Anatomy of an incident disclosure: the importance of dialogue

Jt Comm J Qual Patient Saf. 2012 Oct;38(10):435-42. doi: 10.1016/s1553-7250(12)38057-4.


Background: Disclosure of health care incidents to patients and family members, as an ethical imperative, is becoming increasingly prevalent. The experiences of a woman whose husband died forms the basis for a case study of how she and her family and friends were able to renegotiate clinicians' understandings of what had gone wrong and influence their views of what needed to be done in response.

Methods: The case was constructed in late 2010 using the replicated single-case approach, which involved repeated checking and correcting details of an interview with the patient's wife. Her husband, diagnosed with multiple myeloma in 2006, was hospitalized in January 2009 following a hip replacement. While in the hospital, he received a vasopressin overdose. He died in February 2009. THE DISCLOSURE PROCESS: The basis of the disclosure was the drug error, yet the patient's wife informed the caller (the head of the ICU), "You've got a greater problem than a drug error... you've got a massive, big communication problem here." The disclosure process, which unfolded in a series of phone calls and meetings, enabled the patient's wife and her family not only to ask questions but to put forward their knowledge, views, and concerns, and it moved from "disclosing an incident" (the vasopressin overdose) to addressing repeated communication failures and inappropriate behaviors. As a result, the disclosure process became a genuine dialogue that informed the clinicians as much as the family.

Conclusions: This case study expands our understanding of what is possible as part of disclosure communication. Patients and family members can and should play a critical role in quality improvement and patient safety, given their knowledge and questions about the trajectory of care and their passion for ensuring that similar incidents do not recur to harm others.

MeSH terms

  • Blood Transfusion
  • Communication*
  • Confidentiality
  • Disclosure / ethics*
  • Documentation
  • Drug Overdose / complications
  • Female
  • Hemostatics / poisoning
  • Humans
  • Interviews as Topic
  • Male
  • Medication Errors / ethics*
  • Physician-Patient Relations*
  • Quality of Health Care
  • Vasopressins / poisoning


  • Hemostatics
  • Vasopressins