Disclosing errors and adverse events in the intensive care unit

Critical Care Medicine

Volumn 34, Issue 5, 2006, Pages 1532-1537

  Boyle, Dennis ^a,b   O'Connell, Daniel ^a   Platt, Frederic W ^b   Albert, Richard K ^a,b  

^a DENVER HEALTH MEDICAL CENTER   (United States)

^b UNIVERSITY OF COLORADO   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; CAREGIVER; CASE REPORT; CRITICALLY ILL PATIENT; ETHICS; FEMALE; HUMAN; INTENSIVE CARE UNIT; INTERPERSONAL COMMUNICATION; LEGAL ASPECT; MALPRACTICE; MEDICAL ERROR; NEGLIGENCE; PATIENT CARE; PRIORITY JOURNAL; REVIEW; RISK BENEFIT ANALYSIS; TRAINING; DOCTOR PATIENT RELATION; MIDDLE AGED; RISK MANAGEMENT; STATISTICS; UNITED STATES;

DISCLOSURE; FEMALE; HUMANS; INTENSIVE CARE UNITS; MEDICAL ERRORS; MIDDLE AGED; PHYSICIAN-PATIENT RELATIONS; RISK MANAGEMENT; UNITED STATES;

EID: 33646559186     PISSN: 00903493     EISSN: None     Source Type: Journal    
DOI: 10.1097/01.CCM.0000215109.91452.A3     Document Type: Review

References (62)

