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Communicating about Unanticipated Outcomes and Medical Errors

May 17, 2002

There has been an emerging ethical consensus as well as increasing accreditation and legal mandates that health care providers and organizations communicate forthrightly with patients and families about significant unexpected outcomes, medical errors, and accidents. The July 1, 2001 JCAHO patient safety standards, under the patients’ rights and organizational ethics standards, states that “patients, and when appropriate, their families must be informed about the outcomes of care, including unanticipated outcomes.”

  1. Provide a legal perspective on the full disclosure of significant unanticipated outcomes and errors to patients and families, and the potential impact that such disclosure could have on medical professional liability.
  2. Gain insight from hospitals and health systems that have addressed the issue of disclosure and how they continue to improve upon the process as they’ve learned lessons along the way.
  3. Offer effective strategies for initiating these discussions with patients and families, recognizing the issues that must be addressed to make these conversations healing for all parties involved.
  4. Provide a rare glimpse into press hospital relations, and ways they can effectively communicate regarding unanticipated outcomes.
  5. Provide organizations with practical strategies to address the JCAHO standard requiring patients and families be informed of unanticipated outcomes.


8:15 am – 8:45 am Registration and Continental Breakfast

8:45 am - 9:15 am Welcome and Opening Remarks

John Noble, MD
Chair, Joint Commission on Accreditation of Healthcare Organizations
Co-Chair, Massachusetts Coalition for the Prevention of Medical Errors

Lucian Leape, MD
Adjunct Professor of Health Policy
Department of Health Policy and Management, Harvard School of Public Health

9:15 am – 10:00 am Ethical Aspects of Disclosure

John Combes, M.D.
Senior Medical Advisor
Hospital and Health System Association of Pennsylvania and American Hospital Association

10:00 am – 10:45 am Legal Aspects of Disclosure

Philip Crowe, Esq.
Crowe & Mulvey

William J. Dailey Jr., Esq.
Sloane & Walsh

10:45 am - 11:00 am Break

11:00 am – 11:30 am A Family Member’s Perspective of Disclosure

Roxanne Goeltz
Roxanne Goeltz, is an air-traffic controller whose brother Mike died of a medical error in 1999. She will share her and her family’s experience and discuss her perspective on the process of disclosure.

11:30 am – 12:15 am Hospitals & the Media: Strange Bedfellows

Larry Tye
Larry Tye, who worked as a medical correspondent for the Boston Globe for 15 years, will explain the perspective of the media in looking at issues of errors and ways that hospitals and the media can collaborate to advance error prevention.

12:15 pm – 1:15 pm Lunch

1:15 pm – 1: 45 pm DPH’s Aspect on Disclosure

Nancy Ridley, Assistant Commissioner, Department of Public Health

1:45 pm – 3:00 pm Hospital Strategies for Disclosure-Panel Discussion

Panel Moderator - Leslie Kirle
Senior Director Clinical Policy & Patient Advocacy, Massachusetts Hospital Association

Barbara Lightizer MS, MA, CPHRM, DFASHRM
Director Performance Improvement & Risk Management
St Elizabeth Medical Center

Maureen Connor RN, MPH, CIC
Director Risk Management
Dana Farber Institute

Connie Crowley Ganser MS, RNC
Director QI, Risk Management & Education
Children’s Hospital
Co-Chair, Massachusetts Coalition for the Prevention of Medical Errors

Ruth Fitzpatrick
Risk Manager
Fairview Hospital

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