The use of disclosure as a tool for quality management and patient safety: a systematic review

Authors

DOI:

https://doi.org/10.33448/rsd-v10i13.16252

Keywords:

Disclosure; Medical errors; Patient safety.

Abstract

Intro: Every year, thousands of adverse events occur in health care, and 2/3 of these incidents are caused by human error. Despite the ethical obligation, such errors are not commonly disclosed and the practice of effective communication with patients and families is largely neglected. Objective: to analyze the use of disclosure, as a tool for quality and safety management, among health professionals and patients. Method: The method used was a systematic review, submitted and published in the Prospero, using the databases pubmed, scielo, lilacs and bvs. The keywords used for the search were "disclosure", "medical errors" and "patient safety". Results: 13 articles were analyzed and it was possible to evidence punctually the categories named: medical errors and patient safety, processes and protocols and state of the art.  Conclusion: the disclosure process does not receive enough attention in the scientific community or in health institutions around the world, considering that few countries have formalized and institutionalized practices through protocols or guidelines on this technique of effective communication primarily human.

Author Biographies

Elaine Rossi Ribeiro, Faculdades Pequeno Príncipe

Researcher at Pequeno Príncipe Colleges

Cássia Laura Gheller Bertoldo , Faculdades Pequeno Príncipe

FPP medical student

Ana Clara Kunz, Faculdades Pequeno Príncipe

FPP medical school student

References

Adams, M. A., Elmunzer, B. J., & Scheiman, J. M. (2014). Effect of a health system's medical error disclosure program on gastroenterology-related claims rates and costs. The American journal of gastroenterology, 109(4), 460–464. https://doi.org/10.1038/ajg.2013.375

Alsafi, E., Bahroon, S. A., Tamim, H., Al-Jahdali, H. H., Alzahrani, S., & Al Sayyari, A. (2011). Physicians' attitudes toward reporting medical errors-an observational study at a general hospital in Saudi Arabia. Journal of patient safety, 7(3), 144–147. https://doi.org/10.1097/PTS.0b013e31822c5a82

Bell, S. K., Smulowitz, P. B., Woodward, A. C., Mello, M. M., Duva, A. M., Boothman, R. C., & Sands, K. (2012). Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation. The Milbank quarterly, 90(4), 682–705. https://doi.org/10.1111/j.1468-0009.2012.00679.x

Brasil (2014). Documento de referência para o Programa Nacional de Segurança do Paciente. Brasília: Ministério da Saúde.

Brasil (2015). Disclosure precisa integrar a cultura de segurança do paciente. Brasília: IBSP

Canada (2011). Canadian Disclosure Guidelines. Edmonton: Canadian Patient Safety Institute

Chiang, H. Y., Lin, S. Y., Hsu, S. C., & Ma, S. C. (2010). Factors determining hospital nurses' failures in reporting medication errors in Taiwan. Nursing outlook, 58(1), 17–25. https://doi.org/10.1016/j.outlook.2009.06.001

Daud-Gallotti, Renata Mahfuz, Morinaga, Christian Valle, Arlindo-Rodrigues, Marcelo, Velasco, Irineu Tadeu, Martins, Milton Arruda, & Tiberio, Iolanda Calvo. (2011). A new method for the assessment of patient safety competencies during a medical school clerkship using an objective structured clinical examination. Clinics, 66(7), 1209-1215. https://doi.org/10.1590/S1807-59322011000700015

Erdmann, Thomas Rolf, Garcia, Jorge Hamilton Soares, Loureiro, Marcos Lázaro, Monteiro, Marcelo Petruccelli, & Brunharo, Guilherme Muriano. (2016). Profile of drug administration errors in anesthesia among anesthesiologists from Santa Catarina. Revista Brasileira de Anestesiologia, 66(1), 105-110. https://doi.org/10.1016/j.bjane.2014.06.011

