Narrative Review
Patient disclosure of medical errors in paediatrics:
A systematic literature review
Donna Koller PhD, Anneke Rummens PhD, Morgane Le Pouesard MA, Sherry Espin RN PhD,
Jeremy Friedman MD, Maitreya Coffey MD FAAP FRCPC, Noah Kenneally MA PhD(c)
D Koller, A Rummens, M Le Pouesard, et al. Patient disclosure
of medical errors in paediatrics; A systematic literature review.
Paediatr Child Health 2016;21(4):e32-38.
Medical errors are common within paediatrics; however, little research
has examined the process of disclosing medical errors in paediatric set-
tings. The present systematic review of current research and policy
initiatives examined evidence regarding the disclosure of medical
errors involving paediatric patients. Peer-reviewed research from a
range of scientific journals from the past 10 years is presented, and an
overview of Canadian and international policies regarding disclosure
in paediatric settings are provided. The purpose of the present review
was to scope the existing literature and policy, and to synthesize find-
ings into an integrated and accessible report. Future research priorities
and policy implications are then identified.
Key Words: Disclosure; Medical errors; Paediatrics
M edical errors are considered to be preventable medical
events. Either a patient is harmed because of what was done
(errors of commission) or what was not done but should have been
done to prevent an adverse outcome (errors of omission) (1).
Although the terms ‘medical errors’ and ‘adverse events’ may be
used interchangeably, medical errors do not necessarily lead to
harm, while adverse events usually refer to harm associated with
medical care and can entail some degree of disability and, even
death (2). Errors have been shown to occur within the general
paediatric population (3), and a recent study by the Canadian
Patient Safety Institute (CPSI) (4) found that >9% of children
admitted to hospitals in Canada experience harm caused by health
care management, which can lead to prolonged hospital stay,
readmission, disability and, sometimes, death.
Disclosure of medical errors is a well-established legal obliga-
tion grounded in the common law doctrine of informed consent
(5). The duty to disclose an error is integral to the Canadian and
American Medical Associations’ codes of ethics. According to the
CPSI guidelines (6), medical error disclosure involves explaining
what happened and why, what will be done to prevent recurrence
and offering an apology. Studies involving adult patients show that
patients want to be informed of medical errors (7) and that an
apology reassures the patient that he/she is safe, is not at fault and
that the physician is committed to preventing future harm.
Disclosure of medical errors in paediatric populations is more
complex than in adult care because it involves not only parents
but sometimes also the child. Here, the disclosure process can be
affected by a composite of variables: the child’s desire to know;
cognitive and emotional capacities; parental perspectives on
disclosure; the roles of health care providers; disparate policies
across institutions, organizations and regions; and the degree of
risk or harm associated with the event. Presently, regulatory bod-
ies and patient safety organizations provide limited guidelines
Ryerson University, Toronto, Ontario
Correspondence: Dr Donna Koller, Ryerson University, 350 Victoria Street, Toronto, Ontario M5B 2K3. Telephone 416-979-5000 ext 2513,
fax 416-979-5239, e-mail dkoller@ryerson.ca
Accepted for publication October 20, 2015
e32 ©2016 Pulsus Group Inc. All rights reserved
La divulgation par les patients des erreurs
médicales en pédiatrie : une analyse bibliographique
systématique
Les erreurs médicales sont courantes en pédiatrie. Cependant, peu de
recherches abordent leur processus de divulgation en milieu pédiatrique.
La présente analyse systématique des projets de recherche et de politique
les plus récents a porté sur les données probantes relatives à la divulga-
tion des erreurs médicales auprès de patients d’âge pédiatrique. Les
recherches révisées par les pairs tirées d’une série de revues scienti-
fiques des dix dernières années sont présentées, de même qu’un aperçu
des politiques canadiennes et internationales sur la divulgation en
milieu pédiatrique. La présente analyse visait à évaluer les publications
et les politiques existantes et à synthétiser les résultats dans un rapport
intégré et accessible. Les prochaines priorités de la recherche et leurs
conséquences sur les politiques sont ensuite exposées.
for paediatric health care providers, and there is no consistent
protocol for the disclosure of medical errors for children and
youth in Canada.
The present article primarily examines current research find-
ings regarding the disclosure of medical errors in paediatrics. The
present systematic review provides a synthesis of child, parent and
physician perspectives, and of health care provider practices in the
reporting of medical errors. As a way of providing additional con-
text, the present article also appraises some relevant policies that
often guide the process of disclosure in paediatrics. For the present
article, policy is defined broadly to include legislation, position
statements, frameworks and practice guidelines found in Canada,
the United Kingdom, Australia and the United States.
