Berwick DM. An Agenda for Patient Safety and Quality in Wales. Plenary address to the Welsh Assembly Government and Wales Centre for Health in Cardiff, Wales. Institute for Healthcare Improvement unpublished manuscript; January 15, 2007.

In January 2007, Dr. Donald Berwick, President and CEO of the Institute for Healthcare Improvement, addressed senior government and health care leaders at a conference in Wales to explore establishing a national agenda for patient safety and quality. The Welsh Assembly Government and the Wales Centre for Health asked Dr. Berwick to speak to the necessary role that leaders must play in supporting effective system redesign and continual improvement in health care.

Reason J. Beyond the organisational accident: The need for "error wisdom" on the frontline. Quality and Safety in Health Care. Dec 2004;13 Suppl 2:ii28-33.

Complex, well defended, high technology systems are subject to rare but usually catastrophic organizational accidents in which a variety of contributing factors combine to breach the many barriers and safeguards. To the extent that health care institutions share these properties, they too are subject to organizational accidents. A detailed case study of such an accident is described.

Wojcieszak D, Banja J, Houk C. The Sorry Works! Coalition: Making the case for full disclosure. Joint Commission Journal on Quality and Patient Safety. Jun 2006;32(6):344-350.

The Sorry Works! Coalition, an organization of doctors, lawyers, insurers, and patient advocates, is dedicated to promoting full disclosure and apologies for medical errors as a "middle-ground solution" in the medical liability crisis. If a standard of care was not met (as shown by a root cause analysis) in a bad outcome or adverse event, the providers (and their insurer) should apologize to the patient/family, admit fault, provide an explanation of what happened and how the hospital will ensure that the error is not repeated, and offer compensation. The Sorry Works! protocol is based on the disclosure program developed at the Department of Veterans Affairs Hospital in Lexington, Kentucky.

Mazor KM, Reed GW, Yood RA, et al. Disclosure of medical errors: What factors influence how patients respond? Journal of General Internal Medicine. Jul 2006;21(7):704-710.

This study sought to determine whether full disclosure, an existing positive physician-patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influenced patients' responses to medical errors.

Mazor KM, Simon SR, Yood RA, et al. Health plan members’ views on forgiving medical errors. American Journal of Managed Care. Jan 2005;11(1):49-52.

The authors’ findings suggest that patients are not likely to forgive a physician in circumstances in which they suspect incompetence, inattention, or a lack of caring on the part of the physician involved. A more comprehensive understanding of forgiveness and the effect of forgiveness on the physician-patient relationship following a medical error is needed.

Lesnewski R. A piece of my mind: Mistakes. Journal of the American Medical Association. 2006 Sep;296(11):1327-1328.

The author describes a scenario in which medical students discuss what actions the physician of an imaginary patient should take, if any, to acknowledge a medical mistake that was unlikely to cause harm to the patient. The most troubling part of the experience, claims the author, was “the ease with which a group of medical students defended a kind of deception.”

Lazare A. Apology in medical practice: An emerging clinical skill. Journal of the American Medical Association. 2006 Sep;296(11):1401-1404.

The author states that an effective apology is one of the most profound healing processes between individuals, groups, or nations. It may restore damaged relationships or even strengthen previously satisfactory relationships. For the offender, offering an apology may diminish guilt, shame, and the fear of retaliation. For the offended party, receiving an apology may remove a grudge with its corrosive anger, thereby facilitating forgiveness and reconciliation.

Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: How physicians would disclose harmful medical errors to patients. Archives of Internal Medicine. Aug 2006;166(15):1585-1593.

A gap exists between patients' desire to be told about medical errors and present practice. Little is known about how physicians approach disclosure. The objective of this study was to describe how physicians disclose errors to patients.

Conway J, Nathan DG, Benz EJ, et al. “Key Learning from the Dana-Farber Cancer Institute’s 10-Year Patient Safety Journey.” American Society of Clinical Oncology 2006 Educational Book, 42nd Annual Meeting, June 2-6, 2006, in Atlanta, GA. 2006:615-619.

The tragic chemotherapy overdoses to Betsy Lehman and Maureen Bateman, which were discovered at the Dana-Farber Cancer Institute (DFCI) in February 1995, are well known. During the 10-year anniversary of these events, DFCI leadership assessed its patient safety learning, identifying the six most critical elements of learning.

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Berlinger N, Wu AM. Subtracting insult from injury: Addressing cultural expectations in the disclosure of medical error. Journal of Medical Ethics. Feb 2005;31(2):106-108.

This article proposes that knowledge of cultural expectations concerning ethical responses to unintentional harm can help students and physicians better understand patients’ distress when physicians fail to disclose, apologize for, and make amends for harmful medical errors. The article recommends that learning how to disclose errors, apologize to injured patients, ensure that these patients’ needs are met, and confront the emotional dimensions of one’s own mistakes should be part of medical education and reinforced by the conduct of senior physicians.