Case Study: Disclosure Of Adverse Events

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Running head: DISCLOSURE OF ADVERSE EVENTS AND ITS RELATIONSHIP Disclosure of Adverse Events and Its Relationship with Justice in Health Care Health Care Systems and Environments Graduate Program in Health Care Management Case Study Disclosure of Adverse Events and Its Relationship with Justice in Health Care Providing safe quality care is a priority in health care. Unfortunately, errors occur. Adverse events are unplanned negative outcomes, however, they are not the intention of health care personnel. Research has shown that fatigue and stress account for most errors. Today’s fiscal environment adds an additional stressor to an already burdened infrastructure. Pressures in healthcare fields exist and mistakes are…show more content…
403). Health care workers will not feel safe in situations where blame or punishment is the norm. Maintaining a culture of non-punitive behavior and “just” practice will improve reporting of adverse events, while unfair practices will deter reporting measures for fear of ramifications. The inclination to blame is rooted in hindsight bias and it is difficult to understand that the situation faced by an individual at the time of the event is very different than perceived after the event (The Institute for Safe Medication Practices [ISMP], 2000). If health professionals do not feel that they can expect fair treatment when they report safety incidents, mandatory reporting will only increase the level of fear and drive valuable safety-related information underground (Weiner et al., p.…show more content…
. Retrieved October 13, 2008, from Fein, S. P., Hilborne, L. H., Spiritus, E. M., Seymann, G. B., Keenan, C. R., & Shojania, K. G. et al. (2007). The many faces of error disclosure: A common set of elements and a definition. Society of General Internal Medicine, 22 755-761. doi:10.1007/s11606-007-0157-9 Hofmann, P. B. (2005). Acknowledging and examining management mistakes. In P. B. Hofmann & F. Perry (Eds.), Management mistakes in healthcare (pp. 3-27). Cambridge, United Kingdom: Cambridge University Press. Leape, L. L., & Berwick, D. M. (2005). Five years after to err is human: What have we learned? JAMA, 293(19), 2384-2390. Retrieved from Sexton, J. B., Thomas, E. J., & Helmreich, R. L. (2000). Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. BMJ: British Medical Journal, 320 745-749. Retrieved September 19, 2008. doi:10.1136/bmj.320.7237.745 The Institute for Safe Medication Practices (2000). Discussion paper on adverse event and error reporting in healthcare. Retrieved September 19, 2008, from

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