Consideration is then given to implications for future research
priorities and for much needed policy development.
Methods
A librarian trained in systematic review searches assisted the pro-
ject team in the articulation of search parameters and procedures.
Keywords were identified over the course of several consultations,
and included the following search terms: “pediatrics”, “paediat-
rics”, “children”, “youth”, “minor”, “disclosure”, “communica-
tion”, “medical error(s)”, “adverse events”, “critical incidents”,
“bad news”, “medication error”, “patient perspectives”, “child per-
spectives”, “paediatric perspectives”, “parent perspectives”, “family
perspectives”, “physician perspectives”, “nurse perspectives”,
“safety”, “safety management”, “risk management”, “patient safety
incident”. The search was conducted on a monthly basis from June
2014 to August 2014, across five databases: MEDLine, PubMED,
Scopus, CINAHL and Embase. Through the course of the
searches, additional themes were identified in the literature. For
example, “error reporting” emerged in the literature as a relevant
keyword and significant search term.
Paediatr Child Health Vol 21 No 4 May 2016
 Patient disclosures of medical errors in paediatrics

Table 1
Studies included in the review
Child and parent perspectives on disclosure and information
Author (reference), year Objective Participants Methods Results
Clemente (10), 2007 To determine whether 17 paediatric 15 months of ethnographic fieldwork Clinicians used 4 strategies to evade direct
clinicians’ use of cancer inpatients, was conducted in a hospital in answers to patients’ questions: contingent
partial information their families, Barcelona, Spain. answers, narrow answers, non-answer
disclosure was and clinicians 86 h of interactions between doctors responses, and question forestalling
associated with and teens were videotaped and Information withholding was shown to
adolescents’ ability to analyzed using qualitative methods severely limit patients’ participation
participate in the
management of their
disease
Peña and Rojas (11), 2014 To identify key aspects 30 paediatric Qualitative methods using participant Most of the children expressed a desire to
in the exchange of inpatients (eight to observation and semistructured be informed.
information and to 14 years of age) in interviews Children reported the following barriers: not
determine how Alicante, Spain understanding information; being
nurses communicate excluded; or of not being involved in the
news to hospitalized communication process
children
Hobgood et al (13), 2005 To examine parental 499 parents of A survey portraying 4 scenarios of 99% (P<0.01) of parents want to be
preferences for error paediatric patients errors where parents were asked for informed of errors, regardless of severity
disclosure and presenting at any basic demographics, to categorize The likelihood of legal action decreased in
reporting; and hour to a tertiary the error, express preferences for scenarios in which errors were openly
preferences and care academic disclosure, and report how they disclosed
responses by race/ emergency expected to respond with and Desire for disclosure did not differ by
ethnicity, gender, age department without disclosure parental race/ethnicity, gender age or
and insurance status insurance status
Matlow et al (2), 2010 To assess parental 431 parents of Anonymous questionnaire, surveying 99% of parents wanted disclosure if there
preferences for inpatients and demographic characteristics and was potential or actual harm versus 77%
medical error outpatients at The identifying parents’ thresholds for if there was none (P<0.0001)
disclosure and Hospital for Sick disclosure using a vignette with Most parents (71% versus 41%) wanted
evaluate associated Children (Toronto, 6 levels of harm their child similarly informed (P<0.0001)
factors Ontario) Parental age, education, experience with
error and child’s age did not affect prefer-
ences for disclosure
Parents born in Asia (versus North
America) had a lower disclosure threshold
for their children (P=0.014)
Hsiao et al (12), 2007 To identify aspects of 20 parent and child Parents and children provided Participants identified several beneficial
physician (age nine to 21 individual narratives on their and harmful domains of physician
communication with years) pairs from communication experiences with communication, including relationship
children and their paediatric physicians building, information exchange,
parents that were oncology and Narratives were recorded, coded and appropriate level of child and parent
perceived as being cardiology; from analyzed using qualitative grounded involvement, an arrogant or insensitive
facilitative or two children’s theory methodology attitude, and withholding information,
obstructive in hospitals and one among others
palliative care paediatric hospice
in Los Angeles,
California, USA
Continued on next page

Inclusion criteria consisted of peer-reviewed English language
studies published between January 2004 and August 2014.
