Nearly a decade after the Institute of Medicine's report, “To Err Is Human,”1 training programs are increasingly using simulation programs,2–4 “virtual patients,”5,6 and other educational paradigms that prioritize safety to help trainees gain necessary proficiencies while minimizing the risk of harm to patients. Despite these important interventions, medical error persists, and trainees are often not equipped with the communication skills needed to manage the aftermath of harmful events.7,8
The direct effects of medical mistakes can be devastating, but what happens after mistakes are made can also be harmful for everyone involved. Silence, shame, guilt, and fractured trust disrupt the therapeutic relationship and leave patients, families, and caregivers to suffer alone.9 These collective issues, and the overall emotional toll of medical mistakes, are what we refer to as the “human dimension” of medical error. Responding effectively after medical error involves more than just sharing information: Attention must be paid to the broad range of emotions that affect both patients and clinicians, and caregivers must develop advanced communication skills. However, few strategies and curricula addressing the human dimensions of error are documented and evaluated in the literature.
Full disclosure and apology following medical mistakes may decrease litigation,10–12 and an increasing number of institutions are adopting transparent disclosure policies. However, many physicians feel inadequately prepared to conduct bedside discussions about medical error.8,13–15 Although the American College of Surgeons' Code of Professional Conduct16 and the American Medical Association's Code of Medical Ethics17 highlight the moral imperative of disclosure, caregivers may feel conflicting pressures from personal morals, institutional policies, risk management strategies, and legal considerations. Disclosure and apology can be particularly challenging for trainees, who experience a unique set of hierarchical pressures, personal concerns, ethical challenges, and emotional reactions in the wake of medical mistakes.8,18–23 Trainees frequently do not disclose mistakes to their supervisors or to their patients8,19; such reluctance highlights the importance of educational interventions to address these issues. Attending physicians are the logical ones to teach trainees, but they may be underprepared to teach communication skills related to disclosure and apology.24
We created a curriculum to address the human dimensions of error. Separate tracks for faculty physicians and trainees target improving communication skills for disclosure and apology. In this article, we report on the development, implementation, and assessment of the educational program to raise awareness of the human dimensions of medical error and share our experience with and insights gained from implementing the curriculum. We also describe specific educational materials and strategies that other sites may adapt for their own use.
Designing the Educational Intervention
In our planning stages, we identified several curricular design challenges. First, needs assessment is complicated in the case of medical error. Discussions tend to be both constrained and restricted, because learners may not feel comfortable sharing their own experiences with error or its aftermath. Second, the classroom is far removed from the often-intense disclosure environment. Hypothetical teaching cases or lecture-based didactics may not fully convey lessons imparted by the potentially life-changing events affecting both patients and clinicians as a result of error. With this in mind, we sought a format that would resemble the high-stakes, highly charged, and unpredictable circumstance that follows harmful events, since communication skills are most vulnerable to deterioration in such scenarios. Finally, we wished to include a structured tool to help clinicians implement open disclosure discussions.
Our educational program therefore includes three components: (1) a baseline anonymous assessment of learner experiences, attitudes, and perceptions about medical error, (2) an interactive curriculum that uses filmed patient narratives and focuses on the human dimensions of medical error, and (3) an implementation strategy for real-time disclosure.
The Learner Experience
Assessing experiences and perceptions of error
We designed a survey instrument to identify learners' baseline attitudes and perceptions about disclosure, apology, and personal experiences with medical error from an explorative perspective. Trainees completed the surveys anonymously on paper at the beginning of the session or using an electronic audience response system (ARS; Turning Technologies, LLC, Youngstown, Ohio) that allowed them to respond anonymously to questions embedded in a PowerPoint presentation; faculty physicians used the ARS. Learners responded to 10 to 35 questions (depending on the length and track of the session) posed in yes/no or five-point Likert scale format (1 = strongly disagree to 5 = strongly agree).
