One System's Journey in Creating a Disclosure and Apology Program

After a medical error, patients and families expect the organization to make changes to the system to prevent other patients from being harmed by the same mistake. To minimize the chance that patients and families feel that their suffering has been “in vain,” health care systems will need to put systems in place to deliver on the promise to reduce the risk of future harm. Some of the challenges in sustaining such a program include the ability to promptly investigate, to accurately determine liability, to communicate empathetically even if unable to meet all patient/family expectations, and to ensure establishment of a just culture.