Additional sources were found as a result of manually searching ref-
erences in reviewed articles. The search yielded 1016 articles in
total. The results were sorted to exclude duplicates (eg, multiple
publications of same study) and nonempirical research. Four hun-
dred forty-four original sources remained after articles were elimin-
ated. Titles and abstracts were then scanned for relevance, resulting
in a total of 40 studies eligible for rating. A graduate-level research
assistant with previous experience in systematic reviews provided
additional support with document retrieval and initial analyses.
For quantitative studies, evaluation was based on criteria pro-
posed by Gibbs (8,9). These rating tools assist in evaluating the
quality of a study by assigning points according to various cri-
teria. Criteria for rating quantitative studies include psycho-
metric properties of measurements, sufficiency of data for
synthesis, use of a control group, random assignment, etc. For
qualitative studies, the scale examines rigour, author bias, theor-
etical descriptions and trustworthiness/authenticity, among
others. Studies scoring ≥60% were included in the synthesis, and
studies scoring >55% were re-evaluated by a second rater to con-
firm exclusion or inclusion.
Finally, a total of 17 studies were chosen for the synthesis. All
relevant data were entered into a database. Database categor-
ies included design, sample description, contextual variables,
methodological rigour, findings and outcomes. All literature

Paediatr Child Health Vol 21 No 4 May 2016 e33

Koller et al

Table 1 – CONTINUED
Studies included in the review
Paediatricians’ perspectives on disclosure
Author (reference), year Objective Participants Methods Results
Coffey et al (3), 2010 To explore paediatric 64 paediatric Mixed methods. 64 participants were Most agreed that errors should be disclosed
residents’ knowledge residents at the surveyed, followed by focus groups and that disclosure would be difficult (86%)
and attitudes about University of with 24 of them When shown a scenario involving a
disclosure Toronto (Toronto, medical error, >90% correctly identified
Ontario) the error, but only 40% would definitely
disclose it
Focus group themes included the degree
of responsibility for the error, quality of
team relationships, training level,
existence of social boundaries, and
position within hospital hierarchy
Grant et al (14), 2006 To examine the 270 inpatient Quantitative methods using The Majority (85%; P<0.001) of respondents did
culture of safety in paediatric health Safety Attitudes Questionnaire to not feel rewarded for incident reporting
a children’s hospital care providers assess staff perceptions regarding Participants reported low perceptions of
patient safety management support in error reporting
Loren et al (15), 2008 To determine whether 205 university- Anonymous 11-item survey containing 53% of respondents reported that they
and how affiliated hospital 1 of 2 scenarios (less or more would definitely disclose the error
paediatricians would and community apparent to the child’s parent), in 26% of respondents would offer an explicit
disclose serious paediatricians and which the respondent had caused a apology.
errors to parents paediatric residents serious medical error Twice as many paediatricians who received
in St Louis, the apparent error scenario would dis-
Missouri and close the error to a parent (73% versus
Seattle, 33%; P<0.001), compared with the less
Washington, USA apparent error scenario
Garbutt et al (16), 2007 To examine 557 hospital and Anonymous 68-item survey included Respondents endorsed reporting errors to
paediatricians’ community questions exploring paediatricians’ the hospital (97% serious; 90% minor;
attitudes and paediatricians attitudes and behaviors related to 82% near miss), but only 39% believed
experiences regarding and paediatric reporting errors to the hospital, that current error reporting systems
disclosing errors to residents in St discussing errors with colleagues, were adequate
hospital and families Louis, Missouri and disclosing errors to families Respondents endorsed disclosing errors to
and Seattle, patients’ families (99% serious; 90%,
Washington, USA minor; 39% near miss), and many had
done so (36% serious; 52% minor)
Kersun et al (17), 2009 To examine paediatric 171 graduates of A quantitative 12-question web survey Prior training varied in type and included
fellows’ impressions paediatric sent to physicians completing observing senior physicians (100%), being
of communication hematology/ fellowship in the past 5 years observed (78%), reading (56%), lectures
training received and oncology and (46%), role-play (20%), workshops (16%),
levels of current critical care and simulation/video (26%)
comfort with fellowships across Observing senior physicians was deemed
disclosure the United States most helpful
More years since training (P<0.0005) and
frequent difficult conversations (P=0.009)
were predictors of current comfort
Bradley et al (18), 2013 To describe the extent 50 paediatric chief 31-item telephone survey covering 94% of chief residents stated that their
and type of paediatric residents randomly 4 domains: current patient safety program had a formalized curriculum to
resident training selected from the curriculum, chief resident discuss errors, compared with only 50% in
regarding errors 198 Accreditation knowledge, learning from errors, and 2002
Council for demographics 96% stated that systemic change is required
Graduate Medical to prevent and deal with errors
Education-
accredited resi-
dency programs Continued on next page

was systematically and independently examined by two research
team reviewers.
