Improvement from
Front Office to Front Line

March 2010
Volume 36 Number 3

Disclosure, Apology,
and the Sharp End
Features
Editorial
?

Attitudes Toward Error Disclosure Need to Engage with Systems
Thinking

Reporting Systems
"A disclosure process

?

Risk Managers, Physicians, and Disclosure of Harmful Medical Errors

that promotes collaboration
between risk managers and
physicians could take

Performance Improvement
?

advantage of both parties'
respective strengths and
lead to disclosures that

Organizational Change and Learning
?

better meet patient
expectations."
--Loren et al. (pages 106-107)

Physician Champions Are Key to Improving Antibiotic Prescribing
Quality
Redesigning a Morbidity and Mortality Program in a UniversityAffiliated Pediatric Anesthesia Department

Adverse Events
?

Interruptions and Multitasking in Nursing Care

Teamwork and Communication
?

Does Teamwork Improve Performance in the Operating Room?
A Multilevel Evaluation

Departments
Letter to the Editor
?

www.jcrinc.com

Frequency and Severity of Promethazine Adverse Event Reports
Obligated the ISMP Alert

The Joint Commission Journal on Quality and Patient Safety
Reporting Systems

Risk Managers, Physicians, and Disclosure of Harmful Medical
Errors
David J. Loren, M.D.; Jane Garbutt, M.B., Ch.B.; W. Claiborne Dunagan, M.D.; Kerry M. Bommarito, M.P.H.; Alison
G. Ebers; Wendy Levinson, M.D.; Amy D. Waterman, Ph.D.; Victoria J. Fraser, M.D.; Elizabeth A. Summy, M.Sc.,
C.A.E.; Thomas H. Gallagher, M.D.

T

ransparency is a vital element of efforts to enhance patient
safety. One aspect of transparency that has received particular attention is the disclosure of medical errors.1-6 Although
disclosure of harmful errors to patients is widely recommended,
current practice falls far short of this goal.5,7-10 Disclosure
research to date has focused primarily on physicians' and
patients' attitudes and experiences. Yet at many hospitals,
physicians are not the only institutional participants in a disclosure conversation. Risk managers play a critical role in the disclosure process, collaborating with physicians in planning
disclosures and sometimes actually conducting disclosures.11
Furthermore, risk managers are closely associated with patient
safety reporting systems, and event reporting is often the first
step in disclosing the error to the patient.
Risk managers' and physicians' training, professional roles,
and responsibilities are understandably dissimilar. Consequently, risk managers and physicians may experience differing
forces that both encourage and inhibit error disclosure. Physicians have a fiduciary relationship with patients that entails a
strong moral obligation to provide patients with truthful information about their health care.12-14 Physicians also work at the
"front line" of medical errors and may experience shame, embarrassment, and a fear of being sued when disclosing harmful
errors to patients.15-18 In contrast, risk managers have traditionally been charged with protecting an institution from legal exposure and financial harm and have historically counseled
physicians to share little if any information with patients about
errors.19,20 Yet, because risk managers do not have clinical contact with patients and are not personally involved in errors, they
may feel less inhibited than physicians in either recommending
or performing disclosure of a harmful medical error to a patient.
At many institutions the role of risk managers has been
changing, reflecting an increasing emphasis on promoting
patient safety and responding to calls for greater public
accountability.11 In this new role, risk managers have significant
opportunities to identify safety issues, advocate for systems

March 2010

Article-at-a-Glance
Background: Physicians are encouraged to disclose med-

ical errors to patients, which often requires close collaboration between physicians and risk managers.
Methods: An anonymous national survey of 2,988 healthcare facility-based risk managers was conducted between
November 2004 and March 2005, and results were compared with those of a previous survey (conducted between
July 2003 and March 2004) of 1,311 medical physicians in
Washington and Missouri. Both surveys included an errordisclosure scenario for an obvious and a less obvious error
with scripted response options.
Results: More risk managers than physicians were aware
that an error-reporting system was present at their hospital
(81% versus 39%, p < .001) and believed that mechanisms
to inform physicians about errors in their hospital were adequate (51% versus 17%, p < .001). More risk managers
than physicians strongly agreed that serious errors should
be disclosed to patients (70% versus 49%, p < .001). Across
both error scenario, risk managers were more likely than
physicians to definitely recommend that the error be disclosed (76% versus 50%, p < .001) and to provide full
details about how the error would be prevented in the
future (62% versus 51%, p < .001). However, physicians
were more likely than risk managers to provide a full apology recognizing the harm caused by the error (39% versus
21%, p < .001).
Conclusions: Risk managers have more favorable attitudes about disclosing errors to patients compared with
physicians but are less supportive of providing a full apology. These differences may create conflicts between risk
managers and physicians regarding disclosure. Health care
institutions should promote greater collaboration between
these two key participants in disclosure conversations.

