In the 1930s, doctors were advised to “keep a cautious tongue” with regard to errors [4]. This attitude toward error disclosure persisted throughout much of the twentieth century until specific disclosure programs such as the Lexington Model emerged [5]. In 1987, the Lexington Veterans Administration Medical Center (VAMC) lost two medical malpractice cases and discovered that a patient death was due to medical negligence. Subsequently, the facility, including the chief of staff and staff attorney, decided that the “right thing to do” was to disclose the medical error to the family [5, 6]. Kraman and Hamm, who led this innovative disclosure program, described this approach to ethical dilemmas involving medical error as “humanistic risk management,” in which the physician and facility continued the caregiver role in communicating the error to the patient and/or family [6]. While their policy did not significantly impact litigation, the litigation costs were lower. The Lexington VAMC continued to report a high number of tort claims compared to other VAMCs, but interestingly the Lexington VAMC placed in the lowest quartile for litigation costs [7]. More importantly, the physicians and the VAMC believed disclosure to be their ethical and professional responsibility. The success of the Lexington Model led the Veterans Administration National Center for Ethics in 2008 (updated in 2012) to write a disclosure policy based on their model, although there has been significant variation in the uptake of these disclosure policies [5, 6]. This development of a disclosure policy in the Veterans Administration also prompted the creation of a simulation-based disclosure training programming for the VAMCs [5].

The IOM report and the success of the Lexington Model motivated other institutions and organizations to create policies on error communication. The Joint Commission released the first national standard in 2001 that required physicians to disclose outcomes of any treatment when they “differ significantly from the anticipated outcomes” [8]. Though the Joint Commission provided little detail about what should be disclosed and how this information should be disclosed, the Joint Commission release of the first national standard on disclosure was an important step because of the Joint Commission’s role in accrediting hospitals [9]. Furthermore, the National Quality Forum created a safe-practice guideline on the disclosure of serious unanticipated outcomes with the goal of promoting high-quality health care [10]. Other organizations such as the American Medical Association (AMA) developed their own standards in their Code of Medical Ethics to advise physicians to “deal honestly and openly with patients,” provide full disclosure to patients to support patients’ autonomy in medical decision-making, and not be influenced by legal liability [11]. Another prominent policy addressing error communication is the Charter on Medical Professionalism, which is endorsed by over 100 organizations and calls for open and honest communication with patients including discussions of medical errors [12].

Similar to the Lexington VAMC, other institutions and organizations have demonstrated a link between transparency in error communication and decreased litigation costs [13]. The University of Michigan Health Systems showed that their open disclosure program reduced the number of litigation cases and the cost of litigation over 5 years. At the University of Michigan, the open disclosure program accomplished these reductions in cases and costs by acknowledging medical errors, fairly compensating patients and families, defending cases that did not have merit, and studying prior events to determine prevention strategies [14]. In addition, the American College of Surgeons Closed Claims Study, which examined 460 claims against general surgeons, demonstrated that transparency and communication in the surgeon-patient relationship decreased litigation and prevented errors and bad outcomes [15]. These nationally recognized organizations demonstrate that disclosure policies can be beneficial for all parties involved.

As an autonomous stakeholder in the physician-patient relationship, patients desire full disclosure of medical errors. Delbanco and Bell conducted focus groups with patients and families and three themes emerged [16]: (1) Family members have strong feelings of guilt after an error occurs. (2) Patients and their families may fear further harm and/or retribution if they ask questions about the error or voice their feelings. (3) The patient and family may also feel abandoned, perhaps in response to how the physician feels and behaves toward them [16]. The patients and family members that were interviewed expressed their desire for an apology and direct, honest communication [16]. Furthermore, Gallagher et al. and Marcus et al., after interviewing patients and families about what they wanted after an error had occurred, found that patients and families wanted full disclosure of the error including the implications on their health, a genuine apology and a commitment to prevention of the error in the future [17, 18]. Further supporting the fact that patients want full disclosure, Mazor et al. conducted a study of nearly 1000 patients who responded to a mail survey with vignettes describing medical errors and reported that 98.8% of patients wanted full disclosure and 88% wanted a sincere apology [19]. Of interest, Mazor et al. found that nondisclosure was associated with respondents obtaining legal advice, yet disclosure was associated with increased patient satisfaction and trust – both of which are critical to the physician-patient relationship [19]. Not surprisingly, they also found that the type of error and the severity of the outcome might influence patients to seek legal advice despite physician disclosure [19]. Nevertheless, these studies reinforce the idea that open and honest communication can address the patient’s need for information after a medical error occurs.

The disclosure gap persists despite the existence of many organizational and national policies and the patient’s desire for information. Patients and their families continue to have unmet needs following a medical error. In contrast to institutional disclosure, which is conducted by the organization after an adverse event rises above a certain threshold of harm, clinical disclosure is conducted by the physician and should occur routinely in the physician-patient relationship [5]. Thus, physicians have the greatest potential impact on error disclosure. Several studies have examined physician attitudes on the communication of errors and the barriers that exist which may explain the disclosure gap.