1. Kohn LT, Corrigan JM, Donaldson MS (Eds). To Err is Human: Building a Safer Health System. Washington, DC, National Academy Press, 1999
2. Joint Commission on Accreditation of Healthcare Organizations. 2004 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH). Oakbrook Terrace, IL, Joint Commission on Accreditation of Healthcare Organizations, 2004
3. American Medical Association Council on Ethics and Judicial Affairs. AMA Code of Ethics: Current Opinions With Annotations. Chicago, American Medical Association, 1994
4. American College of Physicians. Ethics Manual. Third Edition. Philadelphia, American College of Physicians, 1993
5. Turnbull JE: Focus on patient safety. National Patient Safety Foundation Newsletter 2001; 4(2):1-3
6. Goldberg RM, Kuhn G, Andrew LB, et al: Coping with medical mistakes and errors in judgment. Ann Emerg Med 2002; 39:287-292
7. Wu AW, Cavanaugh TA, McPhee SJ, et al: To tell the truth. Ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 1997; 12:770-775
8. Robinson AR, Hohmann KB, Rifkin JL, et al: Physician and public opinions on quality of health care and the problem of medical errors. Arch Intern Med 2002; 162:2186-2190
9. Perkins GD, McAuley DF, Davies S, et al: Discrepancies between clinical and postmortem diagnoses in critically ill patients: An observational study. Crit Care 2003; 7:129-132
10. Coombes A, Mokhtari M, Couvelard A, et al: Clinical and autopsy diagnoses in the intensive care unit: A prospective study. Arch Intern Med 2004; 164:389-392
11. Brooks A, Holroyd B, Riley B: Missed injury in major trauma patients. Injury 2004; 35:407-410
12. Van den Bemt PM, Fijn R, van der Voort PH, et al: Frequency and determinants of drug administration errors in the intensive care unit. Crit Care Med 2002; 30:846-850
13. Durie M, Beckmann U, Gillies DM: Incidents relating to arterial cannulation as identified in 7525 reports submitted to the Australian incident monitoring study (AIMS-ICU). Anaesth Intensive Care 2002; 30:60-65
14. McGee DC, Gould MK: Preventing complications of central venous catheterization. N Engl J Med 2003; 358:1123-1133
15. Chastre J, Fagon J-Y: Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002; 165:867-903
16. Andrews LB, Stocking C, Krizek T, et al: An alternative strategy for studying adverse events in medical care. Lancet 1997; 325:245-251
17. Giraud T, Dhainaut J-F, Vaxelaire J-F, et al: Iatrogenic complications in adult intensive care units: A prospective two-center study. Crit Care Med 1993; 21:40-51
18. Rubins HB, Moskowitz MA: Complications of care in a medical intensive care unit. J Gen Intern Med 1990; 5:104-109
19. Osmon S, Harris CB, Dunagan WC, et al: Reporting of medical errors: An intensive care unit experience. Crit Care Med 2004; 32:727-733
20. Flaatten H, Hevroy O: Errors in the intensive care unit (ICU). Experiences with an anonymous registration. Acta Anaesth Scand 1999; 43:614-617
21. Landrigan CP, Rothschild JM, Cronin JW, et al: Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351:1838-1848
22. Tibby SM, Correa-West J, Durward A, et al: Adverse events in a paediatric intensive care unit: Relationship to workload, skill mix and staff supervision. Intensive Care Med 2004; 30:1160-1166
23. Leape LL, Brennan TA, Laird N, et al: The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324:377-384
24. Vincent JL: European attitudes towards ethical problems in intensive care medicine: Results of an ethical questionnaire. Intensive Care Med 1990; 16:256-264
25. Vincent JL: Information in the ICU: Are we being honest with our patients? The results of a European questionnaire. Intensive Care Med 1998; 24:1251-1256
26. Mazor KM, Simon SR, Gurwitz JH: Communicating with patients about medial errors. A review of the literature. Arch Intern Med 2004; 164:1690-1697
27. Lamb RM, Studdert DM, Bohmer RMJ, et al: Hospital disclosure practices: Results of a national survey. Health Affairs 2003; 22:73-83
28. Blendon RJ, DesRoches CM, Brodie M, et al: Views of practicing physicians and the public on medical errors. N Engl J Med 2002; 347:1933-1940
29. Gallagher TH, Waterman AD, Ebers AG, et al: Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 2003; 289:1001-1007
30. Localia AR, Lawthers AG, Brennan TA, et al: Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med 1991; 325:245-251
31. Cantor MD, Barach P, Derse A, et al: Disclosing adverse events to patients. Jt Comm J Qual Patient Saf 2005; 31:5-12
32. Hickson GB, Federspiel CF, Pichert JW, et al: Patient complaints and malpractice risk. JAMA 2002; 287:2951-2957
33. Witman AB, Park DM, Hardin SB: How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med 1996; 156:2565-2569
34. Hickson JB, Clayton EW, Entman SS: Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA 1994; 272:1583-1587
35. Sage WM: Putting the patient in patient safety: Linking patient complaints and malpractice risk. JAMA 2002; 287:3003-3005
36. Mazor KM, Simon SR, Yood RA, et al: Health plan members' views about disclosure of medical errors. Ann Intern Med 2004; 140:409-418
37. Mizrahi T: Managing medical mistakes: Ideology, insularity and accountability among internists-in-training. Soc Sci Med 1984; 19:135-146
38. Green JA: Minimizing malpractice risks by role clarification. The confusion transition from tort to contract. Ann Intern Med 1988; 109:234-241
39. Berlinger N, Wu AW: Subtracting insult from injury: Addressing cultural expectations in the disclosure of medical error. J Med Ethics 2005; 31:106-108
40. Vincent C, Young M, Phillips A: Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994; 343:1609-1613
41. Lester GW, Smith SG: Listening and talking to patients: A remedy for malpractice suits? West J Med 1993; 158:268-272
42. Hickson GB, Clayton EW, Githens PB, et al: Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA 1992; 267:1359-1363
43. Levinson W, Roter DL, Mullooly JP, et al: Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 277:553-559
44. Kraman SS, Hamm G: Risk management: Extreme honesty may be the best policy Ann Intern Med 1999; 171:81-82
45. Gavin K: Selected news coverage of UMHS malpractice approach, 2004-5. University of Michigan Health Sciences Public Relations, June 1, 2005
46. Wu AW: Handling hospital errors: Is disclosure the best defense? Ann Intern Med 1999; 131:970-972
47. Leape L: Errors in medicine. JAMA 1994; 272:1851-1857
48. Wu AW, Folkman S, McPhee SJ, et al: Do house officers learn from their mistakes? JAMA 1991; 265:2089-2094
49. Hilfiker D: Facing our mistakes. N Engl J Med 1984; 310:118-122
50. Newman MC: The emotional impact of mistakes on family physicians. Arch Fam Med 1996; 5:71-75
51. Christensen JF, Levinson W, Dunn PM: The heart of darkness: The impact of perceived mistakes on physicians. J Gen Intern Med 1992; 7:424-431
52. Rowe M: Doctors' responses to medical errors. Crit Rev Oncol Hematol 2004; 52:147-163
53. American College of Physicians. American College of Physicians Ethics Manual. Third Edition. Ann Intern Med 1992; 117:947-960
54. Platt FW, Gordon GH. Disclosing unexpected outcomes and errors. Field Guide to the Difficult Patient Interview. Second Edition. Philadelphia, Lippincott, Williams & Wilkins, 2004, pp 271-276
55. Girgis A, Sanson-Fisher RW: Breaking bad news: Consensus guidelines for medical practitioners. J Clin Oncol 1995; 13:2449-2456
56. Crook ED, Stellini M, Levine D, et al: Medical errors and the trainee: Ethical concerns. Am J Med Sci 2004; 327:33-37
57. Larson EB, Yao X: Clinical empathy as emotional labor in the patient-physician relationship. JAMA 2005; 293:1100-1106
58. Keyes C: Forum. Risk Management Foundation of the Harvard Medical Institutions. Forum 1997; 18:2-4
59. COPIC Insurance Co: Disclosing unanticipated outcomes to patients. Copiscope 2002; 110:1-3
60. Wysoki MG, Covey A, Pollak J, et al: Evaluation of various maneuvers for prevention of air embolism during central venous catheter placement. J Vasc Interv Radiol 2001; 12:764-766
61. Pronovost PJ, Wu AW, Sexton JB: Acute decompensation after removing a central line: Practical approaches to increasing safety in the intensive care unit. Ann Intern Med 2004; 140:1025-1033
62. White JP, Ketring SD: True patient safety begins at the top. Leaders at one large health system rally around safety, avoid blame game. Physician Exec 2001; 27:40