B, Knych SA, Weaver SJ, Liberman A, Abel EM, Oetjen D, Wan TT. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. J Patient Saf. 2014; 10:45–51.

34. Research Institute for Healthcare Policy. Council on Ethical and Judicial Affairs. Seoul: Research Institute for Healthcare Policy;2012.

35. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press;2001.

36. Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood). 2010; 29:165–173.

37. National Quality Forum. Safe practices for better healthcare–2009 update [Internet]. Washington, DC: National Quality Forum;2009. cited 2017 Feb 18. Available from: http://www.qualityforum.org/Publications/2009/03/Safe_Practices_for_Better_Healthcare%E2%80%932009_Update.aspx.

38. Committee on Patient Safety and Quality Improvement. Committee on Professional Liability. ACOG Committee opinion no. 520: disclosure and discussion of adverse events. Obstet Gynecol. 2012; 119:686–689.

39. Ock M, Lee SI, Kim JH, Lee JH, Lee JY, Jo MW, Lee MS, Kim SH, Kim HJ, Son WS. What should we consider for establishing a national patient safety reporting system? J Health Tech Assess. 2015; 3:4–16.

40. Ho B, Liu E. Does sorry work? The impact of apology laws on medical malpractice. J Risk Uncertain. 2010; 43:141–167.

41. Institute for Healthcare Improvement. The IHI Improvement Map: communication with patients & families after an adverse event [Internet]. Cambridge: Institute for Healthcare Improvement;cited 2017 Feb 18. Available from: http://app.ihi.org/imap/tool/#Process=e2af2d43-4135-49a2-b145-bbd65d8a2bee.

42. 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 (Millwood). 2012; 31:383–391.

43. Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, Altman DE, Zapert K, Herrmann MJ, Steffenson AE. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002; 347:1933–1940.

44. Mazor KM, Roblin DW, Greene SM, Lemay CA, Firneno CL, Calvi J, Prouty CD, Horner K, Gallagher TH. Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. J Clin Oncol. 2012; 30:1784–1790.

45. Etchegaray JM, Gallagher TH, Bell SK, Dunlap B, Thomas EJ. Error disclosure: a new domain for safety culture assessment. BMJ Qual Saf. 2012; 21:594–599.

46. Coffey M, Thomson K, Tallett S, Matlow A. Pediatric residents' decision-making around disclosing and reporting adverse events: the importance of social context. Acad Med. 2010; 85:1619–1625.

47. Martinez W, Lo B. Medical students' experiences with medical errors: an analysis of medical student essays. Med Educ. 2008; 42:733–741.