Agency for Healthcare Research and Quality
Total award $1 million
PI: Eric Thomas
This project sought to determine how to make disclosure a process that will not only serve individual patients/families, but also utilize their unique experiences to help hospitals learn from errors and improve safety.
A qualitative pilot project identified the issues and concerns surrounding disclosure of adverse events among 30 patients, families, doctors, nurses and hospital administrators who had direct experience with a disclosure of a medical error.
Information from this pilot project guided a one-day conference of a convened panel of experts in fall 2011. The discussions held suggested that more information was needed about what patients/families experience after harmful events before developing best practice models to pilot in hospitals.
This led to a qualitative project in which 72 patients and families who experienced a harmful event during care were interviewed over the phone. Participants willingly described their event and were asked to identify what contributing factors they felt led to the event. The analysis revealed that all 72 participants were able to identify at least one contributing factor that caused their event. Furthermore, an overwhelming majority of patients/families expressed their interest in wanting to be involved in the post-event analysis processes and offered insightful recommendations as to how hospitals could improve patient safety practices for future prevention.
The final phase of the project included a dissemination conference held in June 2014. This conference convened all stakeholders in the disclosure and resolution processes to share the results of this project, discuss best practices, and determine future directions for patient safety endeavors. Over 100 physicians, nurses, risk managers, lawyers, patient safety researchers, patients and families, patient advocates, hospital executives, and malpractice insurers were in attendance.
Dr. Bill Sage at the University of Texas at Austin reviewed claims data to assess how tort reform has impacted disclosure processes.
Etchegaray JM, Ottosen MJ, Burress L, Sage WM, Bell SK, Gallagher TH, Thomas EJ. Structuring patient and family involvement in medical error event disclosure and analysis. Health Aff. 2014 Jan;33(1):46-52.
Eric J. Thomas, MD, MPH [ 90351 Views ]
Dean F. Sittig, PhD [ 83677 Views ]
Jason M. Etchegaray, PhD [ 82269 Views ]