Error Disclosure Training and Organizational Culture

Objective. Our primary objective was to determine whether, after training was offered to participants, those who indicated they had received error disclosure training previously were more likely to disclose a hypothetical error and have more positive perceptions of their organizational culture pertaining to error disclosure, safety, and teamwork. Methods. Across a 3-year span, all clinical faculty from six health institutions (four medical schools, one cancer center, and one health science center) in The University of Texas System were offered the opportunity to anonymously complete an electronic survey focused on measuring error disclosure culture, safety culture, teamwork culture, and intention to disclose a hypothetical error at two time points—both before (baseline) and after (follow-up) disclosure training was conducted for a subset of faculty. Results. There were significant improvements (all p-values \u3c .05) in the follow-up surveys compared with the baseline surveys for the following domains (percent refers to percent positives before and after, respectively): minor error disclosure culture (33 percent vs. 52 percent), serious error disclosure (53 percent vs. 70 percent), safety culture (50 percent vs. 63 percent), and teamwork culture (62 percent vs. 73 percent). Follow-up survey data revealed significant differences (all p-values \u3c .001) between faculty who had previously received any error disclosure training (n = 472) and those who had not (n = 599). Specifically, we found significant differences in culture (all p-values \u3c .001) between those who received any error disclosure training and those who did not for all culture domains: minor error disclosure (61 percent vs. 41 percent), serious error disclosure (79 percent vs. 58 percent), trust-based error disclosure (61 percent vs. 51 percent), safety (73 percent vs. 51 percent), and teamwork (78 percent vs. 66 percent). Significant differences also existed for intent to disclose an error (t = 4.1, p \u3c .05). We also found that error disclosure culture was significantly associated with intent to disclose for those who received previous error disclosure training, whereas all types of culture we measured were significantly associated with intent to disclose for those who did not receive error disclosure training. Conclusions. Error disclosure, teamwork, and safety culture all improved over a 3-year period during which disclosure training was provided to key faculty in these six institutions. Self‑reported likelihood to disclose errors also improved. The precise impact of the training on these improvements cannot be determined from this study; nevertheless, we present an approach to measuring error disclosure culture and providing training that may be useful to other institutions

Attitudes of Risk Management Professionals Toward Disclosure of Medical Mistakes

The author reports on health care organization risk managers\u27 attitudes toward disclosure of medical mistakes

Errors in Veterinary Practice: Preliminary Lessons for Building Better Veterinary Teams

Case studies in two typical UK veterinary practices were undertaken to explore teamwork, including interprofessional working. Each study involved one week of whole team observation based on practice locations (reception, operating theatre), one week of shadowing six focus individuals (veterinary surgeons, veterinary nurses and administrators) and a final week consisting of semistructured interviews regarding teamwork. Errors emerged as a finding of the study. The definition of errors was inclusive, pertaining to inputs or omitted actions with potential adverse outcomes for patients, clients or the practice. The 40 identified instances could be grouped into clinical errors (dosing/drugs, surgical preparation, lack of follow-up), lost item errors, and most frequently, communication errors (records, procedures, missing face-to-face communication, mistakes within face-to-face communication). The qualitative nature of the study allowed the underlying cause of the errors to be explored. In addition to some individual mistakes, system faults were identified as a major cause of errors. Observed examples and interviews demonstrated several challenges to interprofessional teamworking which may cause errors, including: lack of time, part-time staff leading to frequent handovers, branch differences and individual veterinary surgeon work preferences. Lessons are drawn for building better veterinary teams and implications for Disciplinary Proceedings considered

Evidence-Based Healthcare: The Importance of Effective Interprofessional Working for High Quality Veterinary Services, a UK Example