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The Joint Commission Journal on Quality and Patient Safety
changes, develop hospital error-disclosure policies, and participate in the planning and delivery of error disclosures.11
Improving the quality of communication with patients and
families after an error occurs will depend in part on how closely aligned risk managers' and physicians' attitudes are regarding
effective disclosure strategies. We therefore conducted a
national survey of risk managers' attitudes regarding patient
safety and error disclosure and compared the results with our
previously published survey of medical physicians.21

Table 1. Definitions Provided to Respondents
Adverse event: An injury that was caused by medical management
rather than the patient's underlying disease
Medical error: The failure of a planned action to be completed as
intended or the use of a wrong plan to achieve an aim
Serious error: Error that causes permanent injury or transient but
potentially life-threatening harm
Minor error: Error that causes harm but is neither permanent nor
potentially life threatening
Near miss: An error that could have caused harm but did not either
by chance or timely intervention

Methods
SAMPLE
Between November 1, 2004, and February 28, 2005, invitations to participate in an anonymous Web survey were sent
electronically to members of the American Society for
Healthcare Risk Management (ASHRM). ASHRM, established in 1980, is a personal membership group of the
American Hospital Association (AHA), with approximately
5,200 members at the time of the survey. Surveys were not sent
to members of ASHRM who self-identified as students, were
living outside of the United States, were employees of AHA or
ASHRM, or were U.S. federal government or military employees. Because error disclosure might be less relevant to their
scope of professional practice, survey responses (N = 202) from
those who reported that they did not work in a health care facility or those who reported no involvement in error disclosure
were excluded from analysis. Participation was encouraged
through e-mail and fax reminders. Respondents were also
entered into a drawing to win a $50 gift card or a registration
fee waiver to the 2005 ASHRM annual conference. The inclusion and exclusion criteria for the comparison physician survey
have been previously reported by our group.8,21
Medical physicians and surgeons in the United States and
Canada completed the physician survey. We limited our comparison of risk managers to medical physicians because we had
previously noted differences in error-disclosure attitudes and
behaviors between medical physicians and surgeons.21 We
excluded medical physicians practicing in Canada from the
comparison because we surveyed risk managers only within the
United States. The physician survey was performed in the metropolitan region of St. Louis (including Columbia, Missouri,
and southern Illinois) and the metropolitan region of Seattle.

SURVEY CONTENT
The risk manager survey* was adapted from a similar survey
* The risk manager and physician surveys are available from Dr. Loren by e-mail
request.

102

March 2010

of 3,000 physicians in the United States and Canada conducted between July 2003 and March 2004, which was previously
published by our group.5,8,9,22 Definitions for key terms (adverse
event, medical error, serious error, minor error, and near miss)
were provided at the beginning of the risk manager survey and
via a link at the top and bottom of each survey page (Table 1,
above).
The risk manager survey included questions exploring the
respondent's general attitudes about medical errors, what kinds
of errors should be disclosed, and how disclosure is managed at
his or her institution. Risk managers were asked about the presence and adequacy of error-reporting systems at their hospital,
whether these systems lead to improvements in patient care,
and about the adequacy of mechanisms to inform physicians
about the errors that occur in their hospitals. In addition, risk
managers answered questions regarding the level of opposition
toward error disclosure among physicians as well as what
specific situations might decrease the chance that the risk manager would recommend disclosure of a serious error (for example, whether the patient was aware of the error, concern over
being sued).11
Both risk manager and physician respondents randomly
received one of two medical cases, differing in the patient's
awareness of the error, a factor known to influence physician
disclosure of the error.5,8 The first medical scenario (Sidebar,
page 103), an insulin overdose due to an order error resulting
in an ICU admission with expected complete recovery, was
designed to simulate an event more likely to have been independently recognized as an error by the patient (that is, a more
obvious error). The second medical scenario, a missed laboratory report resulting in symptomatic hyperkalemia requiring cardioversion and hospitalization with expected full recovery, was
designed to simulate an event that the patient was less likely to
have recognized as an error (a less obvious error).
Risk manager respondents answered the same five questions