Flotta, D., Rizza, P., Bianco, A., Pileggi, C., & Pavia, M. (2012). Patient safety and medical errors: knowledge, attitudes and behavior among Italian hospital physicians. International journal for quality in health care: journal of the International Society for Quality in Health Care, 24(3), 258–265. https://doi.org/10.1093/intqhc/mzs014

Gallagher, T. H., Studdert, D., & Levinson, W. (2007). Disclosing harmful medical errors to patients. The New England journal of medicine, 356(26), 2713–2719. https://doi.org/10.1056/NEJMra070568

Hannawa, A. F., Shigemoto, Y., & Little, T. D. (2016). Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes. Social science & medicine (1982), 156, 29–38. https://doi.org/10.1016/j.socscimed.2016.03.026

Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err is Human: Building a Safer Health System. National Academies Press (US).

Kalra, J., Kalra, N., & Baniak, N. (2013). Medical error, disclosure and patient safety: A global view of quality care. Clinical Biochemistry, 46(13-14), 1161–1169. doi:10.1016/j.clinbiochem.2013.03.025

Kiesewetter, J., Kager, M., Lux, R., Zwissler, B., Fischer, M. R., & Dietz, I. (2014). German undergraduate medical students' attitudes and needs regarding medical errors and patient safety--a national survey in Germany. Medical teacher, 36(6), 505–510. https://doi.org/10.3109/0142159X.2014.891008

Kisuule, F., & Howell, E. E. (2015). Hospitalists and Their Impact on Quality, Patient Safety, and Satisfaction. Obstetrics and gynecology clinics of North America, 42(3), 433–446. https://doi.org/10.1016/j.ogc.2015.05.003

McLennan, S. R., Engel-Glatter, S., Meyer, A. H., Schwappach, D. L., Scheidegger, D. H., & Elger, B. S. (2015). Disclosing and reporting medical errors: Cross-sectional survey of Swiss anaesthesiologists. European journal of anaesthesiology, 32(7), 471–476. https://doi.org/10.1097/EJA.0000000000000236

Motta Filho, Geraldo da Rocha, Silva, Lucia de Fatima Neves da, Ferracini, Antonio Marcos, & Bahr, Germana Lyra. (2013). The WHO Surgical Safety Checklist: knowledge and use by Brazilian orthopedists. Revista Brasileira de Ortopedia, 48(6), 554-562. https://doi.org/10.1016/j.rboe.2013.12.010

Ock, M., Kim, H. J., Jo, M. W., & Lee, S. I. (2016). Perceptions of the general public and physicians regarding open disclosure in Korea: a qualitative study. BMC medical ethics, 17(1), 50. https://doi.org/10.1186/s12910-016-0134-0

Raemer, D. B., Locke, S., Walzer, T. B., Gardner, R., Baer, L., & Simon, R. (2016). Rapid Learning of Adverse Medical Event Disclosure and Apology. Journal of patient safety, 12(3), 140–147. https://doi.org/10.1097/PTS.0000000000000080

Sampaio, RF, & Mancini, MC. (2007). Estudos de revisão sistemática: um guia para síntese criteriosa da evidência científica. Brazilian Journal of Physical Therapy, 11(1), 83-89. https://doi.org/10.1590/S1413-35552007000100013

Smeby, S. S., Johnsen, R., & Marhaug, G. (2015). Documentation and disclosure of adverse events that led to compensated patient injury in a Norwegian university hospital. International journal for quality in health care : journal of the International Society for Quality in Health Care, 27(6), 486–491. https://doi.org/10.1093/intqhc/mzv084

Published

04/10/2021

How to Cite

RIBEIRO, E. R. .; BERTOLDO , C. L. G.; KUNZ, A. C. . The use of disclosure as a tool for quality management and patient safety: a systematic review. Research, Society and Development, [S. l.], v. 10, n. 13, p. e67101316252, 2021. DOI: 10.33448/rsd-v10i13.16252. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/16252. Acesso em: 4 dec. 2021.

Issue

Section

Health Sciences