Hospital Practices Article

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H O S P I T A L D I S C L O S U R E

Hospital Disclosure Practices:Results Of A National SurveyMost hospitals disclose harm to patiehts at least some of the tim e,this 2002 survey finds.

by Rae M. Lamb, David M. Studdert, Richard M.J. Bohmer, Donald M.

Berwick, and Troyen A. Brennan

ABSTRACT:New patient safety standards from JCAHO that require hospitals to disclose topatients aii unexpected outcomes of care took effect 1 July 2001, In an early 2002 surveyof risk managers at a nationally representative sample of hospitals, the vast majority re-

ported that their hospitai's practice was to disclose harm at least some of the time, al-

though only one-third of hospitals actually had board-approved policies in place, iVlore thanhalf of respondents reported that they wouid always disclose a death or serious injury, but

when presented with actuai ciinical scenarios, respondents were much less likely to dis-

close preventabie harms than to disclose nonpreventabie harms of comparable severity.Reluctance to disclose preventable harms was twice as likely to occur at hospitals havingmajor concerns about the maipractice implications of disclosure.

TELLING PATIENTS ABOUT UNANTICIPATED OUTCOMES of Care i s an es-tabUshed ethical expectation for physicians and nurses.' However, deci-sions about the appropriateness, timing,and content of disclosure have tra -

ditionally remained a private matter, left to the preferences of individual cliniciansand health care institutions. Advances in informed-consent law and patients' rightsover the past thirty years appear to have had httle demonstrable impacton provid-

ers' willingness to disclose information about errors and adverse outcomes.^Today providers face new constraints in the area of disclosure.The Institute ofMedicine's (IOM's) 1999 report.To Err k Human, prompted calls for greater trans-parency in health care.^ In July 2001 the Joint Commission on Aecreditation ofHealthcare Organizations (JCAHO) responde d by introducing new patien t safetystandards, including a requirement th at all unanticipated outcomesof care be dis-closed.*' Although the requirement itself doesnot specify the need to disclose poor

Roc hamb is a hedtk correspondent or Radio New Zealand in Wdlif^cm. Da^ Studdert is an assistant

p p f ^ fHealth, in Boston. Rkhani B ohnir is an assistant professor of technology and operations management at the

Harvard Business S chool Don Berwtcfe is presidmt anichie/execultve affiixr ofd\e Institute/or Healthcfifc

Improvement in Boston. Troy Brermcm is aprofessor of medicine at Harvard Mcdiall Schoo l and a professor of law

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I N F O B M A T I O N

outcomes, JCAHO has clarified that a ccredited organizations must tell pa tientswhen harms occur to them in the course of treatment.'

To investigate how hospitals are dealingwith this standard, we surveyed riskmanagers from a nationally representative sample of hospitals. We sought infor-mation on how and what hospitals were disclosing six months after the JCAHOstandards took effect. We also sought to gauge the importance of several potentialbarriers to disclosure, including fear of litigation.

Study Methods Suivey design. We developed the survey instrument through extensive con-

sultation vvith physicians, risk managers, senior hospital administrators, patients,and experts in patient safety and quahty improvement. A draft version was pre-tested on chief medical officers and risk managers a t four different hospitals to de-termine validity and the type of respondent best able to answer the questions. Wejudged risk managers to be the most kno^vledgeable and appropriate respondents.

The survey comprised three sections.'^ The first section asked respondentsabout their ins titutional policies and practices related to disclosure. We defineddisclosure as 'honestly telling patients or their families about unexpected harm thatoccurs as a result of treatme nt or care, not directly because of a patient's illness orunderlying condition." Section two elicited specific information on disclosurepractices, including respond ents' propensity to disclose harms of varying severitylevels, the elements commonly included in disclosures (for example, explanation,apology, acknowledgement of harm, and un dertakin g to investigate), and actionsthat com monly accompany a disclosure (for example, pay costs of associated care,pay compensation, and provide details of support groups). We also asked respon-dents to estimate the likelihood that each of four different clinical scenarioswould be disclosed at their institution. The scenarios mixed combinations of se-verity and preventabiHty.' Section three elicited information about the actual fre-quency of disclosure, trends in disclosure practice, barriers to disclosure, and per-

ceptions of malpractice risk. Sampling and administration. We used a stratified random sampling ap-

proac h to select 500 hospitals from the American Ho spital Association (AHA) data-base of 1,218 medical/surgical hospitals with 200 or more beds. One stratum wasbased on facility size, with half of the sample coming from hospitals with 200-399beds and the other half from hospitalswith 400 or more beds. A second stratum,based on region, ensured a representative geographic spread.

