Health care organizations should disclose medical mistakes that affect multiple patients even if patients were not harmed by the event, according to an AHRQ-funded research paper published in the September 2 issue of the New England Journal of Medicine.
Medical mistakes that affect multiple patients, known as large-scale adverse events (LSAEs) to researchers, are incidents or series of related incidents that harm or could potentially harm multiple patients. These events, which can include incompletely sterilized surgical equipment, poor laboratory quality control and equipment malfunctions, are often identified after care has been provided and can affect thousands of patients.
"It's clear that health care organizations face a dilemma regarding disclosure of large-scale adverse events - whether these events lead to patient harm or not," said AHRQ Director Carolyn M. Clancy, M.D. "It's not always clear how to do that in a way that minimizes risk to the patient and the organization, but this research can help."
According to researchers from the University of Washington, Seattle, disclosure policies for adverse events that affect individual patients are becoming more common among health care organizations but often fail to address how to disclose LSAEs that could have affected many patients.