Implementation  status of error disclosure standards reported by Swiss hospitals

Stuart McLennan; Sabrina Engel; Katharina Ruhe; Agnes Leu; David Schwappach; Bernice Elger

doi:10.4414/smw.2013.13820

Original article

Vol. 143 No. 2728 (2013)

Implementation status of error disclosure standards reported by Swiss hospitals

Stuart McLennan
Sabrina Engel
Katharina Ruhe
Agnes Leu
David Schwappach
Bernice Elger

DOI: https://doi.org/10.4414/smw.2013.13820
Cite this as:: Swiss Med Wkly. 2013;143:w13820
Published: 30.06.2013

Summary

QUESTION UNDER STUDY: To establish at what stage Swiss hospitals are in implementing an internal standard concerning communication with patients and families after an error that resulted in harm.

METHODS: Hospitals were identified via the Swiss Hospital Association’s website. An anonymous questionnaire was sent during September and October 2011 to 379 hospitals in German, French or Italian. Hospitals were asked to specify their hospital type and the implementation status of an internal hospital standard that decrees that patients or their relatives are to be promptly informed about medical errors that result in harm.

RESULTS: Responses from a total of 205 hospitals were received, a response rate of 54%. Most responding hospitals (62%) had an error disclosure standard or planned to implement one within 12 months. The majority of responding university and acute care (75%) hospitals had introduced a disclosure standard or were planning to do so. In contrast, the majority of responding psychiatric, rehabilitation and specialty (53%) clinics had not introduced a standard.

CONCLUSION: It appears that Swiss hospitals are in a promising state in providing institutional support for practitioners disclosing medical errors to patients. This has been shown internationally to be one important factor in encouraging the disclosure of medical errors. However, many hospitals, in particular psychiatric, rehabilitation and specialty clinics, have not implemented an error disclosure policy. Further research is needed to explore the underlying reasons.