Exclusion of Veterans Affairs (VA) hospita ls and several other ineligible in stitu -tions resulted in a sample of493 hospitals (245 hospitals wit h 200-399 be ds; 248hospitals with 400 or more beds).^ We derived sampling weights to allow adjust-ment of the survey results to represent the larger sample of AHA hospitals vvlth200 or more beds. Finally, using AHA contact information, we mailed the surveyto risk managers at each of the sampled hospitals in January 2002. Two weeks

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later a second copy of the survey was sent to non responden ts, with intensive tele-phone follow-up.

Analysis. We used existing descriptive data on the sam pled hospitals from theAHA's annual survey for 2000 to categorize them by ow nership (for-profit, not-for-profit, and government), whether or not they were academic medical centers(AMCs), number of admissions, and region (using the four census regions). We cre-ated a binary variable separating the hospitals situated in the sixteen states withmandatory reporting laws in place at the time of our survey from those in stateswithout such laws.'

We used the STATA statistical package to conduct weighted analyses of thesurvey response data. W e calculated descriptive statistics summarizing disclosurepoUcies, practices, and experience. We also used c hi-square tests to test for statis-tically significant differences in responses to the clinical scenarios based on re-spondents' m alpractice perceptions and behefs. Finally, we used logisric regres-sion to investigate factors associated with divergent reporting practices amongrespondents.

Results

Of the 479 surveys mailed, we received 338 replies, yielding 245 usable re-sponses for analysis: a comp letion ra te of51 percent. ' The hospital charac teristicsfor this respondent group closely resembled those of the nonrespondents withtwo exceptions: For-profit hospitals were underrepresented among respondents(p = .05) and AMC hospitals were overrepresented (p < .001) (Exhibit 1).

Disclosure policies and practices. Approximately one in three hospitals hadboard-approved disclosure policies in place, and nearly half were in the process ofdevelopinga formal policy (Exhibit2). The remainder hadno disclosure policy Nev-ertheless, 54 percent of respondents reported that it was routine practice at theirhospital to tell patients or their famihes when a patient had been harmed by care.Another 44 percent reported that such disclosures occurred some of the time, leav-ing only five respondents who said that their hospitals did not disclose harms.

Wi th respect to the types of harms generally disclosed, 65 percent of hospitalsreported always disclosing death or serious injury. A smaller propor don alwaysdisclosed in the case of serious, short-term harms (E xhibit 2).

The most common elements of disclosures were an explanation, an undertak-ing to investigate the Incident, an apology, and an acknowledgement of harm. Rel-atively few respo ndents repo rted tha t a typical disclosure included a declarationof responsibihty for the harm or a promise to share investigation results w ith thepatients or their families. However, thirty-seven respond ents (17 percen t) indi-cated tha t disclosures at their hospitals routinely included all six of the elementswe queried them about. The majority of hospitals also met the costs of health careassociated with th e harm, but few paid com pensation or provided details of out-side support groups, regulatory agencies, or lawyers.

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I N F O R M A T I O N

EXHIBIT1Characteristics Of Sampled Hospitals, Respondents And Nonreapondente

CharactarMtcs

Mean number of beds200-399400 ov more

Mean number of admissionsLess than 20.00020,000 or more

iHospital ownership'^

Government (excluding federal)For-profitNot-for-profit

Academic medical centers"Mandatory reporting laws

RegionNortheastMidwestSouthWest

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EXHtBfT2Hospttal Disclosure Policies And Practices

Policy/practice

Policy statusEstablishedUnder developmentNone

PracticeRoutinely discloseSometimes discioseDo not distose

Number ofhMpttatswrfth

8611 1

44

132108

5

Percent ofhospital* wttlipracttce"

36%4419

5444

2

Tipes of harms disciosedDeath/serious injury

AlwaysFreq uent iy/somet imesNever

Serious shott-term harmAlwaysFrequentlyNever

Elements of typical disclosure"ExplainUndertake to investigateApoiogizeAcknowiedge harmPromise to share Investigation resuitsTake responsibility for harm

15 984

1

9015 4

0

22 421 216 116 0

9476

Actions foiiowing typicai disclosure"

