Medical Error Disclosure Conversations: Not as transparent as you might think.

In reality, when medical errors are disclosed, it doesn't necessarily mean that all details about the error are provided. You might be informed that an error happened, but lack context about the causes and specifics concerning if negligence led to the error. 

Truth about Medical Error Disclosure

Has a healthcare provider disclosed a medical error to you or a family member after receiving care? If so, do you believe you received the full story?

The reality is that when medical error disclosures are made, it doesn’t mean all information regarding the error is shared. You may be told an error occurred but have no context to the causes and details regarding the level of negligence that may have occurred if any. 

With limited knowledge of the complex healthcare processes that come together in the delivery of healthcare services, a layperson puts trust in their providers that the information provided is complete, not a partial retell of information they want patients to hear.

What patients may hear are the facts of the error that are known at the time of the disclosure, but perhaps not what led to mistakes that may have contributed to the error.  

Those factors that may have led to an error are called contributing factors. Think of contributing factors as small failures or mistakes that combine in part or in whole to cause a specific outcome. There may be negligent behavior in contributing factors that may take the form of not effectively communicating, consciously skipping a process required, or not following known standards of care like washing hands, sterile gloving or gowning practices. Bottom line is that contributing factors are important to understand in any disclosure because they are often tied directly to standards of care and generally accepted practice guidelines.  

What may be Missing in a Medical Error Disclosure?

To understand why some disclosure may be missing information, it is important to understand that the amount of information available may change over time. In fact, it is common for organizations to do a formal causal analysis, such as a Root Cause Analysis, when a medical error occurs. Regulatory and accrediting bodies such as CMS and The Joint Commission require hospitals to do causal analysis on medical errors such as sentinel events for specific categories of harm that patients may experience. You can read more by clicking the The Joint Commission link below:

Sentinel Events (SE) - The Joint Commission

www.jointcommission.org › media › tjc › camh_24_se_all_currentpdf

Medical Error Disclosure

When a medical error occurs there should be a disclosure. The factors that may influence the quality or completeness of a medical error disclosure can be charted on a continuum. On one end of the continuum, there is full disclosure of all of the facts and contributing factors that led to the error. On the other end of the spectrum there is no disclosure of a medical error. Complex medical errors may require a more lengthily investigation and therefore not all facts may be known at the time of the disclosure. The outcome of a medical error can vary from death to no harm.

Timing of Disclosure Conversations

Disclosures conversations often occur soon after an error is made. When this occurs, it is important to know that it is likely that not all the facts are known about the error, especially those involving more complex care, where a more thorough evaluation of contributing factors is required.

The reality is that there are many factors that influence the amount of information you get from a medical provider who has made an error. In some complex cases, it may take time to fully review an incident. A formal review of care may be needed by multiple providers. This type of review is often referred to as a quality of care review, or even a mortality review, in the instance where a patient has died. It can take days, weeks or even months to fully understand what occurred because different reviews are aggregated to create a full assessment of the error. Furthermore, even when thorough causal analysis and reviews are conducted, it simply may not find definitive answers. This of course is only true when a hospital, health system or alike has strong quality processes in place. In organizations that don’t have a strong quality culture, it is unlikely that a thorough review will be conducted in practice.

Errors not Disclosed due to being Unaware

In some instances, a medical error may occur and not be known by healthcare providers until a later date when additional care is delivered. For example, a patient who has abdominal surgery could suffer complications for weeks or months before reimaging of the surgical site is ordered.  It may be during this subsequent care that a retain surgical sponge is identified. It is at that time when a disclosure is made regarding the error that occurred during the initial surgical procedure.

It may take months to determine if there are lasting effects from the retained sponge. There has certainly been trauma, pain and suffering and additional surgery.

In other instances, an error may not be as obvious. It could be a missed lab finding, or misread test, or medical results that were not follow up on that later reviewed a medical condition. It these cases there may not be intentional acts but there could be negligent acts leading to an adverse patient outcome.

In other instances, there may be conflicting views if an error occurred. When there is not some level of consensus that an error occurred they are generally not disclosed.