Next, a sampling of Canadian and selected international poli-
cies on disclosure were also reviewed. The purpose of examining
policies was to provide some context for the research literature
because the process of disclosure is often guided by existing poli-
cies and, hence, can inform a deeper understanding of current
research and existing gaps. This examination included reviewing
official legislation where this exists, as well as existing policy and
practice frameworks or guidelines regarding the reporting of med-
ical errors. First, telephone calls were made to the College of
Physicians and Surgeons, the CPSI and the Canadian Medical
Association, who directed the investigators to several Canadian
policy and legislation resources. The CPSI was particularly integral
in directing the authors’ graduate level research assistant to
specific governmental and organizational websites between July

e34 Paediatr Child Health Vol 21 No 4 May 2016


Table 1 – CONTINUED
Studies included in the review
Error reporting in paediatrics
Author (reference), year
Grant and Larsen (19), 2007
Hession-Laband and Mantell
(20), 2011
Kolovos et al (21), 2008
Neuspiel et all (22), 2011
Taylor et al (24), 2007
Taylor et al (23), 2007
Paediatr Child Health Vol 21 No 4 May 2016
Patient disclosures of medical errors in paediatrics
Objective Participants Methods Results
To compare Health care The Patient Safety Report (PSR), an A total of 1119 PSR and 590 PICU
characteristics of providers in a electronic and anonymous system, traditional event reports were submitted
errors reported in the 32-bed combined was developed. All members of the health care team
traditional hospital medical and Over an 18 month period, the PSR completed PSRs including registered
event reporting surgical PICU cards and a locked collection box nurses (64%), nurse practitioners (9%),
system versus a new located in a were placed in 5 locations in the physicians (8%), patient care technicians
anonymous system in university-affiliated, PICU (5%), respiratory therapists (2%) and
a paediatric intensive tertiary care facility The events cataloged in the PSR were pharmacists (2%)
care unit (PICU) compared with those captured in the
traditional reporting system (which is
paper based, not anonymous, and
does not capture near-miss events)
To document a novel 257 nurses from the A paper-based event reporting system The medical and surgical units experienced
error reporting Children’s Hospital was replaced in 2005 by a web- a 35% increase in reported events and a
process by nurses in Boston, based system called the Safety Event decrease in the severity level of events
Massachusetts, Reporting System (SERS) over a 2-year period
USA This system provides anonymous,
self-reporting and can be categorized
into several event types
To examine St Louis Children’s The Medical Error Reporting Tool is a More errors were reported than with the
improvements in error Hospital’s PICU set of color-coded index cards that existing error-reporting system.
reporting by (St Louis, provide instructions and definitions 2936 events were documented.
implementing a novel Missouri, USA) for error-related terms Nurses (83.1%) completed the vast
error-reporting tool for PICU staff anonymously reported majority of medical error reports
the paediatric events by checking all applicable Near misses, previously unrecognized as
intensive care unit category-specific errors listed on cards errors, accounted for 11% of total reports
(PICU) Data comparing the new system with
the existing non-anonymous reporting
system were reported using simple
summary statistics
To implement and All medical staff Health care providers used systems In 30 months, 216 errors were reported,
evaluate a from an academic analysis and rapid redesign to compared with 5 reports in the year
nonpunitive error general paediatric evaluate each error report and before the project
reporting system practice in recommend changes to prevent The most frequently reported errors were
Charlotte, North patient harm misfiled patient information (n=68), labo-
Carolina, USA ratory tests errors (n=27), medication-
related errors (n=24) and vaccine errors
(n=21)
To describe the 140 physicians and A survey regarding the use of 34.8% of respondents indicated that they
proportion and types nurses at a large incident reports was administered had reported <20% of their perceived
of errors that are children’s hospital Differences in use of incident reports errors in the previous 12 months
reported via incident for recording errors between nurses Commonly listed reasons for underreporting
report systems, and to and physicians were assessed using included lack of certainty about what is
determine attitudes chi-squared tests considered an error (40.7%) and concerns
about interventions for about implicating others (37%)
increasing error Interventions that could lead to increased
reports reporting: education (65.4%), feedback
upon reporting (63.8%), evidence of system
changes upon reporting (55.4%), and an
electronic format for reports (44.9%)
To compare reports of Physicians and Over a 3-month period in 2003, A total of 146 reports were made using the
errors submitted nurses from the reports of errors from 2 units were anonymous system, 131 of which
using an electronic, infant intensive made using an electronic, documented errors.