Pay compensationProvide details of support groupsProvide regulatory agencies'ctetaiisProvide information about lawyers

SOURCE: Auttiot^' analysis.' Weighted. The frequencies and percentages may not sum to 245 and 100 percent, respectiveiy, because of a smali numberof missing values and "don't know" responses.Do not sum to 100 percent because respondents had muitipie options.

hospitals were likely to disclose serious and minor harms when those harms werepreventable, the overall propensity to disclose preventable harms was lower thanthe propensity t o disclose nonpreventable harms of corresponding severity (for seri-ous harms, 90 percent versus 94 percent; for minor harms,80 percent versus 97 per-cent). Indeed, specific within-hospital comparisons across the injury scenariosshowed that more than half of hospitals were less likely to disclose the preventableharms than the nonpreventable ones.

Exhibit 4 also contrasts responses to the different clinical scenarios across tw ogroups of respondentsthose who believed that disclosure increased the risk oflitigation and/or wh o cited malpractice concerns as an institutional barrier to dis-closure, and those who reported no such malpr^tice concerns. A significantlysmaller proportion of the group concerned about malpractice was likely to dis'

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EXHIBIT3Hospitals' Experiences With And Beliefs About Disclosure

Experlence/bllef

Mean number of disclosures5 per 10,000 admissions

Trend in numbef of disclosures over past 2 yearsIncreasedDecreasedNo change

Adverse publicity about disclosed harms

Impact (of publicity) on future willingness to disclose"LessMoreNo impact

Number of

hospitals

126119

1702

71

79

21858

Percent Of

51 %

49

701

29

28

32174

Main barriers to disclosure'^Malpractice fears 187Staff opposition 126Fear of scaring patiente 63Physicians/hosp ital had differen t malpractice insurers 54Cost concerns 21

Beliefs about impact of disclosure on malpractice rIncreasedUnchar.gedDecreased

isk

92

6 38 0

37

25

33

SOU fti Authors' analysis.

NOT: The mean number of disclosures was 7.4.

"Weighted. The frequencies and percentages may not sum to 245 and 10 0 percent, respectively, because of a small number

of missing values and 'dm i't know" responses.

"This applies oniy to tbe 79 respondents who reported publicized harm." Do not sum to 100 percent because respondents had multiple ootions.

close preventable serious harms (p = .02). In addition, the group of institutionsworried about litigation was significantly more likely to exhibit a preference fordisclosing nonpreventable ha rms over preventable ones(p = .02).

Multivariate analysis confirmed that malpractice concerns were associatedwith hospitals' being significantly less likelyto disclose preventable harms thannonpreventable ones (ockls ratio2.03, p = .03)." No other hospital chara cteristicsha d a statistically significant association with reluctanceto disclose preventableinjury.

Discussion

The explosion of public interest in medical error following the 1999 IOM repor tgalvanized attention on consumers' expectations around disclosure of medicaler-ror. Several years later it is timely to ask w hat has changed for patients, if one mea-sure of the report's success isthe extent to which hospitals own up to error, thenour study provides some enco ur^^ ii^ results. Virtually all (98 percent)of the re-spondents in our study reported disclosing harms to patientsat least some of the

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EXHIBIT4Hospitals' Willingness To Disclose Harms, By Level Of Concern About Malp ractice

Disclosure re^Hmse to

harm scenarios

Likeiy to disciose preventabieserious harni

Likeiy to disclose preventableminor harm

Likely to disdose nonpreventabieserious harm

Likeiyto disclose nonpreventabieminor harm

Less likely to disclose preventablethan nonpreventabie harms'"

Number of

hospHals

( N - 2 4 5 )

21 9

195

23 2

23 6

12 9

Percent of

hospitals

94

97

53

Percwrtofho^ritalsconcerned aboutmslfKactlce '*

(n - 77)

90

95

65

Percent ofhospitals notconcernedaboutmalpractice*(n -168 )

96

98

47'=

SOURCE: Authors' analysis,' Weighted.' Consists crt responderrts wtio reported Oelief that disclosure increased their hospitars probability of being sued and notedconcerns about lawsuits as a main barrier to developing and implementing a disclosure policy.'p < ,05 n adjusted Pearson's chi-square test for difference with "concerned at>out malpractice' group."Consists of respondents who reported that they were likely to disclose the scenario Involving nonpreventabie serious harm ornonpreventabie minor harm, but unlikely to disclose the corresponding scenarios involving preventable harm.

time, and 80 percent had disclosure policies in place or under development. Thefact that 44 pe rcent of surveyed hospitalsv ere in the process of developing disclo-sure policies at the time of our survey suggests that th e IOM's message, togetherwith the patient safety initiativesit has sparked at JCAHO and other agencies,isdriving substantial reform. Follow-up investigationof the final form and c ontentof th e many institutional policies that were buddingat the time of this surveywould add greatly to our knowledge in this area.