The ARS reports aggregate results for a given question as a percentage of respondents selecting each response category. For the Likert scale questions, we dichotomized the data and used “agree” or “strongly agree” responses to determine respondents who agreed. We calculated the aggregate percentage of responses across sessions for each question using ARS or written survey data. Using the number of participants in each session, we then created a weighted average for each response. The weighted average did not take into account participants who did not respond to any given question, but the average response rate across sessions was above 80%. Our aim was explorative—to better understand areas in need of curricular focus, barriers to disclosure and apology, and implications for adjunctive institutional supports.
To address the limits of survey methodology in gaining a deeper understanding of learners' attitudes, perceptions, and barriers to disclosure and apology, we also allowed time for open discussion after showing the DVD described below to better understand participants' experiences with medical error and the reactions of caregivers, patients and families, and the institution. This helped learners voice their own impressions and concerns and gave us insight into ways in which the so-called hidden curriculum25—the powerful messages and practices of role models and institutional culture that are internalized by learners in the clinical environment—may stifle curricular development efforts. This “focus group” part of the session generated hypotheses and gave us ideas for tailoring the curriculum and shaping future educational interventions to address learners' needs.
At the end of the session, we asked participants to evaluate the curriculum's relevance to their clinical practice and its usefulness for future patient care. Learners responded anonymously to five yes/no or Likert scale questions. The baseline evaluation and the assessment of the curriculum were approved by the institutional review board at both Beth Israel Deaconess Medical Center and Harvard Medical School.
The “When Things Go Wrong” Curriculum
We developed the “When Things Go Wrong” (WTGW) curriculum to deepen the learners' understanding of the human consequences of error for patients, families, and clinicians. We established two tracks: “Teach the Trainee” (addressing students, residents, and fellows) and “Teach the Teacher” (addressing faculty). We designed the latter track to equip educational leaders with experience, tools, and resources to conduct sessions addressing the human dimensions of medical error and disclosure in their own departments or institutions.
To put a human face on medical error, we used filmed narratives of real patients and their families instead of more traditional (and often hypothetical) paper-based cases, so that learners could work with real and immediate emotional reactions to the filmed segments. Just as “standardized patients” and improvisational actors have worked successfully in this domain,26 we felt that real patients reflecting on their experiences would have high impact on learners. We designed the curriculum to be interactive because managing unpredictable circumstances and practicing communication skills were priorities.
The curriculum centers around a DVD-based educational program entitled When Things Go Wrong: Voices of Patients and Families.27 The DVD program includes a 26-minute documentary film as well as shorter vignettes and theme-based segments (4–10 minutes long) created by one of the authors of this article (T.D.). During the film, eight patients and families from diverse geographic and socioeconomic backgrounds tell their stories: Each was injured by a medical error that resulted in severe disability or death. For example, one patient was paralyzed after clinicians ignored symptoms of increased intracranial pressure. Another developed Steven–Johnson syndrome following administration of a medication to which she was known to be allergic. This teaching tool focuses on six central themes—emotions, communication, isolation, trust, apology, and closure—and is accompanied by a learner's/facilitator's guide (written with consideration for adult learning methodologies, and cocreated by one of the authors of this article [S.K.B.]) that features role-play scenarios and questions designed to explore both patient and clinician perspectives. In both tracks, after learners viewed the DVD, a faculty member (T.D. or S.K.B.) trained in the WTGW educational content and facilitation techniques led role-plays and discussion.
We integrated the Teach the Trainee track into six small-group training sessions (8–24 trainees) and one large plenary session for the third-year medical student class at the Beth Israel Deaconess Medical Center and Harvard Medical School. The average length of the trainee sessions was one hour. We presented the Teach the Teacher track at four national educational conferences. Each of those sessions lasted about 90 minutes. All sessions took place between spring 2007 and fall 2008.
Disclosure Implementation Strategy
To relate classroom educational paradigms to real-time bedside discussions and interactions, we believed it was important to include in the Teach the Teacher track a hands-on, guided and supported disclosure model. We drew from the work done by a task force of leaders—from patient safety, quality of care, graduate medical education, nursing administration, social service, risk management, and clinical ethics—that our institution convened to explore and collaboratively develop a disclosure model.
