Zdrowie Publiczne i Zarządzanie

Programy otwartego ujawniania niepożądanych zdarzeń medycznych pacjentom i ich bliskim – przegląd rozwiązań w wybranych krajach

Data publikacji: 2024

Tom 20, Numer 3

Zdrowie Publiczne i Zarządzanie, 2022, s. 111 - 118



Agniezka Gibalska-Dembek Orcid , Dorota Sys Orcid


The programs for open disclosure of adverse medical events to patients

The aim of this study is to present and compare programs for open disclosure of adverse medical events to patients by medical personnel. Australia, Canada, and the United States, based on apology laws, procedures, medical staff handbooks, training, and fair culture, have implemented solutions that focus on the needs of the patient after the adverse event. It has been proven that a proper patient communication process can reduce the number of claims brought against staff or medical institutions. However, there are barriers to communicating adverse events to patients. These are ingrained in the “deny and defend” strategy, which does not promote a culture of learning from mistakes. The paper also discusses the second victim syndrome, which is the second victim of an adverse event such as medical personnel experiencing emotional damage after an incident.


  1. World Health Organizations, Patient Safety, who.int/news-room/fact-sheets/detail/patient-safety (dostęp: 14.04.2023).
  2. Ponad 520 zgłoszeń do rejestru zdarzeń niepożądanych RPP, Portal Medycyna Praktyczna, https://www.mp.pl/pacjent/szczepienia/aktualnosci/304037,ponad-520-zgloszen-do-rejestru-zdarzen-niepozadanych-rpp (dostęp: 17.03.2023).
  3. Witczak I., Zdarzenia niepożądane oraz błędy medyczne występujące w procesach diagnostyczno-terapeutycznych usług zdrowotnych, [w:] Bezpieczeństwo pacjentów i personelu medycznego: uwarunkowania ergonomiczne, red. I. Witczak, Ł. Rypicz, Wydawnictwo Uniwersytetu Medycznego im. Piastów Śląskich, Wrocław 2020.
  4. Dekker , Just Culture: Restoring Trust and Accountability in Your Organization, Third edition, CRC Press, Taylor and Francis Group, Burlington 2017.
  5. Australian Commission on Safety and Quality in Health Care, Australian Open Disclosure Framework – Better Communication, a Better Way to Care, 2014, https://www.safetyandquality.gov.au/publications-and-resources/resource-library/australian-open-disclosure-framework-better-communication-better-way-care (dostęp: 17.04.2023).
  6. Canadian Patient Safety Institute, Canadian Disclosure Guidelines: Being Open and Honest with Patients and Families, Edmonton, Alta, 2011, https://www.patientsafetyinstitute.ca/en/toolsResources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines.pdf (dostęp: 17.04.2023).
  7. Wojcieszak D., Sorry Works! Toll Kit Book, Sorry Works, Glen Carbon.
  8. Dawis , I’m Sorry I’m Scared of Litigation: Evaluating the Effectiveness of Apology Laws, „The Forum: A Tennessee Student Legal Journal” 2016; 3 (1): Article 4.
  9. Dekker , Adamczyk-Garbowska M., Garbowski M., Just culture: kultura sprawiedliwego traktowania: między bezpieczeństwem a odpowiedzialnością, Wydawnictwo Uczelnia Łazarskiego, Warszawa 2018.
  10. Ho , Liu E., Does Sorry Work? The Impact of Apology Laws on Medical Malpractice, „Journal of Risk and Uncertainty” 2011; 43 (2): 141–167.
  11. Ross E., Newman W.J., The Role of Apology Laws in Medical Malpractice, „The Journal of American Academy of Psychiatry and the Law” 2021 (dostęp: 24.03.2023).
  12. Kraman S., Hamm G., Risk Management: Extreme Honesty May Be the Best Policy, „Annals of Internal Medicine” 1999; 131 (12): 963.
  13. Russell D., Disclosure and Apology: Nursing and Risk Management Working Together, „Nurs Manage” 2018; 49 (6): 17–19.
  14. Schulz J., Reforming Clinical Negligence in England: Lessons about Patients’ and Providers’ Values from Medical Injury Resolution in New Zealand and the United States of America, „Future Health” 2022; 9 (3): 230–237.
  15. Moore J., Bismark M., Mello M., Patients’ Experiences With Communication-and-Resolution Programs After Medical Injury, „JAMA Internal Medicine” 2017; 177 (11): 1595–1603.
  16. Bell S.K., Smulowitz P.B., Woodward C., Mello M.M., Duva A.M., Boothman R.C., Disclosure, Apology, and Offer Programs: Stakeholders’ Views of Barriers to and Strategies for Broad Implementation, „Milbank Quarterly” 2012; 90 (4): 682–705.
  17. Australian Commission on Safety and Quality in Health Care, Saying Sorry. A Guide to Apologising and Expressing Regret During Open Disclosure, https://www.safetyandquality.gov.au/sites/default/files/2021-09/saying_sorry_-_a_guide_to_apologising_and_expressing_regret_during_open_disclosure.pdf (dostęp: 14.04.2023).