Disclosure frequency. Our stu dy also suggests that th ere is still a long way togo before serious harm is consistently and thoroughly disclosed to pa tients. For ex-ample, our respondents reported considerably fewer disclosures than wouid be ex-pected from epidemiologic estimatesof general rates of iacrogenic Injury. Leadingstudies of medical injury from Utah/Colorado and New York, which were usedasthe basis of the IOM estimates, found that adverse events occurredin 2.9 perce ntand 37 percent of hospitalizations, respectively.'^ These rates imply 290-370 poten-tially disclosable harms per 10,000 admissions. Adjusting the estimatesof adverseevents to include only the most serious incidents suggests approximately 44-66medical injuries per 10,000 admissions that shou ld be disclosed. Only two hospitalsin our study were in this range. In fact, only sixteen hospitals (less than10 percent)reported making more than twenty disclosures per year.

Alternative explanations certainly existfor the gap between these estimatesand the number of disclosures reported in our survey. Specifically, the risk manag-

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"The openness of providers about error depends on reforms of themalpractice system that can mitigate the fear it generates."

ers we surveyed may not be aware of all disclosures in their hospitals, and rates ofinjury in our national sample of hospitals may be louver than those previouslyidentified in New York, Utah, and Colorado. Nevertheless, it seems likely that dis-closure of the most serious events would come to risk managers' attention. H ence,the relatively low rate of disclosure reported in our study raises questions a boutboth the e xtent to w hich harms are recognized by hospital staff an d the frequencywith which known harms are disclosed.

The malpractice barrier. Hospitals' heightened reluctance to disclose pre-ventable harms raises further questions. Of all hospital and respondent characteris-tics we examined, fear of litigation was most strongly associated with this reluc-tance. The challenge that the medical malpractice environment poses for patientsafety efforts has been well docum ented, as have the fears of physicians." Some con-clude that the cultural change necessary for major safety improvements cannot oc-cur against the backdrop ofa litigation system that induces secrecy and silence, andthey stress the need for malpractice reform.^**

A different, and increasingly prominent, tw ist on the malpractice issue is thatclinicians' and hospitals' perceptions about litigation risk may be worse than thereality." The experience of theVA Medical Center in L exington, Kentucky, wherea proactive disclosure policy has reportedly not resulted in higher hability pay-ments at the institutional level, is widely cited."^ There is also growing anecdotalevidence from some nongovernmental hospitals, such as the Dana Farber C ancerInstitute in B oston, that their policies to disclose have not been accompanied by abig increase in lawsuits.' ' Another Massach usetts hospital. Sturdy M emorial, saysthat it found owning u p to error a positive experience.'^ These reports find sup-port in studies suggesting that patients who are dealt with openly and honestlyare less likely to sue.'^

Our findings do not contradict any of this. However, they do suggest that re-gardless of whether or not providers' concerns about malpractice are wellfounded, litigation fears continue to pose a serious obstacle to transparen cy aboutpatient injury. Importan t breakthrough s in the openness of providers about errormay thus depend on reforms of the malpractice system that can mitigate theblame, guilt, and fear it generates." Malpractice reforms area top priority forpolicymakers at the federal and state levels.^' However, these proposals tend to fo-cus on the imm ediate problem of claims volume and awa rd size, not the more fun-damental issue of the barriers the system creates for advances in the patient safetyarena.

Adv eise publicity. There is ongoing debate about the impact of adverse pub-licity on patient safety advances, with some commentators arguing that it provides

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important impetus and others that it may cause inertia,^ Our survey results suggestthat such coverage has Uttle effect in the area of disclosure. Only two respondentsindicated that thdr hospital's willingness to disclose had decreased as a result ofprominent reporting of cases of harm.