anonymous reporting care unit and the anonymous system The rate of reporting was significantly higher
system with those medical unit at 3 reviewers independently evaluated with the anonymous system (rate ratio
submitted via Children’s Hospital each report and determined whether 1.54 [95% CI 1.26 to 1.90])
traditional incident and Regional the events described constituted a With the anonymous system, 25.2% of
reports Medical Center, in medical error reported errors were near-misses com-
Seattle, An identical procedure was used to pared with 12.6% of the errors reported
Washington, USA categorize medical error data with the traditional incident report system
collected via traditional incident (P=0.001)
reporting before 2003
e35
Koller et al
and August 2014. Additional contact was made with a sample of
organizations, including paediatric hospitals across Canada and
federal legislative bodies, to identify additional sources. A keyword
search within collected sources was conducted to determine
whether Canadian policies contained specific guidelines per-
taining to paediatrics. If guidelines did include specific considera-
tions for paediatric settings, content was thematically analyzed for
depth and clarity of emerging issues.
Once data saturation was achieved from Canadian policies, a
sampling of international policies and legislation was undertaken
to provide some basis for comparison. Policies from Australia, the
United Kingdom and the United States were chosen as a focus for
several reasons. First, they use comparable terminology surround-
ing medical errors and disclosure. Second, it was important to
consider countries that hold similar societal views of childhood
and ethical care in paediatrics. Third, by sampling policies writ-
ten in English, it enabled the authors to easily conduct a com-
parative analysis of policies. Despite contextual similarities,
policies from these countries yielded contrasting approaches to
error disclosure, citing a range of perspectives.
Results
The results of the systematic review of the research are summarized
in Table 1. A variety of perspectives and topics ranging from com-
munication styles to error reporting were found. We chose to cat-
egorize these synthesized findings according to stakeholder group to
reflect the way in which current literature was presented in the past
10 years. Findings regarding error reporting and policies were organ-
ized separately from stakeholder perspectives. Error reporting was
deemed as an emergent and distinct theme because much of the
literature focused on reporting rather than disclosure processes.
Children’s perspectives on disclosure and information
No studies were found that specifically examined children’s per-
spectives on the disclosure of medical errors. To provide some
related research on paediatric patient perspectives, three studies
that addressed the perspectives of children and youth (age three to
21 years across the three studies) on participation in health care
discussions and decision making were reviewed. Receiving infor-
mation appears to be important to children because failure to
obtain full and open disclosure about their medical care may cause
them anxiety and feelings of uncertainty (10), and some children
report feeling excluded from communication in medical settings
(11). In hospital settings, children may prefer to have a private
conversation with their physician, without parents present (12).
The manner in which information is delivered to children can
influence their emotional reaction and, in one study, children
found physicians’ use of medical terminology anxiety inducing and
would have preferred lay language (11). Overall, it appears that
there is no ‘one-size-fits-all’ manner of disclosing information to
children because individual children can differ in their prefer-
ences, and there are also age- and maturity-based considerations
(11).
Parents’ perspectives on paediatric disclosure
Parents generally want to be informed of medical errors in their
child’s care, regardless of severity or level of harm (2,13). In one
study, desire for disclosure did not differ according to parental
ethnicity/race, sex, age or insurance status (13). In another
study, ‘Asian’ parents were shown to be more likely than ‘North
American’ parents to wish for disclosure at lower levels of harm
(2). Parental likelihood of seeking legal action may decrease
with disclosure (13). In terms of disclosure to the child, parents
e36
sometimes wish to receive information first before conveying it to
their child (12). Matlow et al (2) found that a higher percentage
of parents wanted errors disclosed to their child if there was any
potential or real harm than if there was no possibility of injury.
This preference was significantly related to the age of the child,
with parents of older children being more likely to disclose errors
to their child.
