Error Disclosure Modules
Error Disclosure Module 1: Safe and Just Culture
“Thank you for being here. We need to discuss your mother’s care.”
Understanding that medical error disclosure is an ethical obligation and should be seen an extension of informed consent.
- Duclos Patient Perspective on Adverse Events
- Gallagher Three Tough Cases
- Heyland Discussing Prognosis Open Medicine 2009
- Hochberg 2011 Malpractice in an Academic Medical Center
- Singh H Medical Errors by Trainees Intern Med 2007
- West Medical Errors and Resident Distress JAMA 2006
- White Medical Error Disclosure Hanbook Clinical Neurology 2014
Error Disclosure Module 2: Explaining the Error
“Unfortunately, things did not go as we expected.”
How to sequence two kinds of “bad news:” the poor outcome, and its causes.
Error Disclosure Module 3: Managing the Relationship
“I am truly sorry. This was my responsibility. On behalf of the whole care team, I apologize.”
How to recognize the signs of a deteriorating conversation; how to rebuild trust.
Error Disclosure Module 4: Error Prevention
“As a health system, we need to learn from this event.”
Take ownership for practice improvement.
Error Disclosure Module 5: Care Plans and Closure
“Let’s review what we decided to do, based on today’s conversation.”
Don’t leave the room before you clarify next steps and avenues for further conversation.