The task force participants (including D.W.M.) decided that the disclosure model should apply not only to medical error but also to adverse events in general, because the needs of patients, families, and clinicians may be similar in both instances and the type of event may not be known at the time of the incident. The model the task force developed, entitled “Communicating About Adverse Events,” is intended to be sensitive to patient and caregiver needs when things go wrong and also to be transparent, interdisciplinary, easy to activate, rapidly responsive, guided and supported by experts in crisis management, and equipped with specific tools for trainees.
The central principle of the model, presented below, is that disclosure should not be a singular or solitary event. Rather, it should be a series of interactions and family meetings that follows a three-step process of acknowledgement (“first disclosure”), then data gathering, and, finally, full disclosure:
- As soon as possible following the event, clinicians should acknowledge the event to establish open communication with the patient and family.
- To provide accurate and timely information, clinicians should explain that not all the facts are yet known and that rigorous information gathering will follow. This approach relieves clinician stress about needing to have all the answers when first meeting with harmed patients and families.
- Clinicians should reassure patients that they will be supported and cared for throughout the process. Patients are assigned a specific liaison to work closely with them, address questions, and help them feel heard on a regular basis.
- Data are gathered to conduct a root cause analysis and to gain a better understanding of the events.
- As appropriate, full disclosure and apology are offered to the patient and family once data analysis is complete.
The task force developed a communication poster with specific written guidelines for trainees and faculty who facilitate the family meetings. The poster helps clinicians identify an adverse event, assess the threshold for disclosure, and get help (the version at our hospital includes a 24-hour pager number designated for communication after harmful events). The poster is available in clinical settings at our hospital, and we used a modified version in Teach the Teacher educational sessions (Chart 1). The approach draws on some principles from “just in time” coaching models28 but can be used in settings where a fully developed coaching system is not available.
Curriculum and learner experience
In conjunction with Teach the Trainee educational sessions, 154 trainees (108 third-year medical students as well as 46 medical and surgical residents) at our hospital responded anonymously to written or electronic survey questions about their experience with medical error and adverse events. Of participating trainees, 93% had witnessed an error and 62% had made a mistake (Figure 1). Of those who made a mistake, 62% reported that they did not apologize to the patient or family. Of all trainees, 20% reported adequate training to respond to the human aspects of medical error. We asked trainees how they would get help after a harmful event: 65% reported they would seek help from more senior doctors, while 26% reported having no set system to get help.
Seventy-five faculty physicians collectively participated in the four Teach the Teacher workshops we presented at national medical education conferences. We surveyed the participants in two of the four conference workshops (one surgical [n = 13], one medical [n = 13]) using a PowerPoint presentation that incorporated the ARS, with a 100% response rate. Of surveyed physicians, 88% reported they had made a medical mistake; 73% reported that an error they had made put the patient at risk for major disability or death. Although none of the participating attending physicians believed patients were more likely to sue if a health provider admits making a mistake, 78% reported having made a mistake without apologizing to the patient or family. Only 21% of participants felt that their hospital or practice setting had adequately trained them to respond to the human aspects of medical error.
A subset of sessions in both tracks included additional questions: 42% of trainees and 55% of faculty physicians were not comfortable with the way the patient involved in the error they made or observed was treated. Comfort discussing error was reported by 55% of trainees and 69% of faculty physicians. We asked about institutional support for physicians: 38% of trainees and 41% of faculty physicians felt that doctors involved in error were adequately supported at their hospital or practice. Across participants of both tracks, 56% of faculty physicians and 9% of surveyed trainees were familiar with the disclosure policy at their hospital or practice. Similarly, 48% of faculty physicians but only 9% of trainees were familiar with the “I'm sorry” law in their state or province29 (Figure 1).
After participating in the curriculum, surveyed participants indicated that the session would affect their own practice as clinicians, independent of their level of training (79% of trainees; 92% of faculty physicians). At the conclusion of the Teach the Teacher workshops, 100% of surveyed faculty-level participants indicated they felt better prepared to teach about addressing the human consequences of medical error.
