Case Study: Disclosure of Errors Should Include Conversations With Patient/Families

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A case study involving a 2009 medical error suggests ongoing conversations with patients and families following an adverse event could reveal more information to prevent similar occurrences in the future.

 

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The case study, which was published in the Joint Commission Journal of Quality and Patient Safety, involved a man diagnosed with multiple myeloma in 2006. He was admitted to the hospital after an orthopedic surgery in January 2009 and died from a drug overdose in February 2009.

Disclosure and quality improvement efforts following the death revealed the event involved more than the adverse drug event.

"You've got a greater problem than a drug error…you've got a massive, big communication problem here," the patient's wife said to a hospital employee. Ongoing communications revealed communication failures and inappropriate behaviors by staff. The researchers concluded meaningful conversations with patients and families following an adverse event could reveal more information than clinicians could discover on their own.

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