Study limitations. There are several Hmitations to our study. A survey com ple-tion rate of 51 percent introduces the possibility of nonresponse bias. The similarityin hospital characteristics between respondents and nonrespondents provides somecomfort in this regard, although for-profit hospitals and non-AMCs were under-represented among respondents, and their disclosure behavior may have differedsystematically.^^ However, the fact tha t a substantia l propo rtion (27 percent) of theninety-three respondents who said that they would not complete the survey citedlegal concerns as the reason bolsters rather than undercuts our findings about theimpact of litigation fears on willingness to disclose.

Second, the findings may also be limited because the survey is focused on riskmanagers. Our decision to target this group was based on a recognition that riskmanagers in many hospitals are at the center of efforts to develop formal writtendisclosure proce sses and policies to comply w ith the new JCAH O standards.^"* Al-though physicians have not always viewed hospital risk managers as advocates ofdisclosure, a previous survey of 650 risk managers suggested that their personalsupport of disclosure is consistent with that of other managers and may even ex-ceed the willingness of their organizations to disclose.^' Finally, we used only fourinjury scenarios to measure the willingness to disclose preventable versus non-preventable harm. These findings should be explored further by testing a widerrange of possible clinical events.

THE RESULTS OB THIS SURVEY give some cause for optimism; A large pro-portion of hospitals appear to be telling patients about harms caused bymedical care. Moreover, the far-reaching impact of the IOM report and the

JCAHO standard are evident in the sizable number of hospitals that are in theprocess of developing disclosure policies. However, it is clear that the spread andexecution of such policies and practices fail short of the standards that wo uld beexpected in a therapeutic model based on partnership and patient empower-ment.^'

There is stiU marked variation in the types of harm that hospitals are preparedto disclose and how they handle such disclosure. Malpractice concerns appear tobe the m ost prominent foil to aspirations of openness. As malpractice insurancecosts spiral for physicians in a number of states and pundits herald a fresh se t ofmalpractice "crises," the litigation barrier looks set to g

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The authors thank Shimon Shaykcvichforpro^mming si^port; Meghan Mattinofordatxi entry work and other

icgistical help; thechitf medical officers, risk managers, and others w hooffered expertise in the surveydevelopment; and the respondents who took time to participate. This work was conducted while Rae Lamb w as a

2001-2002 Harkncss Fellow in Health Policy, bdsed oinrl)'at the Harvard School 0/Public Healtfiand liheInstitute fov Healthcare Improvement and supported by the CommonwealthFund. David Studdert w as supported

inparthyGrantm}.K02HSlUS5fromthe/^ncyforHea}thcarc'Researchandûality.Theviewspresentcdherc

are tftoseo/rfie authors and not necessarily those ofthe Co mmonwealthFund.

HOTES

1. American Medical Association, ""Code of Medical Ediics; Current Opimons,"31 July 2002, www.ainii 'assn.o]^ aina/pub /category/ 2503.h tml (30 December 2002); Artierican College of Physicians, "Ethics Man-ual, Fouith Edinon,"Annuls ofMcma\ Medicine128, no . 7 (1998): 576-594; and American Nurees Association,"Code of Ethics for Nurses with Interpretive Statements," 2001, www.nursingworld.org/ethics/code/

etl i icscodeI50.htm (30 December 2002).2. T.A. Brennan, JusiDoctorir^ Medical Ethics in the Ubcral State (Berkeley: University of C alifornia Press, 1991);

M.L. Millenson,DemandingMedical Excellence:Doctors and Accountability in thelrôrmationA^ (Chicago: Univec-sity of Chicago Piess, 1997); and L.M. Peterson and T.A. Brennan, "Medical Ethics and Medical Injuries:Takii^ Our Duties Seriously,7ouma(ofCUnicd Ethics 1, no. 3 (1990):207-211.

3. LT . KohnJ.M, Corrigan, andM.S.Donaldson, e6s.,ToErrIsHuman:Buildii aSaferHcalthSyitem (Washing-ton: National Academy Press, 1999); Institute of Medicine,Crossir^ the Quality Chasm: A New Health System ortk Vwmty-fintCemury (Washii^^n: National AcademyPress, 2001); and White Hou se Press CSice, -Med-ical Errors Remarks by President Chnton," Press Release, 7 December 1999.