Variation in the Quality of Disclosures

There are several factors that are helpful to know about how disclosures are made. Disclosures philosophies can vary from one medical professional to another and from organization to organization. Disclosures can be driven by the provider, an office of patient safety, a risk management or legal department, policy or perhaps a combination thereof.

Regardless of the variation that exists and knowing patient rights is an important first step to getting the answers.

The results of a survey performed by Gallegher et al. was published in Choosing your words carefully: how physicians would disclose harmful medical errors to patients.

The findings showed that when asking physicians about how they would disclose clinical errors 56% of physicians would state the adverse event that occurred but not the error. Only 42% would state the error that occurred. Two percent would not make a disclosure.

This finding is key and really supports the premise that there is wide variation in the manner in which disclosures are made and the reluctance to admit and/or disclose medical error. The reality is that patients would not necessarily know the difference between an adverse event and an error. The former is what happened that was not expected. The latter is the cause (error) that led to the adverse event occurring. Only 42% of the 2,637 physicians would disclose the error. Patients when told just about the adverse event that they experienced might assume that they experienced a bad outcome and it was a normal part of the risk of care. They might assume that it was not a result of anyone’s actions, or lack of action. It is wrong to not disclose the error.

In a journal article published in the National Center for Biotechnology Information (NCBI), it was identified that physicians tend to provide minimal information about medical errors and often do not offer apologies. (Robbernnolt, J. 2009)

How Patients Can Overcome Poor Disclosures – Five Whys Technique

Gallagher et al. found that patients want to be fully informed of medical errors. They want to know why it occurred, how it occurred and most important how the error has and will potential affect their health. Many patients want to also hear how it will be prevented.

You can try to get the facts by asking the “five whys,” which is a technique for finding the root cause of an undesirable outcome.

Why did you I get a surgical site infection? Because you were exposed to germs during surgery. How was I exposed to germs? We believe it was due to a break in the sterile field during the surgery. Why was there a break in the sterile field during the procedure? We broke protocol when the surgeon made several adjustments to equipment during the procedure. Why did the surgeon do that? The technician who operates the equipment was not available. Why was the surgery performed without a technician? The hospital doesn’t cancel surgeries due to being short staffed. The cause of the adverse outcome of a surgical site infection was that the hospital performed a surgery without the needed personnel.

From this example, the root cause of a surgical site infection may not seem even linked or connected to the outcome. Not following a practice guideline of maintaining a sterile field during surgery, the surgeon’s decision making, hospital culture, and poor policy are all contributing factors.

When errors involve more complex care, it is unlikely that being curious and asking the five whys will yield answers.

How To Get The Facts

Healthcare is complex. You have access to your record but some things are not recorded. And the result of hospital reviews are peer review protected, so they are not discoverable.  

An external independent quality review by medical experts can identify gaps in standards of care and errors that likely caused an outcome due to lack of following known standards. An external review is similar to getting a second opinion of a diagnosis. It looks at the information available to create another professional opinion of the facts weight against known practice standards and guidelines.

What is your Recourse After Disclosure?

The type of recourse will depend on many factors such as the type of error, the provider or organization who made it, and the impact to the patient, just to name a few.

Recourse after a disclosure can also be influenced by the organization or provider who made the error. If an error is made at a large hospital, there are resources such as patient and family advocates who work with patients to follow up on care concerns, beginning when you are in the hospital and continuing well after. There are patient complaint processes that can help get the issue visibility.

Many healthcare providers or organizations are likely to temporarily hold charges until more information can be gather and analyzed. Many will forgive charges for additional care needed and provided as a result of the injury. Whether this is enough to will depend on a person’s unique situation.

Peer Review

Any conversation about disclosures should include peer review, which is an essential part of a robust healthcare quality program. The Health Care Quality Improvement Act of 1986 (HCQIA) is the statute that in part was created to protect patients from poor quality care incompetent medical professionals.

Peer review at its essences is exactly what its name suggests, a method of reviewing and evaluating the care delivered by practicing healthcare professionals as evaluated by other professionals to ensure known practice standards and guidelines are followed.