References

National Patient Safety Agency. Being Open: Saying Sorry When Things Go Wrong. NHS: National Patient Safety Agency; 2009.
Canadian Patient Safety Institute. Canadian Disclosure Guidelines. Ottawa: Canadian Patient Safety Institute; 2008.
Australian Commission on Safety and Quality in Health Care. Open Disclosure Standard: A National Standard for Open Communication in Public and Private Hospitals, Following an Adverse Event in Health Care. Sydney: ACSQHC; 2008.
Massachusetts Coalition for the Prevention of Medical Errors. When Things go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Massachusetts Coalition for the Prevention of Medical Errors; 2006.
Aubert de la Ruee R. Medizinische Behandlungsfehler und Patientenrechte in Schweden. Schweizerische Ärztezeitung. 2007;88:46.
Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001–7.
Iedema R, Sorensen R, Manias E, Tuckett A, Piper D, Mallock N, Williams A, Jorm C. Patients’ and family members’ experience of open disclosure following adverse events. Int J Qual Health Care. 2008;20:421–32.
Cleopas A, Villaveces A, Charvet A, Bovier PA, Kolly V, Perneger TV. Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness. Qual Saf Health Care. 2006;15:136–41.
Gallagher TH, Bell SK, Smith KM, Mello MM, McDonald TB. Disclosing Harmful Medical Errors to Patients: Tackling Three Tough Cases. Chest. 2009;136:897–903.
Gallagher TH, Lucus MH. Should we disclose harmful medical errors to patients? If so, how? J Clin Outcomes Manag. 2005; 12:253–9.
Schwappach DLB, Frank O, Hochreutener MA. ‘New perspectives on well-known issues’: Patients’ experiences and perceptions of safety in Swiss hospitals. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 2011;105:542–8.
Iedema R, Allen S, Sorensen R, Gallagher TH. What Prevents Incident Disclosure, and What Can Be Done to Promote It? Jt Comm J Qual Patient Saf. 2011;37:409–17.
Gallagher T, Waterman AD, Garbutt JM, Kapp JM, Chan DK, Dunagan WC, Fraser VJ, Levinson W. US and Canadian physicians’ attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006;166:1605–11.
von Laue N, Schwappach DLB, Hochreutener MA. “Second victim” – error, crises and how to get out of it. Therapeutische Umschau. 2012;69:367–70.
McLennan S, Beitat K, Lauterberg J, Vollmann J. Regulating Open Disclosure: A German Perspective. Int J Qual Health Care. 2012;24:23–7.
Iedema R, Mallock N, Sorensen R, et al. Final Report: Evaluation of the National Open Disclosure Pilot Program. Sydney: Australian Commission on Safety and Quality in Health Care; 2008.
Institute of Medicine. To err is human: building a safer health system. Washington, D.C.: The National Academies Press, 2000.
Schweizerische Akademie der Medizinischen Wissenschaften. Aus- und Weiterbildung in Patientensicherheit und Fehlerkultur. Projekt «Zukunft Medizin Schweiz» – Phase lll. Bern, 2007.
SAMW. Aktuell gültige Richtlinien. http://www.samw.ch/de/Ethik/Richtlinien/Aktuell-gueltige-Richtlinien.html (last accessed 08.10.2012)
Bundesgesetz vom 18. März 1994 über die Krankenversicherung (KVG), SR 832.10.
Briner M, Kessler O, Pfeiffer Y, Wehner T, Manser T. Assessing hospitals’ clinical risk management: Development of a monitoring instrument BMC Health Services Research 2010;10:337.
Lauterberg J, Blum K, Briner M, Lessing C. Abschlussbericht: Befragung zum Einführungsstand von klinischen Risiko-Management (kRM) in deutschen Krankenhäusern. Bonn: Institut für Patientensicherheit der Universität Bonn, 2012.
Rabia L, Rothhardt V. Aussergerichtliche FMH-Gutachterstelle-Jahresbericht 2011. Schweizerische Ärztezeitung. 2012;93:803–6.
Thomas EJ, Studdert DM, Runciman WB, et al. A comparison of iatrogenic injury studies in Australia and the USA. I: context, methods, casemix, population, patient and hospital characteristics, Int J Qual Health Care. 2000;12:371–8.
Runciman WB, Webb RK, Helps SC, et al. A comparison of iatrogenic injury studies in Australia and the USA. II: reviewer behaviour and quality of care, Int J Qual Health Care. 2000;12:379–88.
Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322:517–9.
Davis P, Lay-Yee R, Briant R, et al. Adverse events in New Zealand public hospitals: principal findings from a national survey. Wellington, New Zealand: Ministry of Health, 2001.
Schioler T, Lipczak H, Pedersen BL, et al. Incidence of adverse events in hospitals. A retrospective study of medical records (in Danish). Ugeskr Laeger. 2001;163:5370–8.
Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170:1678–86.
Nath SB, Marcus SC. Medical Errors in Psychiatry. Harv Rev Psychiatry. 2006;14:204–11.
Lamb RM, Studdert DM, Bohmer RMJ, Berwick DM, Brennan TA. Hospital Disclosure Practices: Results Of A National Survey. Health Affairs. 2003;22:73–83.
Weissman JS, Annas CL, Epstein AM, Schneider EC, Clarridge B, Kirle L, et al. Error Reporting and Disclosure Systems: Views From Hospital Leaders. JAMA. 2005;293:1359–66.
Gallagher TH, Brundage G, Bommarito KM, Summy EA, Ebers AG, Waterman AD, Fraser VJ, Dunagan C. National survey: Risk managers’ attitudes and experiences regarding patient safety and error disclosure. ASHRM J. 2006;26:11–6.
Briner M, Manser T, Kessler O. Clinical risk management in hospitals: strategy, central coordination and dialogue as key enablers. J Eval Clin Pract. 2013;19(2):363–9.
Morris-Donovan B, Hopkins G, Watts I. Regaining trust after an adverse event: An education module on managing adverse events in general practice. The Royal Australian College of General Practitioners, 2008.
Hobgood C, Peck CR, Gilbert B, Chappell K, Zou B. Medical Errors – What and When: What Do Patients Want to Know? Acad Emerg Med. 2002;9:1156–61.
Lopez L, Weissman JS, Schneider EC, Weingart SN, Cohen AP, Epstein AM. Disclosure of Hospital Adverse Events and Its Association With Patients’ Ratings of the Quality of Care. Arch Intern Med. 2009;169:1888–94.
Helmreich RL, Merritt AC. Culture at Work in Aviation and Medicine. National, Organisational and Professional Influences. Aldershot: Ashgate Publishing Limited; 1998.
Baruch Y, Holtom BC. Survey response rate levels and trends in organizational research. Human Relations. 2008;6:1139–60.

How to Cite

1.

McLennan S, Engel S, Ruhe K, Leu A, Schwappach D, Elger B. Implementation status of error disclosure standards reported by Swiss hospitals. Swiss Med Wkly [Internet]. 2013 Jun. 30 [cited 2024 Nov. 14];143(2728):w13820. Available from: https://smw.ch/index.php/smw/article/view/1711

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Most read articles by the same author(s)