Themes in open discussions
Recurrent themes emerged during the open discussion portion of the educational sessions. Participants at all levels of training uniformly commented that they had received little or no training on addressing medical error prior to this educational intervention. Frank and open discussions about patient and clinician experiences with error were often missing in their practice settings, even in hospitals or practices where errors themselves were openly discussed:
It's refreshing to have a discussion like this, because I feel like except for M and Ms [Morbidity and Mortality conferences], which really focus on the actual mistake from a medical perspective, we rarely, if ever, talk about how the mistake affects patients or doctors.
I sat on the committee that reviewed the M and M case; now that I think about it, we never once discussed if and how the error was disclosed to the patient/family.
In the sessions, many participants described debilitating guilt, fear, and isolation following medical error.
It has taken two years for me to say anything to anyone, but I cannot tell you how alone I felt and how guilty since the mistake I made happened.
“Can a resident be sued?” one trainee asked, worried that mistakes made in training carry the risk of liability. Several trainees struggled with the notion of “error” in the context of a training hospital:
How do you define “error” for a trainee?
If it takes me three tries to find the cervix when I am doing a Pap smear, is that an error?
The catch-22 of needing experience to gain proficiency, but needing proficiency to safely gain experience, arose frequently, especially as related to procedures:
Preventing a renal fellow from doing a renal biopsy in July doesn't solve the problem; if he/she is doing his/her first procedure in December, he/she is still inexperienced … it is still the first one.
Finally, trainees routinely discussed barriers to “speaking up the ladder,” including fear of a poor evaluation, power and hierarchy dynamics in clinical medicine, and disincentives to add work to their busy services or burden their clinical teachers.
The last thing I want to do is add stress to my already overworked intern's or resident's day.
Despite the adoption of important prevention strategies, mistakes still occur in medical practice. Our findings—that 93% of trainees have witnessed error and 62% have made a mistake (notable to us because half the trainees had only three months' experience on the wards at the time of the survey)—underscore the pervasive nature of experience with error. Of those trainees who made mistakes, 62% did not apologize and 26% were not sure how to get help. These findings highlight the need for a disclosure curriculum early in medical education.
Our curriculum focuses on apology as part of disclosure because patients (including those in the film) and scholars alike recognize an expression of regret as an important component of effective disclosure.30–32 Even when clinicians disclose error, they may not apologize.14 Such disclosures may fall short of meeting patients' expectations.33
Our results are similar to other studies focusing on trainees8,13,19,20,34 and demonstrate an ongoing, substantial deficit in disclosure practices, despite more than 15 years since publication of the earliest studies. At a time when increased attention is being paid to disclosure and apology, actual practices among faculty and trainees suggest that good role models, support systems, and adequate education strategies are lacking. This article offers three novel components to help improve disclosure: a curriculum to shed light on the human dimensions of medical error, concrete suggestions for implementing a disclosure policy that translates educational theories into bedside practices, and the discovery that an intervention targeting teachers—in conjunction with a program directed at trainees—may be necessary to provide disclosure role models and support for trainees. Our curriculum and disclosure model can be modified to suit various levels of training and different teaching venues, ranging from small-group sessions, seminars, workshops, retreats, or support groups, to large orientation sessions, faculty development programs, or a grand-rounds-type format.
Enriching the educational experience with patient narratives
Clinicians may shy away from challenging discussions focusing on the human cost of error, partially to cope with their own shame, guilt, fear, or lack of understanding. Although mindful communication is central to effective disclosure, institutional pressure to “choose words carefully” can be extreme14,33 and may also restrict a physician's comfort with disclosure and apology. These forces cause damaging silence and distancing between patients and doctors, leading to increased distrust on the part of patients and ineffective disclosures on the part of physicians.