  18. Wu W., Boyle D..J, Wallace G., Mazor K.M., Disclosure of Adverse Events in the United States and Canada: An Update, and a Proposed Framework for Improvement, „Journal of Public Health Research” 2013; 2 (3): 186–193.
  19. Reason J., Human Error: Models and Management, „British Medical Journal” 2000; 320 (7237): 768–770.
  20. Canadian Medical Protective Association, https://www.cmpa-acpm.ca/en/home (dostęp: 14.04.2023).
  21. Apology Act, 2006, https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/00_06019_01 (dostęp: 14.04.2023).
  22. Wojcieszak D., Review Of Disclosure And Apology Literature: Gaps And Needs, „Journal of Healthcare Risk Management” 2020; 40 (1): 8–16.
  23. Wojcieszak , Banja J., Houk C., The Sorry Works Coalition: Making the Case for Full Disclosure, „Joint Commission Journal on Quality and Patient Safety” 2006; 32 (6): 344–350.
  24. Hüner , Derksen C., Schmiedhofer M., Lippke S., Riedmüller S., Janni W., Reister F., Scholz Ch., Reducing Preventable Adverse Events in Obstetrics by Improving Interprofessional Communication Skills – Results of an Intervention Study, „BMC Pregnancy Childbirth” 2023; 23 (1): 55, doi:10.1186/s12884-022-05304-8.
  25. McMichael B.J., Van Horn R.L, Viscusi W.K, “Sorry” Is Never Enough: How State Apology Laws Fail to Reduce Medical Malpractice Liability Risk, „Stanford Law Review” 2019;71 (2): 341–409.
  26. Słownik Języka Polskiego PWN, https://www.sjp.pwn.pl (dostęp: 17.04.2023).
  27. Wielki Słownik Języka Polskiego PAN, https://wsjp.pl/ (dostęp: 17.04.2023).
  28. Harrison , Walton M., Smith-Merry J., Manias E., Iedema R., Open Disclosure of Adverse Events: Exploring the Implications of Service and Policy Structures on Practice, „Risk Management and Healthcare Policy” 2019; 12: 5–12.
  29. Rohrich R.J., It’s Okay to Say “I’m Sorry”, „Plastic & Reconstructive Surgery” 2021; 148 (5S): 48S–50S.
  30. Pasowicz M., Zdrowie i medycyna – wyzwania przyszłości, Krakowskie Towarzystwo Edukacyjne, Oficyna Wydawnicza AFM, Medycyna Praktyczna, Kraków 2013.
  31. Ozeke O., Ozeke V., Coskun O., Budakoglu I.I., Second Victims in Health Care: Current Perspectives, „Advances in Medical Education and Practice” 2019; 10: 593–603.
  32. Carmack H.J., A Cycle of Redemption in a Medical Error Disclosure and Apology Program, „Qualitative Health Research” 2014; 24 (6): 860–869.
  33. Denham C.R., TRUST: The 5 Rights of the Second Victim, „Journal of Patient Safety” 2007; 3 (2): 107–119.
  34. Armstrong Institute for Patient Safety and Quality, ForYOU Team, https://www.muhealth.org/about-us/quality-care-patient-safety/office-of-clinical-effectiveness/foryou (dostęp: 17.04.2023).
  35. University of Missouri Health Care, Caring for the Caregiver: The RISE Program, https://www.hopkinsmedicine.org/armstrong_institute/training_services/workshops/Caring_for_the_Caregiver/ (dostęp: 17.04.2023).
  36. Hughes , The Development of a Just Culture in the HSE, https://www.hse.ie/eng/about/who/nqpsd/qps-incident-management/just-culture-overview.pdf (dostęp: 17.04.2023).
  37. Edmondson A.C. Malcherek M., Firma bez strachu: jak zbudować kulturę organizacyjną, w której bezpiecznie jest wyrażać pomysły, zadawać pytania i przyznawać się do błędów, MT Biznes, Warszawa 2021.
  38. Rathert C., Phillips W., Medical Error Disclosure Training: Evidence for Values-Based Ethical Environments, „Journal of Business Ethics” 2010; 97 (3): 491–503.
  39. Petschonek S., Burlison J., Cross C., Martin K., Laver J., Landis R.S. et al., Development of the Just Culture Assessment Tool: Measuring the Perceptions of Health-Care Professionals in Hospitals, „Journal of Patient Safety” 2013; 9 (4): 190–197.
  40. Giraldo , Sato L., Castells X., The Impact of Incident Disclosure Behaviors on Medical Malpractice Claims, „Journal of Patient Safety” 2020; 16 (4): e225–e229.
  41. , Strategic Apologies in Medical Malpractice Mediation, „Pepperdine Dispute Resolution Law Journal” 2020; 20 (1): 60–77.


Informacje: Zdrowie Publiczne i Zarządzanie, 2022, s. 111 - 118

Typ artykułu: Oryginalny artykuł naukowy



The programs for open disclosure of adverse medical events to patients

Publikacja: 2024

Status artykułu: Otwarte __T_UNLOCK

Licencja: CC BY  ikona licencji

Udział procentowy autorów:

Agniezka Gibalska-Dembek ( Autor) - 50%
Dorota Sys ( Autor) - 50%

Korekty artykułu:


Języki publikacji:


Liczba wyświetleń: 6

Liczba pobrań: 3