Most healthcare organizations are required to have peer review committees and an active peer review process. This review process may be managed differently from organization to organization.  It could involve a utilization review committee, or utilization management committee, a patient safety committee or alike. Reviews can be external or internal or a combination of both. Reviews evaluate different areas of care utilization and delivery. For instance, reviews may focus on care delivery, clinical quality, financial billing quality, compliance and more. Regardless of the purpose, internal evaluation is an important part of what helps make care safe.

The Importance Peer Review Protections

Most peer review activities are protected from discovery in legal cases. This is good in that it ensures that healthcare professionals can speak freely about medical errors that occur without worrying that their comments and opinions will be used against them in court.

Federal and state peer review protection may have some carve outs for these protections but overall they are consistent in the general protection of the confidentiality of activities in quality review of errors. Patient safety programs rely heavily on these protections to improve care and so we should all be thankful of that.

Establishing Clear Goals

When disclosures of errors are made, It often results in some level of harm, making it difficult to be in the right mindset to ask questions or get more information. It is common to reflect on care and later want answers. Patients may want some of the costs of care forgiven, others may want compensation for pain and suffering. Regardless of what is desired, the key is to be clear about what the goals are. That will help determine next steps.

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Eva, EvaluCare’s AI-powered SaaS, delivers quality review for inpatient care by checking adherence to thousands of evidence-based guidelines and protocols. It identifies care gaps, routes clear actions to the right clinicians, and accelerates improvement cycles, strengthening documentation and coding while reducing HACs, HAIs readmissions, length of stay and more. The result is an ROI, starting in the seven figures even for critical access hospitals. Learn more at evalucare.net or contact info@evalucare.net.

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About the Author

Jason Minor is a healthcare quality and transformation leader with nearly 30 years of continuous improvement experience. A Certified Lean Six Sigma Black Belt, Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, and Certified Utilization Review Professional, he has led thousands of end‑to‑end improvement projects, mentored dozens of quality professionals, and pioneered healthcare SaaS innovations.

As Board Chair of the Vermont Program for Quality in Health Care, Jason has partnered with hospitals, non‑profits, and state agencies to elevate patient safety and care quality statewide. Previously, as Network Vice President of Quality at the UVM Health Network and through the Jeffords Institute for Quality, he guided the redesign of a system‑wide quality framework and led initiatives that achieved a number‑one patient safety ranking among the nation’s top academic medical centers.

In 2020, Jason founded EvaluCare to help organizations shift from episodic improvement to a robust quality assurance approach.

EvaluCare’s Eva platform leverages AI‑powered natural language processing, machine learning, and agentic orchestration to analyze and improve inpatient care and support comprehensive quality, mortality, peer, and utilization reviews.

Jason Minor, EvaluCare Executive Director

Network Director Continuous Systems Improvement Jeffords Institute for Quality UVM Health

Board Chair Vermont Program for Quality in Health Care Inc.,

Vice Chair Northwestern Counseling & Support Services, Inc

Lecturer UVM College of Nursing & Health Sciences in Healthcare Quality

Quality Peer Reviewer Vermont Care Partners: Centers of Excellence

References & Resources

Gallagher, T. H., Garbutt, J. M., Waterman, A. D., Flum, D. R., Larson, E. B., Waterman, B. M., … Levinson, W. (n.d.). Choosing your words carefully: how physicians would disclose harmful medical errors to patients. https://www.ncbi.nlm.nih.gov/pubmed/16908791?dopt=Abstract

Robbennolt J. K. (2009). Apologies and medical error. Clinical orthopaedics and related research, 467(2), 376–382. https://doi.org/10.1007/s11999-008-0580-1

-EvaluCare Faculty

EvaluCare’s team of quality, medical and research professionals offers in-depth analysis and review of medical care quality to support medical malpractice claims. Clients are patients and attorneys who need answers in determining the strength of a malpractice claim. Services range reviewing care against practice guidelines and known standards of care to trial support.

Learn More at www.EvaluCare.net or email info@EvaluCare.net