Sharing actual patients' filmed narratives with clinicians is a particularly important part of our curriculum because the filmed remarks provide both specific and rich context from which to launch discussions about harmful events. Filmed patients provide important messages for clinicians. In the DVD we used, a man who suffered third-degree burns from a heating blanket applied to anesthetized skin notes that it is important “to go see the patient more often, not less often” following a medical error. A patient who ultimately died of infection after intestinal rupture during surgery states, “You have no idea how far a ‘sorry’ will go.”27
Old and new tools for teaching about error
The one-room schoolhouse.
We have also used the WTGW curriculum in presentations to mixed faculty–trainee audiences, with dedicated time for interactive discussion. (These sessions were not included as part of this study because attendees were not surveyed.) Such “one-room schoolhouse” sessions allow trainees to witness and integrate the reactions and responses of senior physicians—their role models—and of their peers, which may normalize discussions about error in other clinical venues. At a grand-rounds-type WTGW session in our hospital, one senior clinician commented, “All I kept thinking while watching the film is … ‘That could have been me.’” A resident said, “If it weren't for this session, I wouldn't have known what others have experienced.”
The electronic ARS.
The electronic ARS is uniquely suited to discussions focused on the delicate subject of medical error, given its anonymity and ability to instantaneously display, through a PowerPoint slide, aggregate audience responses to sensitive questions such as “Have you made a medical mistake?” It provides the discussion facilitator the opportunity to incorporate into the session data that are likely more reliable than those coming from asking for a show of hands. Such aggregate data immediately level the discussion because the experience with error is nearly universal for trainees and attending physicians. In addition, the ARS provides direct real-time feedback to discussion leaders concerning participant knowledge, attitudes, and comfort with the learning agenda.
As we presented the WTGW curriculum to trainees and staff physicians with widely varying levels of experience, we were struck by the similarity of results in several domains, including perceptions of adequate training (20% of trainees, 21% of faculty) and lack of apology following a medical mistake (62% of trainees, 78% of faculty). These results highlight a key finding: the potential deficiency of disclosure role models for trainees. Well-meaning clinical faculty simply may not have the experience (or training) to lead a disclosure discussion effectively. Further, some faculty physicians tend to shield trainees from delicate or difficult situations by choosing to leave them out of disclosure-related family meetings, especially when the trainee is directly or indirectly responsible for the mistake. Although trainees may worry about being “humiliated in front of the family,” foregoing the family meeting may result in a missed opportunity for learning and for healing. Even when trainees are not directly involved in error, they may not be witnessing disclosure and apology— data suggest that many of their teachers are not having such discussions with their own patients. Although medical educators often think first (and sometimes only) of focusing educational programs on trainees, disclosure and apology initiatives should target all levels of training in parallel. Recent data also highlight the importance of providing feedback to trainees when they participate in disclosures outside the classroom setting.7
Second, we found illuminating that the majority of trainees indicated they would turn to their senior doctors for help after an adverse event, while the majority of faculty physicians reported that they feel themselves underprepared to respond to such events. In addition, it was striking that 26% of trainees reported having no system for finding help after an adverse event. All trainees should know where to turn when they make a mistake. It is critical to establish a clear, well-publicized plan with information detailing whom to call (preferably a 24-hour pager number) when things go wrong, so that trainees and clinicians are not trying to figure that out in the midst of crisis.
Third, we found that the debilitating guilt, fear, and isolation that often characterize the patient and family experience with medical error (depicted in the When Things Go Wrong DVD) are frequently paralleled by the physician experience (Figure 2). During the discussions we led, trainees and faculty physicians revealed consistently that they felt guilty, afraid, and alone. But even though there are striking similarities in what clinicians and patients feel, these two injured parties often lack an effective means of communication. While clinicians and patients also each have unique needs after error and require specific support systems to address these needs,35,36 the first step in addressing the human dimensions of medical error may be as simple as giving them permission to talk to one another and to representatives of the institution. Despite an ongoing emphasis on discussing and learning from errors, roughly 30% of faculty physicians and nearly 50% of trainees did not even feel comfortable discussing error with their colleagues. Providing a formal, safe, and recognized means of communication sends a powerful message that their views are important and respected. Patient and clinician comfort with voicing concerns may both be important metrics in work to develop an institutional “culture of safety.” Patients' and clinicians' first-hand narratives about their experiences offer a wealth of relatively untapped resources to guide programmatic reform. The opportunity to discuss what happened may also ultimately play an important role in decreasing both lawsuits and physician burnout.