Paediatricians’ perspectives on disclosure
Factors, such as worrying about one’s reputation, fear of litigation
and lack of perceived support from health care organizations, can
prevent paediatricians from disclosing errors (3,14), and they may
be more willing to disclose an error if it is apparent (15). Many
paediatricians report wanting more education and training about
medical errors and disclosure (3,16,17). Although education about
medical errors appears to have improved in the past decade, the
focus continues to be on error avoidance with much less emphasis
on disclosure (18). Paediatricians are calling for a nonpunitive,
supportive culture around medical error disclosure (3,14,16), and
identify a need for systemic change (3,14,16,18) in the form of
better error prevention mechanisms (3) and more convenient sys-
tems for error reporting (16).
Error reporting in paediatrics
Currently, the subject of error reporting is studied in isolation from
that of error disclosure. Anonymous error reporting systems tend
to increase rates of reporting (19-23). Nurses tend to report more
errors than physicians (21,24). Factors that physicians cite as
being likely to increase error reporting include education about
errors (20,24), the prospect of systemic changes being imple-
mented as a result of reporting (22,24) and a nonpunitive culture
(22). Reporting of ‘near misses’ is another theme in the literature
(19), noted as important for identifying system hazards (19) and
resulting in ‘good catches’ (20).
Policies regarding disclosure of medical errors
The CPSI’s Canadian Disclosure Guidelines: Being open with Patients
and Families (6), underscores the lack of formal Canadian legis-
lation at the federal and provincial levels regarding disclosure,
specifically to paediatric patients. Four provinces have legislation
regarding mandatory disclosure and reporting to patients in gen-
eral – Manitoba, Ontario, Quebec and Saskatchewan – but none
of these refer to particular processes with children.
The first version of CPSI’s guidelines (25) recommended that
the child’s ability to make treatment decisions is generally used as
a guide for determining their inclusion in disclosure discussions.
The revised 2011 document (6) elaborates on child capacity by
stating that the Canadian Paediatric Society’s Position Statement
on Treatment Decisions is generally used as a guideline when
deciding whether to include paediatric patients in disclosure con-
versations. While it states that “capacity is not age- or disease-
related,” it also indicates that “the majority of children will not
have decision-making capacity and will require a proxy to make
decisions for them”. This position statement reflects the legal con-
cept of a mature minor in acknowledging that the child may be
“considered intellectually capable and emotionally mature enough
to make his or her own decisions”.
Selected international examples highlight that some countries
have been more specific with regard to policy including children.
The United Kingdom’s National Patient Safety Agency’s Being
Open (26) contains a specific section regarding children, outlining
that while some patients of legal age of maturity are able to con-
sent to treatment (16 years), younger children have been found
capable of understanding what is involved in a procedure and can
Paediatr Child Health Vol 21 No 4 May 2016

also give consent. It recommends that “children who have the
cognitive and emotional maturity to understand the information
provided… should be involved directly in the Being Open process
after a patient safety incident”.
Similarly, the Australian Open Disclosure Framework (27),
developed and presented by the Australian Commission on Safety
and Quality in Health Care, proposes that the clinical team and
parents need to decide together how to involve young patients,
and that “the clinical team should assess the involvement of young
people in the open disclosure process on a case-by-case basis, tak-
ing account of whether the child is sufficiently mature to receive
the information and having regard to the wishes of the young
person and the parents, where appropriate”.
Finally, in the United States, the most recent version of Safe
Practices for Better Healthcare (28), published by the National
Quality Forum, suggests that “the patient and, as appropriate, the
family should receive timely, transparent, and clear” information
regarding an adverse event, but does not include any specific rec-
ommendations for paediatrics.
Discussion
Despite the prevalence of medical errors in paediatric settings,
little research exists regarding the process of disclosing errors to
patients and their families, such as how to determine whether
to disclose, who should be present, when disclosure should hap-
pen and how physicians should best proceed in these situations.
More troubling is the lack of research examining children’s own
perspectives regarding the disclosure of medical errors, despite
evidence that paediatric patients have unique communication
preferences for receiving other types of medical information (11)
and, in many cases, are able to participate in complex health-
related discussions.
The research highlights that parents generally want to be
informed of medical errors in their child’s care, regardless of
severity or level of harm (2,13). Sometimes, parents prefer to
receive information first before sharing with their child (12).
The subsequent decision of whether to inform the child depends
on a range of factors such as the age of the child or the likelihood
of real harm (2).