Andrea Martani, Philipp Egli, Michael Widmer, Bernice Elger, Data protection and biomedical research in Switzerland: setting the record straight , Swiss Medical Weekly: Vol. 150 No. 3536 (2020)
Verina Wild, Fourie Carina, Regula Frouzakis, Caroline Clarinval, Margrit Fässler, Bernice Elger, Thomas Gächter, Agnes Leu, Rebecca Spirig, Michael Kleinknecht, Dragana Radovanovic, Corine Mouton Dorey, Bernard Burnand, John-Paul Vader, Jean-Marie Januel, Nikola Biller-Andorno, The IDoC group, Assessing the impact of DRGs on patient care and professional practice in Switzerland (IDoC) – a potential model for monitoring and evaluating healthcare reform , Swiss Medical Weekly: Vol. 145 No. 0708 (2015)
Viktoria Gloy, Stuart McLennan, Matthias Rinderknecht, Bettina Ley, Brigitte Meier, Susanne Driessen, Pietro Gervasoni, Bernard Hirschel, Pascal Benkert, Ingrid Gilles, Erik von Elm, Matthias Briel, Uncertainties about the need for ethics approval in Switzerland: a mixed-methods study , Swiss Medical Weekly: Vol. 150 No. 3334 (2020)
Bettina Zimmermann, Georg Starke, David Shaw, Bernice Elger, Insa Koné, Actionability and scope should determine the extent of counselling for presymptomatic genetic testing , Swiss Medical Weekly: Vol. 150 No. 2728 (2020)
Franziska Reiser Crelier, David Schwappach, René Schwendimann, Supporting health professionals after an adverse event in Swiss hospitals: a cross-sectional study , Swiss Medical Weekly: Vol. 150 No. 2526 (2020)
Stuart McLennan, Roxanne Maritz, David Shaw, Bernice Elger, The inconsistent ethical oversight of healthcare quality data in Switzerland , Swiss Medical Weekly: Vol. 148 No. 2728 (2018)
Ina Otte, Corinna Jung, Bernice Elger, Klaus Bally, Advance directives and the impact of timing , Swiss Medical Weekly: Vol. 144 No. 3940 (2014)
Insa Koné, Bettina Zimmermann, Tenzin Wangmo, Silvia Richner, Markus Weber, Bernice Elger, Hospital discharge of patients with ongoing care needs: a cross-sectional study using data from a city hospital under SwissDRG , Swiss Medical Weekly: Vol. 148 No. 0304 (2018)
Stuart McLennan, David Shaw, Agnes Leu, Bernice Elger, Professional liability insurance and medical error disclosure , Swiss Medical Weekly: Vol. 145 No. 2728 (2015)
David Schwappach, Katrin Gehring, Markus Battaglia, Roman Buff, Felix Huber, Peter Sauter, Markus Wieser, Threats to patient safety in the primary care office: concerns of physicians and nurses , Swiss Medical Weekly: Vol. 142 No. 2324 (2012)

1 2 > >>

[1] National Patient Safety Agency. Being Open: Saying Sorry When Things Go Wrong. NHS: National Patient Safety Agency; 2009.

[2] Canadian Patient Safety Institute. Canadian Disclosure Guidelines. Ottawa: Canadian Patient Safety Institute; 2008.

[3] Australian Commission on Safety and Quality in Health Care. Open Disclosure Standard: A National Standard for Open Communication in Public and Private Hospitals, Following an Adverse Event in Health Care. Sydney: ACSQHC; 2008.

[4] Massachusetts Coalition for the Prevention of Medical Errors. When Things go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Massachusetts Coalition for the Prevention of Medical Errors; 2006.

[5] Aubert de la Ruee R. Medizinische Behandlungsfehler und Patientenrechte in Schweden. Schweizerische Ärztezeitung. 2007;88:46.

[6] Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001–7.

[7] Iedema R, Sorensen R, Manias E, Tuckett A, Piper D, Mallock N, Williams A, Jorm C. Patients’ and family members’ experience of open disclosure following adverse events. Int J Qual Health Care. 2008;20:421–32.

[8] Cleopas A, Villaveces A, Charvet A, Bovier PA, Kolly V, Perneger TV. Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness. Qual Saf Health Care. 2006;15:136–41.

[9] Gallagher TH, Bell SK, Smith KM, Mello MM, McDonald TB. Disclosing Harmful Medical Errors to Patients: Tackling Three Tough Cases. Chest. 2009;136:897–903.

[10] Gallagher TH, Lucus MH. Should we disclose harmful medical errors to patients? If so, how? J Clin Outcomes Manag. 2005; 12:253–9.

[11] Schwappach DLB, Frank O, Hochreutener MA. ‘New perspectives on well-known issues’: Patients’ experiences and perceptions of safety in Swiss hospitals. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 2011;105:542–8.

[12] Iedema R, Allen S, Sorensen R, Gallagher TH. What Prevents Incident Disclosure, and What Can Be Done to Promote It? Jt Comm J Qual Patient Saf. 2011;37:409–17.

[13] Gallagher T, Waterman AD, Garbutt JM, Kapp JM, Chan DK, Dunagan WC, Fraser VJ, Levinson W. US and Canadian physicians’ attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006;166:1605–11.

