Talking with Patients and Families about Medical Error: A Guide for Education and Practice

Annotated Bibliography of Key Works

141 Annotated Bibliography of Key Works Background and Incidence of Medical Error Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370–376. The Harvard Medical Practice Study (HMPS) was designed to obtain empirical data about adverse events, negligence, and malpractice claims. The study included a review of a large, randomized sample of medical records of patients discharged from nonpsychiatric hospitals in New York in 1984. This review reveals a high incidence of adverse events and negligence. Specifically, the authors estimate a statewide rate of adverse events among hospitalized patients of 3.7 percent (or 98,609 events) and a rate of adverse events caused by negligence of 1 percent (or 27,179). The methodology and findings of the HMPS proved influential in future research and policy discussions. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–271. Using methods similar to the HMPS and reviewing the records of 15,000 patients discharged from nonpsychiatric hospitals in Utah and Colorado in 1992, Thomas and colleagues arrive at relatively similar results. Although the estimates for the occurrence of adverse events (2.9%) and the percentage of those caused by negligence (27.5 in Colorado and 32.6 in Utah) are slightly lower, the authors conclude that iatrogenic injuries remain a significant problem. Institute of Medicine [U.S.]. Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. This landmark report, presenting evidence of the high frequency and cost of medical error, provided the impetus for the growth of the patient safety 142 ANNOTATED BIBLIOGRAPHY OF KEY WORKS movement of the twenty-first century. The report examines the nature of error, concluding that much error in medicine is systems based and must be addressed on a systemwide basis. The report promotes error reporting and protection of information voluntarily reported. It offers numerous specific recommendations for creating safer systems in health care. This report was followed by several other influential IOM reports on patient safety. Reason JT. Human Error. Cambridge, England: Cambridge University Press; 1990. Reason’s classic text on human error has three major subdivisions: an introduction to the concepts and research regarding human error; a presentation of basic error mechanisms; and a review of the consequences of human error. Reason’s detailed study and rich analysis inform much of the later work on medical error. Disclosure: General Overview Banja JD. Medical Errors and Medical Narcissism. Sudbury, MA: Jones and Bartlett Publishers; 2004. Banja focuses on responses of health care professionals/organizations to error and the degree of—and reasons for—nondisclosure. He acknowledges that fear of litigation has contributed to nondisclosure but also introduces, as another factor, a type of narcissism that may be fostered by medical training and practice. Banja also explores the psychological and moral characteristics of forgiveness and its place in the aftermath of harmful error. He suggests three kinds of support that would contribute to increased disclosure: a structured teaching curriculum (including role-modeling); the bolstering of the moral environment within which clinicians practice; and tort reform. Finally, he examines the nature and role of empathy in professional-patient interactions , giving examples of empathic techniques and responses. He provides suggestions for, and examples of, the content and process of disclosure. Baylis F. Errors in medicine: nurturing truthfulness. J Clin Ethics 1997;8:336– 340. In this early article, Baylis examines and counters common justifications for not disclosing (or only partially disclosing) medical error: uncertainty about whether an error has occurred; the belief that disclosure only increases patients ’ suffering; and fear of litigation. She posits an even more encompassing reason: the culture of medicine, which accepts, and may even encourage, nondisclosure. Baylis recommends that the profession encourage disclosure by developing a more open, supportive environment among clinicians; em- ANNOTATED BIBLIOGRAPHY OF KEY WORKS 143 phasizing truthfulness as the foundation of the patient-physician relationship; working to support appropriate tort reform; and acknowledging that medical professionals (like other humans) are fallible. Berlinger N. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, MD: Johns Hopkins University Press; 2005. Berlinger’s work examines the emotional and psychological aftermath of...