Research investigating physician perspectives reveals a fear of
disclosing errors to patients and families. Physicians are worried
about their reputation, fear litigation and perceive a lack of sup-
port from health care organizations that tend to have a punitive
culture regarding errors (3,14). Even when willing to disclose,
many physicians report feeling unequipped to do so and wanting
education and training about medical errors and disclosure – a
relative shift from the current focus on error avoidance (3,16,17).
Furthermore, there appears to be a division between studies on
error disclosure and on error reporting, with no research examin-
ing the two as linked processes. Because the direction of research
impacts evidence-based practice, future studies should examine
the needs of physicians in terms of both the disclosure and the
reporting of errors. Additionally, the impact of no-fault disclosure
on reporting outcomes, ‘good catches’, process improvements and
child health indicators also require further investigation.
A review of Canadian policy uncovered a lack of paediatric-
specific guidelines. Only four Canadian provinces have legislation
regarding mandatory disclosure and reporting to patients. None of
this legislation, however, refers specifically to disclosure practices
with children. Similarly, a limited paediatric focus is found in
American disclosure policies and practices, reinforcing the need
for guidelines that support paediatric disclosure processes within a
North American context.
Paediatr Child Health Vol 21 No 4 May 2016
Patient disclosures of medical errors in paediatrics
While the United Kingdom relies on age of consent (16 years)
as a guideline for the disclosure of medical errors to paediatric
patients, Australia’s Open Disclosure Framework states that the
clinical team and parents need to decide together how to involve
young patients. In so doing, Australian policy appears to promote
a shared or collaborative form of decision making and one that
acknowledges the significance of adopting a case-by-case approach.
In particular, Australian policies appear to be most aligned with
current research that supports a nuanced, case-by-case analysis of
several variables, including patient capacity to receive disclosure
information. Clearly, adjustments to Canadian policies and practi-
ces should comprise more detail regarding paediatric processes that
similarly account for the preferences of parents and their
children.
Summary
There is a pressing need for the development of policies and prac-
tices that inform and address the complexities of disclosing med-
ical errors in paediatrics. We must begin by examining children’s
understanding of medical errors and what they expect from their
health care providers when errors occur. Future research, therefore,
should examine children’s perspectives as an essential starting
point for the development of policy and the identification of eth-
ical and best practices. This critical vantage point, in combination
with parent and physician perspectives and experiences, is critical
to advancing our understanding of error disclosure in paediatric
settings.
Acknowledgements: This research was funded by the
Canadian Institutes of Health Research (#132282). The authors grate-
fully acknowledge the participation of several organizations including
the Canadian Association of Paediatric Health Centres, the Canadian
Patient Safety Institute, and The Hospital for Sick Children’s Child
Life and Social Work Departments. They also thank Elaine Orrbine
and Lisa Stromquist from the Canadian Association of Paediatric
Health Centres, as well as Ioana Popescu and Carola Bravi from the
Canadian Patient Safety Institute, for their support of this research.
References
1. Hébert PC, Levin AV, Robertson G. Bioethics for clinicians:
23. Disclosure of medical error. CMAJ 2001;164:509-13.
2. Matlow AG, Moody L, Laxer R, Stevens P, Goia C, Friedman JN.
Disclosure of medical error to parents and paediatric patients:
Assessment of parents’ attitudes and influencing factors.
Arch Dis Child 2010;95:286-90.
3. Coffey M, Thomson K, Tallett S, Matlow A. Pediatric residents’
decision-making around disclosing and reporting adverse events:
The importance of social context. Acad Med 2010;85:1619-25.
4. Matlow AG, Baker GR, Flintoft V, et al. Adverse events among
children in Canadian hospitals: The Canadian Paediatric Adverse
Events Study. CMAJ 2012;13:E709-18.
5. Health Care Consent Act (1996). S.O. 1996, c. 2, Sched. A.
Government of Ontario. 2010 July [cited 2015 Jun 7]. <www.canlii.
org/en/on/laws/stat/so-1996-c-2-sch-a/latest/so-1996-c-2-sch-a.
html> (Accessed June 20, 2014).
6. Canadian Patient Safety Institute. Canadian Disclosure Guidelines:
Being open with patients and families.2011 Nov [cited 2015 Jun 7].
<www.patientsafetyinstitute.ca/english/toolsresources/disclosure/
pages/default.aspx> (Accessed June 20, 2014).
7. Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Error or
“act of God”? A study of patients’ and operating room team
members’ perceptions of error definition, reporting, and disclosure.