<p class="AbstractSummary"><strong>Objective: </strong></p><p class="AbstractSummary">To highlight the importance of evidence-based research, not only for the consideration of clinical diseases and individual patient treatment, but also for investigating complex healthcare systems, as demonstrated through a focus on veterinary interprofessional working.</p><p class="AbstractSummary"><strong>Background:</strong></p><p class="AbstractSummary">Evidence-Based Veterinary Medicine (EBVM) was developed due to concerns over inconsistent approaches to therapy being delivered by individuals. However, a focus purely on diagnosis and treatment will miss other potential causes of substandard care including the holistic system. Veterinary services are provided by interprofessional teams; research on these teams is growing.</p><p class="AbstractSummary"><strong>Evidentiary value:</strong></p><p class="AbstractSummary">This paper outlines results from four articles, written by the current authors, which are unique in their focus on interprofessional practice teams in the UK. Through mixed methods, the articles demonstrate an evidence base of the effects of interprofessional working on the quality of service delivery.</p><p class="AbstractSummary"><strong>Results:</strong></p><p class="AbstractSummary">The articles explored demonstrate facilitators and challenges of the practice system on interprofessional working and the outcomes, including errors. The results encourage consideration of interprofessional relationships and activities in veterinary organisations. Interprofessional working is an example of one area which can affect the quality of veterinary services.</p><p class="AbstractSummary"><strong>Conclusion: </strong></p><p class="AbstractSummary">The papers presented on veterinary interprofessional working are an example of the opportunities for future research on various topics within evidence-based healthcare.</p><p class="AbstractSummary"><strong>Application:</strong></p><p class="AbstractSummary">The results are pertinent to members of veterinary teams seeking to improve their service delivery, to educators looking to enhance their students’ understanding of interprofessional working, and to researchers, who will hopefully be encouraged to consider evidence-based healthcare more holistically. </p><br /> <img src="https://www.veterinaryevidence.org/rcvskmod/icons/oa-icon.jpg" alt="Open Access" /> <img src="https://www.veterinaryevidence.org/rcvskmod/icons/pr-icon.jpg" alt="Peer Reviewed" /

Beyond Training Prosecutors about their Disclosure Obligations: Can Prosecutors\u27 Offices Learn from their Lawyers\u27 Mistakes Symposium: New Perspectives on Brady and Other Disclosure Obligations: What Really Works

Prosecutors, criminal defense lawyers, judges, and legal academics from around the country recently met at the Benjamin N. Cardozo School of Law in New York to discuss prosecutors\u27 compliance with their disclosure obligations. The overarching question was how prosecutors\u27 offices could do a better job. To assist representatives of the legal profession in approaching this question from new directions, the Symposium organizers invited speakers from outside the legal profession to talk about the causes of error and methods used to reduce error in other contexts. One of the themes was that, outside the practice of law, individuals and institutions learn from their mistakes. This Article considers whether prosecutors\u27 offices can identify and learn from their lawyers\u27 disclosure mistakes

Medical errors: Mandatory reporting, voluntary reporting, or both?

This work evaluates policy recommendations on medical error reporting systems presented in, To err is human, a report published by the Institute of Medicine. Here mandatory reporting should be applied for adverse events, while voluntary reporting is recommended for near misses. This analysis shows that an error reporting scheme of this type is not an optimal one since both near misses and adverse events may remain unreported. This work makes evident that penalising health care decision makers for not reporting errors, independent of error category, is crucial for reaching the first-best solution.Microeconomic theory; agency; iatrogenic injury

Published incidents and their proportions of human error

The file attached to this record is the author's final peer reviewed version. The Publisher's final version can be found by following the DOI link.Purpose - The information security field experiences a continuous stream of information security incidents and breaches, which are publicised by the media, public bodies and regulators. Despite the need for information security practices being recognised and in existence for some time the underlying general information security affecting tasks and causes of these incidents and breaches are not consistently understood, particularly with regard to human error. Methodology - This paper analyses recent published incidents and breaches to establish the proportions of human error, and where possible subsequently utilises the HEART human reliability analysis technique, which is established within the safety field. Findings - This analysis provides an understanding of the proportions of incidents and breaches that relate to human error as well as the common types of tasks that result in these incidents and breaches through adoption of methods applied within the safety field. Originality - This research provides original contribution to knowledge through the analysis of recent public sector information security incidents and breaches in order to understand the proportions that relate to human erro

Escaping the Shadow of Malpractice Law

Abinovich-Einy addresses several constituencies operating at the meeting point of alternative dispute resolution (ADR), communication theory, healthcare policy, and medical-malpractice doctrine. From an ADR perspective, the need for, and barriers to, addressing non-litigable disputes, for which the alternative route is the only one, is explored. It is shown that ADR mechanisms may not take root when introduced into an environment that is resistant to collaborative and open discourse without additional incentives and measures being adopted