Volume 36 Number 3

Copyright 2010 Joint Commission on Accreditation of Healthcare Organizations

The Joint Commission Journal on Quality and Patient Safety
STATISTICAL ANALYSIS

Sidebar. Text of Scenarios
Insulin Overdose
A diabetic patient is admitted to the hospital for a chronic obstructive pulmonary disease (COPD) exacerbation. The attending physician handwrites an order for the patient to receive "10 U" of insulin.
The "U" in the order looks like a zero. The following morning the
patient is given 100 units of insulin, 10 times the patient's normal
dose, and is later found unresponsive with a blood sugar level of
35. The patient, who is resuscitated and transferred to the ICU, is
expected to make a full recovery.
Hyperkalemia
A physician starts an outpatient on a new medicine with a common
side effect of increasing the potassium level. The patient's baseline
potassium level is normal (4.0). The physician orders a repeat
potassium blood test to be drawn in the next week, but forgets to
check the lab results. Two weeks after the patient begins this new
medicine the patient starts feeling palpitations and goes to the
emergency department (ED). In the ED, the patient experiences an
episode of ventricular tachycardia requiring cardioversion. The
patient's potassium at the time of this event is 7.5. The patient is
hospitalized for four days and makes a full recovery. The patient
returns to the physician's office for a follow-up visit. On reviewing
the patient's chart, the physician sees the overlooked labs, which
showed the patient's potassium had risen substantially from 4.0 to
5.6. Had the physician seen this elevated potassium earlier, he
would have stopped the medicine and treated the hyperkalemia,
likely avoiding the life-threatening arrhythmia.

about the scenarios that were in the physician survey: (1) "How
likely do you think it is that the patient will file a malpractice
suit due to this error?" (2) "What would you most likely recommend about error disclosure to the patient?" (3) "What would
you most likely recommend the patient be told about what
happened?" (4) "What would you most likely recommend the
patient be told regarding an apology?" and (5) "What would
you most likely recommend the patient be told about how the
error would be prevented in the future?" The phrasing of these
risk manager survey questions was modified slightly from the
parallel questions in the physician survey to reflect the differences between the risk manager and physician roles in disclosure (that is, the risk managers were asked what they would
recommend regarding disclosure, whereas the physicians were
asked what they would disclose). For each of these scenario
questions (except "How likely do you think it is that the patient
will file a malpractice suit due to this error?") scripted responses representing increasing levels of disclosure detail were provided as answer choices. The full text of the responses has been
previously published.8
The Institutional Review Board at Washington University in
St. Louis approved both the risk manager survey and the physician survey.

March 2010

Descriptive statistics were calculated for demographic variables. Continuous variables are reported as means with standard deviations, and categorical variables are reported as
percentages. Four-choice Likert scales were dichotomized at the
midpoint (for example, agree and strongly agree versus disagree
and strongly disagree). Recent literature supports the expectation that harmful errors should be disclosed to patients.23
Consequently, for the question asking respondents whether
serious errors should be disclosed, the response "strongly agree"
was dichotomized from the three other responses ("agree", "disagree," and "strongly disagree"). Similarly, for the question
asking respondents if they would recommend disclosing the
scenario error, the response "definitely disclose" was
dichotomized from the three other responses ("probably disclose", "disclose only if asked by the patient", "do not disclose"). The parallel responses to each question in the insulin
overdose and hyperkalemia scenarios were first aggregated to
explore general scenario disclosure trends between the risk
managers and the physicians. The risk managers' and the physicians' responses to each scenario question were then compared
independently. Chi-square or Fischer exact tests were used to
compare proportions between risk mangers and physicians.
Two-tailed tests with p < .05 were used throughout the analyses for establishing statistical significance. Analyses were performed with SPSS version 15.0 (SPSS, Chicago) and Prism 4
(GraphPad Software, Inc., San Diego) for Macintosh.