4. Joint Com mission on Accreditation t^ Healthcare Organisatioiis, Standard RI.1.2.2,1 July 2001.

5. JCAHO, JCAHO press conference transcript,2 July 2001. Atlanta, Georgia,6. The Insntutionai Review Board at the Harvard School of Public Health approved boiii the survey and the

study design.

7. The four clinical scenarios were (1) prevent able event with seriou s outcome (a pati ent suffei^ a cata-strophic hemorrhagic cerebrovascular accident following heparin pump failure that causes heparin over-dose); (2) nonpreventable event with serious outcome (patient w idi no k no\\ 'n dru g alleigies dies as a re-sult of anaphylactic shock secondary to arapid lhn); (3) preventable event with minor ou tcome (coumaditioverdose leads to elevated prothromb in time and tw o additional, otherwise unnecessary, hospital days);and (4) nonp reventable event vidth minor outcome (patient wdth no drug allergies develops rash and itch-i i^ secondary to antibiotic reaction).

B. VA hospitals were excluded from bo th strata. We also removed seven hospitals from the sampled group:Six were in Puerto Rico, and one had specially requested exclusion.

9. J. Rasentha l et aL, State R^rt ir ^ 0/ MaJicalErrors and AdverseEvents:Results 0/ a Fifty-Stare Survey (Portland,

Maine: National Academy for State Health Policy, 2000). Utah has a Patient Safety Senrinel Event Re-porting Rule R380-200-3, effective.15 October 2001.

10. Of tlK 338 total replies we received, ninety-three were refusals to complete the full survey, withtwenty-five of these dd ng as their primary reason that they or oth ers at their insti tution had legal con-cerns about doingso. An additional eighteen of the refusers said they were too busy, fifteen said that theydid not participate in surveys, and ten said it was too early in the development of their disclosure pohciesto answer our questions.

11. The depen dent variable in this multivariate model was propensity to disclose preventable harm, as deter-mined by responses to the clinical scenarios. The independent variables were msdpractice cca:icems, AMCstatus, ownership, numb er of beds, reporting law environment, and region.

12. EJ. Tho mas et aL, "Incidence and Types of Adverse Evetits and Negligpnc Care in Uta h and ColOTado,"Medical Care 38, no. 3 (1999):261-271;aad T,A. Brennan et aL, "Indcknce of Adverse Events and Negligencein Hospitalized Patients: Results of the Harvard Medical Practice Study I," NewEr^Jand Journal of Medicine324, no. 6 (1991): 370-376.

13. B.A. l iar^ , "En or in Medicine: Legal Impediments toUS . Reform," Journalf^HeaitfiRjItrics,Policy andLaw 24,no . 1 (1999): 27-58; L. Gostin, "A Public Healdi ^^roach to Reduci:EITOT: Medical Malpractice as aBaina:,'-JoumdofÂmmcanMedical Association 283, no . 13 (2000 ): 1742-1743; A.W. Wu , "Handling H ospi-tal Errors: Is Disclosure the Best Defenser Atmh t^ internal Mdicint Bl, no. 12 0999)-. 970-972; M.

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Hingorani,T. Wong , and G. Vafidis, "Patients ' and Doctors ' Atti tudes to A mount of Infonnation Given af-ter Unintended Injury during Treatment: Cross Sectional, Questionnaire Survey," BritishMedmlpurmd 318,no, 7184 (1999):640-641; an d A.W. Wu e t a l, , " Do Ho u s e O ff ic er s L ea m fr om T li ei r M i s t a k e s ^ l / f tAmerican tvkdicalAssociation 264, no. 4 (1991): 2089-20 94.

14. T.A. Brennan, "The Insti tute of Medicine Report on Medical Errors Could ItDo Harm?" ^Joumaio/fitaiicira: 542.no.15 (2000): 1123-1125; andD.M. Stud dert an dXA. B mman , "No-Fault Corrqsensa'don for Medical Injuries: The Prospect for Error Prewntion,"Jourml oftk American Medical AisocMm 286,no. 2 (2001): 217-228.

15. G. Porto, "Disclosure of Medical Error: Facts andd]hcies" jourmlc^HmlAcare Risk Maru^ment21, no. 4(2001): 67-76: C. Vincent, Clinical Risk Management: Enhancing Patient Safety (London: BMJ Books, 2001),476-478; andM.B. Kapp, "Legal Anxieties and M edical M istakes," Joumaf o/GeneralInternal Me^dm 12, no .12 (1997): 787-788.