Disclosure training programs must be sensitive to the unfolding relationship between litigation and physician–patient communication. Studies suggest that in addition to seeking compensation, patients sue because they feel that information was withheld—they were not told the whole story; no one really explained what happened and why.31 They feel a lack of empathy from their providers or health care system and want to see someone held accountable for the error, in the hope of preventing similar incidents in the future. A strong institutional commitment to full disclosure and sincere apology is therefore critical, because partial disclosure or rote apology may leave patients and families skeptical and unfulfilled. The disclosure process is further complicated by the differences between what clinicians say and what patients actually hear.37
Finally, although educators focus on designing specific curricula, the hidden curriculum may be more commanding and influential than structured syllabi on trainees. Our sessions revealed novel aspects of medical error for trainees, and the medical student in particular. The establishment of a shared-responsibility approach to reporting and disclosing error may face significant barriers in hierarchical systems where students rely on their superiors for evaluations, and errors—whether made by students or their superiors—are viewed as performance blemishes and liability risks. In medicine, a highly competitive culture deeply entrenched in power and hierarchy, getting a good grade and staying “in line” may trump speaking up.
Our study has several limitations. Given the small sample sizes and diverse types of learners, ranging from students to attending physicians, we can make no statistical inferences; our assessments of learner perceptions, experiences, and attitudes are intended primarily to be hypothesis generating. In addition, our findings are likely colored by sampling bias. Although our results are similar to those published from other sites,8,19 we surveyed trainees at only one teaching hospital and one medical school, and the respondents were likely influenced by local culture. In addition, although educators attending our national conference workshops represented many institutions, they likely had underlying interest in or experience with the topic. Given such potential biases, we found even more striking the participants' consistent reports of inadequate communication after harmful events and lack of prior education about the human dimensions of medical error. Assessment of whether our WTGW curriculum and/or the disclosure model actually improve the rate or quality of bedside disclosure requires further study.
In our sessions, only 56% of faculty physicians and 9% of trainees were familiar with their institution's disclosure policy. Our results suggest that institutions must invest further in preparing their clinicians and trainees to realize effective and comprehensive implementation of disclosure policies.
Our results also raise additional questions for research. Aside from educational sessions, what are the optimal venues to provide clinicians with safe and timely opportunities to talk about their experiences following adverse events? Permission to talk may be an important component to healing for both doctors and patients: Who should hear these accounts? As educators strive to design effective curricula addressing medical error and adverse events, how can we better understand the mismatch between educational paradigms and actual conversations at the bedside? What effects does the hidden curriculum have on disclosure practices and litigation? When we are equipped with a better understanding of these issues, we can begin to approach “unhiding” the barriers that still limit communication after harmful events, and work toward promoting full and open healing for doctors and patients alike.
The authors thank Nadine Farag and Anna Mattson-DiCecca for assistance with the program and the manuscript; Tom A. Augello, Grace Huang, MD, and Lori R. Newman, MEd, for their contributions to the When Things Go Wrong curriculum; and Thomas Gallagher, MD, for his thoughtful review of the manuscript.
Supported in part by grants from the Sergei S. Zlinkoff Fund for Medical Education and the Harvard Risk Management Foundation.
This study was approved by the institutional review board at both Beth Israel Deaconess Medical Center and Harvard Medical School.
Presented in part as workshops at the 2008 Society of General Internal Medicine annual meeting, Pittsburgh, Pennsylvania; the 2008 American Program Directors of Internal Medicine meeting, Lake Buena Vista, Florida; the 2008 Association for Program Directors in Surgery meeting, Toronto, Ontario, Canada; and the 2008 American Academy of Communication in Healthcare meeting, Milwaukee, Wisconsin.
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