Results
CHARACTERISTICS OF RESPONDENTS
There were 1,673 eligible responses from risk managers, representing a 56% response rate (1,673 responses/2,988 risk managers eligible to receive surveys). Eighty-eight percent of the
risk managers worked in a hospital setting, and 28% of these
hospital-based respondents reported working in an academic
medical center (Table 2, page 104). Risk managers were distributed across all states, including Alaska and Hawaii. The majority were female (86%) and had been working in their current
position for at least 7 years, with a mean age of 49.6 years. As
previously reported, 49% of responding risk managers were
present during error-disclosure conversations, and 26% personally disclose errors to patients.11
The physician survey response rate (63%) and detailed characteristics of the physicians who participated have been reported elsewhere.8,21 Forty-one percent of the physicians were in
private practice, 33% were affiliated with an academic medical
center, 72% were male, and 74% spent a least half of their time

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The Joint Commission Journal on Quality and Patient Safety
in clinical practice. The physicians reported an average age of
48 years (standard deviation [S.D.], 9 years) and had been
practicing for 16 years (S.D., 9 years).

RISK MANAGERS' GENERAL PATIENT SAFETY AND
DISCLOSURE ATTITUDES
Eighty-three percent of responding risk managers agreed
that medical errors are one of the most serious problems in
health care and are usually caused by system failures (Table 3,
page 105). Fifty-seven percent of the risk managers agreed that
current systems for physicians to report patient safety problems
are adequate, and only 51% of the risk managers agreed that
current mechanisms to inform physicians about errors that
occur in their hospitals or health care organizations are
adequate.
As shown in Table 4 (page 105), 70% percent of responding risk managers strongly agreed with the statement that serious errors should be disclosed; 19% agreed that near misses
should be disclosed. Thirty-nine percent of the risk managers
agreed that physicians are opposed to disclosing serious medical errors, and 73% agreed that physicians are opposed to disclosing minor errors to patients.

RISK MANAGERS' RECOMMENDATIONS REGARDING
DISCLOSURE OF THE SCENARIO ERROR
As shown in Table 5 (page 106), 47% of the risk managers
responded that they thought the patient was somewhat or very
likely to file a malpractice suit due to the scenario error. Across
both scenarios, 76% of the risk managers would definitely recommend that the error be disclosed. Forty-two percent of the
risk managers would use the word error in the explanation of
the events, 21% would offer a full apology recognizing the
harm caused, and 62% would offer full details about how the
error would be prevented in the future.
The risk managers who received the insulin overdose scenario (more obvious error), compared to the risk managers who
received the hyperkalemia scenario (less obvious error), were
more likely to definitely recommend that the error be disclosed
(87% versus 64%, p < .001) and use the word error in their
explanation to the patient (48% versus 36%, p < .001) but were
less likely to offer full details about how the error could be prevented in the future (56% versus 68%, p < .001).

COMPARISON OF RISK MANAGERS AND PHYSICIANS:
GENERAL ATTITUDES
As shown in Table 3, risk managers were more likely than
the physicians to agree that medical errors are one of the most
104

March 2010

Table 2. Characteristics of Risk Managers (N = 1,673)
Work Environment
Hospital-based employment (n = 1,472)
? Academic medical center
? Pediatric hospital

88%
28%
14%

Hospital size
? < 200 bed
? 200-399 beds
? 400 or greater beds

43%
31%
26%

Job Characteristics
Worked in health care risk management 7 years or greater
Time associated with patient safety work
? <= 25%
? 26%-50%
? 51%-75%
? > 75%

31%
34%
23%
12%

Nature of Involvement with Disclosing
Medical Errors to Patients*
? None
? General education about error disclosure
? Just-in-time coaching for staff who will disclose error
? Present for error disclosure
? Personally disclose the error
? Follow up with patient and family
? Had disclosed a serious error to a patient

7%
74%
62%
49%
26%
55%
64%

Demographics
Gender (female)
Mean age (years)

86%
49.6

62%

* Gallagher T., et al.: National Survey: Risk managers' attitudes and
experiences regarding patient safety and error disclosure. ASHRM Journal
26(3):5, 2006.