[14] von Laue N, Schwappach DLB, Hochreutener MA. “Second victim” – error, crises and how to get out of it. Therapeutische Umschau. 2012;69:367–70.

[15] McLennan S, Beitat K, Lauterberg J, Vollmann J. Regulating Open Disclosure: A German Perspective. Int J Qual Health Care. 2012;24:23–7.

[16] Iedema R, Mallock N, Sorensen R, et al. Final Report: Evaluation of the National Open Disclosure Pilot Program. Sydney: Australian Commission on Safety and Quality in Health Care; 2008.

[17] Institute of Medicine. To err is human: building a safer health system. Washington, D.C.: The National Academies Press, 2000.

[18] Schweizerische Akademie der Medizinischen Wissenschaften. Aus- und Weiterbildung in Patientensicherheit und Fehlerkultur. Projekt «Zukunft Medizin Schweiz» – Phase lll. Bern, 2007.

[19] SAMW. Aktuell gültige Richtlinien. http://www.samw.ch/de/Ethik/Richtlinien/Aktuell-gueltige-Richtlinien.html (last accessed 08.10.2012)

[20] Bundesgesetz vom 18. März 1994 über die Krankenversicherung (KVG), SR 832.10.

[21] Briner M, Kessler O, Pfeiffer Y, Wehner T, Manser T. Assessing hospitals’ clinical risk management: Development of a monitoring instrument BMC Health Services Research 2010;10:337.

[22] Lauterberg J, Blum K, Briner M, Lessing C. Abschlussbericht: Befragung zum Einführungsstand von klinischen Risiko-Management (kRM) in deutschen Krankenhäusern. Bonn: Institut für Patientensicherheit der Universität Bonn, 2012.

[23] Rabia L, Rothhardt V. Aussergerichtliche FMH-Gutachterstelle-Jahresbericht 2011. Schweizerische Ärztezeitung. 2012;93:803–6.

[24] Thomas EJ, Studdert DM, Runciman WB, et al. A comparison of iatrogenic injury studies in Australia and the USA. I: context, methods, casemix, population, patient and hospital characteristics, Int J Qual Health Care. 2000;12:371–8.

[25] Runciman WB, Webb RK, Helps SC, et al. A comparison of iatrogenic injury studies in Australia and the USA. II: reviewer behaviour and quality of care, Int J Qual Health Care. 2000;12:379–88.

[26] Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322:517–9.

[27] Davis P, Lay-Yee R, Briant R, et al. Adverse events in New Zealand public hospitals: principal findings from a national survey. Wellington, New Zealand: Ministry of Health, 2001.

[28] Schioler T, Lipczak H, Pedersen BL, et al. Incidence of adverse events in hospitals. A retrospective study of medical records (in Danish). Ugeskr Laeger. 2001;163:5370–8.

[29] Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170:1678–86.

[30] Nath SB, Marcus SC. Medical Errors in Psychiatry. Harv Rev Psychiatry. 2006;14:204–11.

[31] Lamb RM, Studdert DM, Bohmer RMJ, Berwick DM, Brennan TA. Hospital Disclosure Practices: Results Of A National Survey. Health Affairs. 2003;22:73–83.

[32] Weissman JS, Annas CL, Epstein AM, Schneider EC, Clarridge B, Kirle L, et al. Error Reporting and Disclosure Systems: Views From Hospital Leaders. JAMA. 2005;293:1359–66.

[33] Gallagher TH, Brundage G, Bommarito KM, Summy EA, Ebers AG, Waterman AD, Fraser VJ, Dunagan C. National survey: Risk managers’ attitudes and experiences regarding patient safety and error disclosure. ASHRM J. 2006;26:11–6.

[34] Briner M, Manser T, Kessler O. Clinical risk management in hospitals: strategy, central coordination and dialogue as key enablers. J Eval Clin Pract. 2013;19(2):363–9.

[35] Morris-Donovan B, Hopkins G, Watts I. Regaining trust after an adverse event: An education module on managing adverse events in general practice. The Royal Australian College of General Practitioners, 2008.

[36] Hobgood C, Peck CR, Gilbert B, Chappell K, Zou B. Medical Errors – What and When: What Do Patients Want to Know? Acad Emerg Med. 2002;9:1156–61.

[37] Lopez L, Weissman JS, Schneider EC, Weingart SN, Cohen AP, Epstein AM. Disclosure of Hospital Adverse Events and Its Association With Patients’ Ratings of the Quality of Care. Arch Intern Med. 2009;169:1888–94.

[38] Helmreich RL, Merritt AC. Culture at Work in Aviation and Medicine. National, Organisational and Professional Influences. Aldershot: Ashgate Publishing Limited; 1998.

[39] Baruch Y, Holtom BC. Survey response rate levels and trends in organizational research. Human Relations. 2008;6:1139–60.