Surgery 2006;139:6-14. <www.ncbi.nlm.nih.gov/pubmed/16364712>
(Accessed June 20, 2014).
8. Gibbs LE. Quality of Study Rating Form: An instrument for
synthesizing evaluation studies. J Soc Work Educ 1989;25:55-67.
e37
 Koller et al
9. Gibbs LE. Evidence-based practice for the helping professions:
A practical guide with integrated media. BrooksCole an Imprint of
Wadsworth Publisher (CA), 2003.
10. Clemente I. Clinicians’ routine use of non-disclosure: Prioritizing
“protection” over the information needs of adolescents with cancer.
Can J Nurs Res 2007;39(4):19-34.
11. Peña AL, Rojas JG. Ethical aspects of children’s perceptions of
information-giving in care. Nurs Ethics 2014;21:245-56.
12. Hsiao JL, Evan EE, Zeltzer LK. Parent and child perspectives on
physician communication in pediatric palliative care.
Palliat Support Care 2007;5:355-65.
13. Hobgood C, Tamayo-Sarver JH, Elms A, Weiner B. Parental
preferences for error disclosure, reporting, and legal action after
medical error in the care of their children. Pediatrics
2005;116:1276-86.
14. Grant MJ, Donaldson AE, Larsen GY. The safety culture in a
children’s hospital. J Nurs Care Qual 2006;21:223-9.
15. Loren DJ, Klein EJ, Garbutt J, et al. Medical error disclosure among
pediatricians: choosing carefully what we might say to parents.
Arch Pediatr Adolesc Med 2008;162:922-7.
16. Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing
medical errors: Pediatricians’ attitudes and behaviors. Arch Pediatr
Adolesc Med 2007;161:179-85.
17. Kersun L, Gyi L, Morrison WE. Training in difficult conversations:
a national survey of pediatric hematology-oncology and pediatric
critical care physicians. J Palliat Med 2009;12:525-30.
18. Bradley CK, Fischer MA, Walsh KE. Trends in medical error
education: Are we failing our residents? Acad Pediatr
2013;13:59-64.
19. Grant MJ, Larsen GY. Effect of an anonymous reporting system on
near-miss and harmful medical error reporting in a pediatric
intensive care unit. J Nurs Care Qual 2007;22:213-21.
e38
20. Hession-laband E, Mantell P. Lessons learned: Use of event
reporting by nurses to improve patient safety and quality.
J Pediatr Nurs 2011;26:149-55.
21. Kolovos NS, Bratton SL, Levy FH. A novel error-reporting tool in
pediatric intensive care. J Healthc Qual 2008;30:43-50.
22. Neuspiel DR, Stubbs EH, Liggin L. Improving reporting of
outpatient pediatric medical errors. Pediatrics 2011;128:e1608-13.
23. Taylor JA, Brownstein D, Klein EJ, Strandjord TP. Evaluation of an
anonymous system to report medical errors in pediatric inpatients.
J Hosp Med 2007;2:226-33.
24. Taylor JA, Brownstein D, Christakis DA, et al. Use of incident
reports by physicians and nurses to document medical errors in
pediatric patients. Pediatrics 2004;114:729-35.
25. Canadian Patient Safety Institute. Canadian Disclosure Guidelines:
Being open with patients and families. 2008 May [cited 2015 Jun 7].
<www.chirofed.ca/english/pdf/CPSI_Canadian_Disclosure_
Guidelines_EN.pdf> (Accessed June 20, 2014).
26. National Patient Safety Agency. Being Open: Communicating
patient safety incidents with patient, their families and carers. 2009
Nov [cited 2015 Jun 7] <www.nrls.npsa.nhs.uk/
beingopen/?entryid45=83726> (Accessed June 20, 2014).
27. Australian Commission on Safety and Quality in Health Care.
Australian Open Disclosure Framework, ACSQHC, Sydney:
Australia. 2013 [cited 2015 Jun 7]. <www.safetyandquality.gov.au/
wp-content/uploads/2013/03/Australian-Open-Disclosure-
Framework-Feb-2014.pdf> (Accessed June 20, 2014).
28. National Quality Forum (NQF). Safe Practices for Better
Healthcare–2010 Update: A Consensus Report. Washington, DC:
NQF; 2010. <www.qualityforum.org/Publications/2010/04/Safe_
Practices_for_Better_Healthcare_%E2%80%93_2010_Update.
aspx> (Accessed June 20, 2014).
Paediatr Child Health Vol 21 No 4 May 2016