Open Dialogue with Patients during Disclosure Essential to Quality and Safety Efforts

When a genuine dialogue is achieved during the disclosure of medical mistakes, patients and family members can play a critical role in quality improvement and patient safety, concludes an article published in the October 2012 Joint Commission Journal on Quality and Patient Safety. The article discusses a case study in which a woman’s husband died from a vasopressin overdose while hospitalized following a hip replacement procedure. During the hospital’s disclosure process, the woman asserted that the drug overdose was not the main problem in the situation and that she believed a greater communication breakdown occurred that led to the overdose. In a series of interviews, she noted that, first, her attempts to convey concern about the patient’s worsening condition and confusion on the ward were not acknowledged, or were dismissed, as was her concern that her neutropenic husband was placed in a room with nonneutropenic patients.