Getting doctors to report medical errors: project DISCLOSE

Jt Comm J Qual Patient Saf. 2006 Jul;32(7):382-92. doi: 10.1016/s1553-7250(06)32050-8.


Background: Despite the number of patient safety incidents that occur in hospitals, physicians currently may not have the ideal incident reporting tools for easy disclosure. A study was undertaken to assess the effectiveness of a simplified paper incident reporting process for internal medicine physicians on uncovering patient safety incidents.

Design: Thirty-nine internal medicine attending physicians were instructed to incorporate the use of a simplified paper incident reporting tool (DISCLOSE) into daily patient rounds during a three-month period. All physicians were surveyed at the conclusion of the three months.

Results: Compared with physician reporting via the hospital's traditional incident reports from the same time period, a higher number (98 incidents versus 37; a 2.6-fold increase) of incidents were uncovered using the DISCLOSE reporting tool in a larger number of error categories (58 versus 14, a 4.1-fold increase). When reviewed and classified with a five-point harm scale, 41% of events were judged to have reached patients but not caused harm, 33% to have resulted in temporary harm, and 9% of reports, though not considered events, were to indicate a "risky situation." Surveyed physicians were more satisfied with the process of submitting incident reports using the new DISCLOSE tool.

Discussion: A simplified incident reporting process at the point of care generated a larger number and breadth of physician disclosed error categories, and increased physician satisfaction with the process.

Publication types

  • Evaluation Study

MeSH terms

  • Attitude of Health Personnel
  • Data Collection / methods
  • Feasibility Studies
  • Forms and Records Control* / methods
  • Humans
  • Internal Medicine
  • Medical Errors / statistics & numerical data*
  • Medical Staff, Hospital / psychology*
  • Personal Satisfaction
  • Philadelphia
  • Risk Management / methods*
  • Truth Disclosure*