serious problems in health care (83% versus 65%, p < .001) and
are usually caused by system failures (84% versus 58%,
p < .001). Risk managers were more likely than physicians to
report that system changes to improve patient safety occur after
errors are reported (94% versus 75%, p < .001) and that current mechanisms to inform physicians about errors that occur
in their hospitals or health care organizations are adequate
(51% versus 17%, p < .001).
As shown in Table 4, risk managers were more likely to
strongly agree with the statement that serious errors should be
disclosed (70% versus 49%, p < .001) and were less likely to
agree that near misses should be disclosed (19% versus 32%,
p < .001). Risk managers were also less likely than physicians to
endorse each of the described potential barriers to disclosure,
such as if the patient was unaware of the error or might become
angry (Table 6, page 107).

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Copyright 2010 Joint Commission on Accreditation of Healthcare Organizations

The Joint Commission Journal on Quality and Patient Safety
Table 3. Risk Managers' and Physicians' General Attitudes About Patient Safety and Error Reporting
Risk Managers
(N = 1,472)

Medical Physicians
(N = 1,311)

p

Medical errors are one of most serious problems in health care. (agree)

83%

65%

< .001

Medical errors are usually caused by system failures. (agree)
Does your hospital/health care organization have an error reporting system for
physicians to use to improve patient safety?

84%

58%

< .001

No

15%

16%

.370

Yes

81%

39%

< .001

Don't know

4%

45%

< .001

Current systems for physicians to report patient safety problems are
adequate. (agree)

57%

29%

< .001

At my hospital or healthcare organization, system changes to improve
patient safety occur after errors are reported. (agree)

94%

75%

< .001

Current mechanisms to inform physicians about errors that occur in their
hospitals or health care organizations are adequate. (agree)

51%

17%

< .001

Table 4. Risk Managers' and Physicians' Attitudes About Error Disclosure

Near misses should be disclosed. (agree/strongly agree)

Risk Managers
(N = 1,472)
19%

Medical Physicians
(N = 1,311)
32%

p
< .001

Minor errors should be disclosed. (agree/strongly agree)

75%

77%

.118

Serious errors should be disclosed. (agree or strongly agree)

98%

98%

Serious errors should be disclosed (strongly agree)

70%

49%

< .001

Physicians are opposed to disclosing serious errors to patients.
(agree/strongly agree)

39%

N/A

N/A

Physicians are opposed to disclosing minor errors to patients. (agree)

73%

N/A

N/A

Disclosure would make it LESS likely that the patient would sue.
(agree/strongly agree)

58%

69%

< .001

COMPARISON OF RISK MANAGERS AND PHYSICIANS:
ERROR SCENARIOS
Risk managers were more likely than physicians to endorse
disclosure of the error across both scenarios (Table 5). For
example, 76% of risk managers would "definitely recommend"
disclosure, while 50% of physicians would "definitely disclose"
the error (p < .001). However, risk managers and physicians did
not similarly endorse all elements of full error disclosure (statement that an error occurred, complete description of the event,
apology recognizing harm caused by the error, description of
how the error will be prevented from recurring) in the scenarios. Overall, a greater proportion of risk managers than physicians recommended disclosing full details about how the error
would be prevented in the future (62% versus 51%, p < .001).
However, risk managers were nearly half as likely to recom-

March 2010

mend offering a full apology compared with physicians (21%
versus 39%, p < .001). Within the more-obvious insulin overdose scenario, a lower proportion of risk managers supported
using the word error in the disclosure statement compared with
physicians (48% versus 71%, p < .001).

Discussion
Increasingly, planning and conducting error-disclosure conversations involves multiple team members including risk managers. This study, the first to our knowledge to compare
medical physicians' and risk managers' attitudes regarding
patient safety and error disclosure, found that these two stakeholders differ regarding whether errors are a serious health care
problem, the adequacy of error-reporting mechanisms, and
whether and how errors should be disclosed. Although these

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The Joint Commission Journal on Quality and Patient Safety
Table 5. Risk Managers' and Physicians' Responses to Scenarios
Combined

Insulin Scenario
(more visible)
Risk
Medical
Managers Physicians
(N = 463)
(N = 400)

Hyperkalemia Scenario
(less visible)
Risk
Medical
Managers Physicians
(N = 413)
(N = 393)
P

Risk
Managers
(N = 876)

Medical
Physicians
(N = 793)

P

How likely do you think it is
that you will be sued/the
patient will file a malpractice
suit due to this error?
(somewhat/very likely)

47%

39%

.01

51%

38%

.001

43%

39%

.328

Definitely disclose/definitely
recommend disclosure?