16. S. Kraman and G. Hamm, "Risk Management: Ex tremeHonest} ' May Be the Best Policy,"Amah oflntcrmlMedicine 31. no. 12 (1999): 963-967

17 J. Tieman. "Enforcinga New Openness,"Modem Healthcare 31,no. 26 (2001):4-5 ; and j . Conway,"Q:eaiing aCulture of Safety: Challenge Your Mental Models 'Cause It Ain't NecessarilySo!" (Speech at Anierican So-ciety for Healthcare Risk Management conference, Boston, 29 October 2001).

18. D. Pietro et al., "Detecting and Reporting Med ical Errors: Wh y the Dilemma?"Briti^MedicalJountd 320. no .;^37 (2000) : 794-7%.

19. A. Wi tman , D. Park, and S. Hardin, "How Do Patients W ant Physicians to Hand le Mistakes? A SurveyoEInternal Medicine Patients in an Academic Setting," Archivesoflnterml Medicine 156, no. 22 (1996): 256 5-2669; W Le^'inson, "Physician-Patient Co mmunication: The R elationship with M alpractice Claimsamong Primary Care Physicians andSurgeons," journal of the American Medical Association 277, no, 7 (1997):553-559; and G.B. Hickson et al., "Factors That Prompted EamiHes to File Medical Malpracdce Claimsfollowing Perinatal Inj'uries,'' joumai ofhe American MedicalAssociation 267, no. 10 (1992): 1359-1^ 3.

20. Studdert and Brennan, "No-Fault Compen sation for Medical Injuries."

21. See, for exam ple,U.S. House of Representatives, "Help Efficient, Accessible, Low Cost, Timely Health Care(HEALTH) Act of 2002; H.R. 4600,107th Cong,, 2d sess. (25 April 2002); and "Healthcare Ser\1ces Mal-practice Act," H.B. ]8O2,186di Leg., Reg. Sess. (Pa. 2002 ), Public Law154, No . 13, Sec. 5104.

22. M.L. Millenson, "Pushing the Profession: How the News Media Turned Patient Safety into a Priority."Quality and Safety in Health Care 11. no . 1 (2002): 57-63.

23. For example, if low frequency of disclosure (for instance, as a proportion of all harms) were correlatedwith low quality, the gap we identified between disclosures and actual adverse events may be even^leatet, ^veri some evidence of relatively low quality of care in for-proiit hospitals. See E.J. Thomas et al.,"Hospital Ownership and Preventable Ad\'erse E\'ents," journalof Gcncml Imenud Medicine 15, no. 4 (2000):211-219; PJ. Devereaux et al., "A Systematic Review and Meta-Analysis of Stud ies Comp aring Mortal ityRates of Private For-Profit and Private Not-for-profit Hospitals,"Canadian'MedicalAssociatimJmmal 166 no11 (2002): 1399-1406; and Y.C. Shen. "The Effect of Hospital Ownership Choice on Patient Outcomes afterTreaonent for Acute, Myocardial Infarction,"]mrmi t^Hedrfi Economics21, no . 5 (2tX)2); 901--922.

24. Amori, "President's Message"; American Society for tfcalthcare Risk Management. ASHRM conferenceagenda. 2001; and M. Ott, "Key Considerations on Drafting a Policy on Disclosure of Unanticipated Out-com es, " Journal offferitfecarcRisfeJVtoiagemcnt 21, no. 4 (2001):27-31.

25. Porto. "The Risk Mans^er's Role"; andD. Finkelstein et aL, "When a Physician Harros a Patient by M edi-cal Error: Ethical, Legd, and Risk Management Considerations," loumo!of Clinical Ethics 8, no 4 (1997)-330-335.

26. E.J. Emanuel and L.L. Gorman. "Four M odels of the Physician-Patient Relationship," Jbiima!c^Oic AmericanMedical AsiOciaHm 267, no. 16 (1992): 2221-2226.

27. T. Gorman, "Physicians Fold under Malpractice Fee Burden," LosA J ^ Times, 4 Marc h 20 02; K. Hiindiey,"Prognosis for Tro uble," St fttersk^g Times,11 March 2002; M. Freedman, "The Tort Mess."Forbes. 13 May2002; andJ.B. Treaster. "New York Doctors Ead ng B igjump in Insurance Rates."New York Times, 22 March2002.

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Hospital Practices Article

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