This paper was contracted by the Robert Wood Johnson Foundation.Preliminary interviews wereconducted in support of the workshop entitled, “Disclosure: What’s Morally Right Is OrganizationallyRight,” at the 18th Annual IHI National Forum on Quality Improvement in Health Care, December 10-13,2006, Orlando, Florida, USA.For more information, contact Eve Shapiro, Medical Writer, at[email protected]Disclosing Medical Errors:Best Practices from the “Leading Edge”By Eve ShapiroIntroductionMary McClinton went into Virginia Mason Medical Center for a relatively routineprocedure in 2004. While there she died after receiving an injection of chlorhexidine, acaustic cleaning solution, instead of normal saline.Both were clear liquids and had beenplaced side by side in unlabelled cups in the operating room.A 9-year-old girl who had just undergone surgery at the University of Michigan HealthSystem in 2001 gave herself a lethal dose of dilaudid because she was given amiscalibrated PCA pump.Betsey Lehman, aBoston Globereporter, and Maureen Bateman were being treated forbreast cancer at the Dana-Farber Cancer Institute in late November 1994. Lehman diedon December 3 and Bateman suffered permanent heart damage because, in one day, theyreceived four times the daily dose of the anticancer drug cyclophosphamide.In 1999, the Institute of Medicine shocked the nation by reporting that between 44,000and 98,000 people die in hospitals each year as a result of medical errors. That report,ToErr Is Human,1raised awareness about the prevalence of medical errors in our nation’shospitals. Six years later, in 2006, the Institute of Medicine released the report,Preventing Medication Errors,2which revealed that a hospitalized patient can expect toexperience, on average, one medication error per day.Dr. Donald Berwick, president of the Institute for Healthcare Improvement, experiencedsuch errors himself when his wife was a patient in a well-known Boston hospital. “It wasnot just how she was treated,” Berwick toldTimemagazine,3“it was that so little of whathappened to her was unusual.” Despite Berwick’s best efforts on his wife’s behalf, hesays, “tests were repeated unnecessarily, data were misread, information was misplaced.Things weren’t just slipping through the cracks; the cracks were so big there was no solidground.”The prevalence of medical errors and their impact on the lives of patients and theirfamilies is profound. Why, eight years after the IOM issued its indictment of the health1Institute of Medicine.To Err Is Human: Building a Safer Health Care System. Washington, DC: NationalAcademies Press; 1999.2Institute of Medicine.Preventing Medication Errors. Washington, DC: National Academies Press, 2006.