76%

50%

< .001

87%

65%

< .001

64%

34%

< .001

Use the word error in
an explanation of what
happened?

42%

56%

.63

48%

71%

< .001

36%

40%

.547

Offer a full apology
recognizing the
harm caused?

21%

39%

< .001

23%

42%

<.001

18%

35%

< .001

Offer full detail about
how the error will be
prevented in the future?

62%

51%

< .001

56%

41%

< .001

68%

60%

.064

divergent attitudes might foster conflict within the health care
team and might inhibit open communication about errors, our
study also highlights opportunities for collaboration between
risk managers and physicians that could enhance disclosure.24,25
Risk managers have historically been portrayed as resisting
the disclosure of errors to patients, fearing disclosure's financial
impact on the institutions that employed them.19,20,26 However,
we found that risk managers in this study were generally more
supportive of disclosing medical errors than physicians.
Previous research has suggested that physician shame and
embarrassment, as well as fear of being sued, are important factors that prevent physicians from disclosing errors to
patients.15,18,27 Our data suggest that risk managers are less likely than physicians to be influenced by such barriers. Risk managers' high level of support for disclosure makes them
potentially important advocates for open communication with
patients about adverse events and errors.
Despite their overall support for disclosure, these risk managers were less likely to recommend using the word error and
less likely to offer a full apology than were the physicians in
these hypothetical scenarios. These risk managers also expressed
greater concern than did physicians that the error would lead to
litigation. Risk managers may be concerned that specific elements of a disclosure, such as an explicit apology, could represent an admission of liability. Yet if risk managers inadvertently
106

March 2010

P

send mixed messages, such as advocating for disclosure but
advising against apology, confused physicians may conduct disclosures that move even farther away from patient and family
expectations.
Many organizations are using risk managers as "disclosure
coaches" to provide "just-in-time" support for clinicians, a
practice recommended by the National Quality Forum.28,29*
Risk managers bring several strengths to the disclosure process,
including their overall support for disclosure and first-hand
knowledge of the consequences of defective disclosures. In
addition, in their role as patient safety administrators, risk managers may be more likely than physicians to become involved in
error analyses. Despite these strengths, risk managers may not
be comfortable with all the elements of error-disclosure conversations that patients desire, such as a full apology.30 In this
study, physicians exhibited a greater willingness than the risk
managers to explicitly use the word error and to offer an apology in disclosure conversations. Thus a disclosure process that
promotes collaboration between risk managers and physicians
could take advantage of both parties' respective strengths and
* The 2009 Executive Summary, which summarizes Safe Practice #7 (Disclosure)
can be found at http://www.qualityforum.org/Publications/2009/03/
Safe_Practices_for_Better_Healthcare-2009_Update.aspx (National Quality
Forum: Safe Practices for Better Healthcare-2009 Update; last accessed Jan. 12,
2010).

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The Joint Commission Journal on Quality and Patient Safety
Table 6. Risk Managers' and Physicians' Perceived Barriers to Disclosure*
Risk Managers
(N = 1,472)

Medical Physicians
(N = 1,311)

p

Patient unaware of the error

9%

24%

< .001

If I think the patient would not want to know about the error

19%

32%

< .001

If I think the patient would become angry

2%

13%

< .001

If the physician did not know the patient very well

1%

20%

< .001

If I think the physician might get sued

3%

27%

< .001

If I think the patient would not understand the information

47%

61%

< .001

Which of the following would make it LESS likely that you would
recommend disclosure (RM) or disclose (MD) a serious error to a patient (yes)

* RM, risk manager; MD, medical physician.

lead to disclosures that better meet patient expectations.
However, the differences that we found between risk managers' and physicians' disclosure attitudes could also lead to
conflict between these parties and diminish the effectiveness of
disclosures. As disclosures increasingly involve collaborations
between risk managers and physicians, organizations should
anticipate such potential conflicts and develop procedures for
resolving disagreements about disclosures. Programs to train
physicians and risk managers in disclosure should include basic
conflict resolution skills to reduce the likelihood that such disagreements will impair the disclosure process. In addition,
institutional disclosure policies should clearly articulate who in
the organization has final authority over whether and how disclosures will take place.
Preventing future errors depends on recognition and identification of medical errors and confidence among its users that
their observations will lead to changes.2,3,31-34 The risk managers
in this study were more likely than physicians to believe that
current error-reporting systems are adequate, that changes take
place after errors are reported, and that physicians are informed
about these errors when they occur. Yet, both risk managers and
physicians indicated that there is much room for improvement
in error-reporting systems. Closer collaboration between risk
managers and physicians around implementation and management of event-reporting systems could increase physicians'
awareness of these systems, help risk managers both understand
the challenges that end users experience with these systems, and
identify strategies for improvement.
The strengths of this study include the robust response rates
from both risk managers and physicians and the broad geographic representation of responding risk managers. Our study
also has several limitations. The risk managers in this study

March 2010

were sampled from the entire United States, whereas the physicians were sampled in two broad metropolitan regions and thus
were not identical geographic groupings. The risk manager and
physician surveys were conducted two years apart, which could
partially account for the observed differences in the two groups.
The methodologic challenges of comparing different surveys
may limit the ability to compare risk managers' and physicians'
disclosure attitudes. The social desirability of responses in these
surveys may have influenced the reported attitudes or selections
of scenario responses, skewing our results to suggest that
respondents have more favorable attitudes than they actually
hold. Furthermore, this study employs scenarios and does not
capture in situ practices of either risk managers or physicians.
Future research should seek to study how risk managers and
physicians participate in actual disclosures. We only included
health care facility-based risk managers in our analysis, so that
these results may not generalize to risk managers in other settings.

Conclusions
Risk managers and physicians are both involved in the disclosure of harmful errors to patients but have different attitudes
about effective disclosure strategies. Institutional strategies that
foster effective collaboration between these two key participants
in the disclosure process could help ensure that patients' needs
are better met after errors. J
Funding for this study was provided by grants 1U18HS11890 and 1K08HS0140201
from the Agency for Healthcare Research and Quality. Dr. Gallagher was also supported by the Greenwall Foundation Faculty Scholars Program and the Robert
Wood Johnson Investigator Award in Health Policy Research program. The authors
express their gratitude for the thoughtful feedback on the manuscript provided by
Kara Clark (Executive Director of ASHRM) and Geri Amori (recent past-Executive
Director).

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The Joint Commission Journal on Quality and Patient Safety
David J. Loren, M.D., is Assistant Professor of Medicine, Division
of Pediatrics, University of Washington, Seattle. Jane Garbutt,
M.B., Ch.B., is Associate Professor of Medicine, Department of
Medicine, Washington University School of Medicine, St. Louis. W.
Claiborne Dunagan, M.D., is Professor of Medicine, Washington
University School of Medicine and Vice-President, Quality, BJC
HealthCare, St. Louis. Kerry M. Bommarito, M.P.H., is Program
Coordinator, the Goldfarb Patient Safety and Quality Fellowship,
Department of Medicine, Washington University School of
Medicine. Alison G. Ebers is Program Coordinator, KL2
(Translational Research Scholars) Program, Department of
Medicine, Washington University School of Medicine. Wendy
Levinson, M.D., is Sir John and Lady Eaton Professor and Chair,
Department of Medicine, University of Toronto, Toronto. Amy D.
Waterman, Ph.D., is Assistant Professor of Medicine, Department
of Medicine, Washington University School of Medicine; and
Victoria J. Fraser, M.D., is J. William Campbell Professor of
Medicine, Division of Infectious Diseases. Elizabeth A. Summy,
M.Sc., C.A.E., is Vice President, American Hospital Association,
Chicago. Thomas H. Gallagher, M.D., is Associate Professor of
Medicine, Department of General Internal Medicine, University of
Washington, Seattle. Please address correspondence to David
Loren, dloren@uw.edu.

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Volume 36 Number 3

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