| Course | IHP 315 Patient Safety Systems and Strategies |
|---|---|
| Module | Module 5 |
| Paper type | short paper on disclosure of medical errors |
| Length | About 1,060 words, 6 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | BS Healthcare Administration |
| Updated | September 2026 |
Free sample paper for IHP 315 Module 5
Disclosing a Heparin Dosing Error: What the Patient Deserves and What the Hospital Should Do
[Student Name]
Southern New Hampshire University
IHP 315: Patient Safety Systems and Strategies
Module Five Short Paper
[Instructor Name]
[Date]
Disclosing a Heparin Dosing Error: What the Patient Deserves and What the Hospital Should Do
When Mrs. R., the patient in the heparin event analyzed in Project One, asked her nurse why her urine was pink, the nurse told her the doctor would explain. Two days later, no one had. Her daughter was starting to ask pointed questions. This paper considers how Maple Grove should disclose the error, drawing on research about what patients want, what makes disclosure hard for clinicians and what disclosure programs have achieved, and it proposes both a plan for this case and a hospital policy.
What Patients Want
Gallagher et al. (2003) held focus groups with patients and physicians to compare their views on disclosure. Patients wanted to be told about every error that harmed them, and they wanted a clear statement that an error had happened, an explanation of what went wrong and why, information about how its effects would be managed, an account of what would be done to keep it from happening to someone else and an apology. Several said that learning what the hospital would change mattered most to them, because it gave the harm some meaning.
Physicians in the same study accepted the principle of telling patients about harmful mistakes, yet many admitted to picking their words with care, mentioning an adverse event without saying an error had occurred and avoiding an explicit apology out of concern about lawsuits. The gap between what patients want and what clinicians tend to say is the central problem disclosure policy must solve.
What the Research Shows About Communicating Errors
Mazor et al. (2004) reviewed studies of communication about medical errors. They found consistent evidence that patients want disclosure and that most physicians support it in principle, yet also evidence that disclosure in practice is inconsistent. Few studies had examined actual disclosure conversations, and evidence on how disclosure affects patients' trust and decisions to sue was limited and mixed. The authors called for training and organizational support so that clinicians are not left to handle these conversations alone.
For Maple Grove, the review suggests two things. First, the hospital cannot assume that disclosure will happen just because it is the right thing to do; it needs a process. Second, clinicians need help to have the conversation well.
What Disclosure Programs Have Achieved
Concern about liability is the most common reason clinicians hesitate. Kachalia et al. (2010) studied the University of Michigan Health System, which adopted a program of disclosing errors, investigating promptly and offering compensation when care was unreasonable. Comparing years before and after the program, they found that fewer new claims and suits were filed, cases closed sooner and overall spending on liability, compensation included, went down. The study was a before-and-after comparison at one institution, and shifts in the wider legal climate over those years may also have played a part, but it offers strong reassurance that honesty does not necessarily increase legal exposure and may reduce it.
A Disclosure Plan for Mrs. R.
Disclosure should happen within a day, not after the investigation is complete. The attending physician, accompanied by the unit's nurse manager and the patient safety officer, should meet Mrs. R. and her daughter in a private room. The physician should state plainly that an error occurred: her weight was entered wrongly, and she received too much heparin, which caused the bleeding. The team should explain how her bleeding is being monitored and treated, apologize sincerely and describe the steps already under way, such as changing the weight field so it accepts only kilograms. They should promise a follow-up conversation once the analysis is complete, give her a single contact person and tell her that charges related to the error will be waived.
Staff should avoid speculation about individuals, defensive language and promises the hospital cannot keep. Notes should record what was said.
Supporting the Staff Involved
The triage nurse who entered the weight and the two nurses who performed the double check are also affected by this event. Clinicians involved in errors often feel guilt, shame and fear of punishment, and some leave their jobs or the profession. The research on disclosure repeatedly notes that clinicians need support to have honest conversations, and that support should extend to their own recovery. Maple Grove should offer each nurse a confidential conversation with a trained peer supporter within a few days, make clear that the event analysis focused on system causes and invite them, if they wish, to help design the fixes. Treating these nurses fairly also sends a message to the rest of the staff about whether it is safe to report the next error.
A Hospital Disclosure Policy
Maple Grove's current policy says only that adverse events should be communicated to patients as appropriate. A stronger policy would commit the hospital to disclosing all errors that reach the patient and cause harm, name who leads disclosure and who supports it, set a time frame, require documentation and a follow-up meeting and provide a consultation service so clinicians can rehearse with a trained colleague before difficult conversations. It should also describe support for clinicians involved in errors, who often experience guilt and distress, and establish a process for early review of possible compensation modeled on the Michigan approach.
Table 1. Elements of a Disclosure Policy
| Element | Provision |
|---|---|
| Scope | All errors reaching the patient that cause harm |
| Timing | Initial disclosure within 24 hours; follow-up after review |
| Team | Attending physician leads; nurse manager and safety officer support |
| Content | Error acknowledged, explanation, care plan, apology, prevention steps |
| Support | Coaching before conversations; peer support for involved clinicians |
| Resolution | Early review of billing and compensation |
Note. Elements reflect the research reviewed and the case.
Measuring the Policy
The patient safety office should track the share of harmful errors disclosed within 24 hours, the share with a documented follow-up meeting and the number of clinicians using the coaching service. Brief follow-up calls with patients who received disclosure could ask whether they felt the explanation was honest and complete. Over several years, the hospital can watch claims and costs, while recognizing that many factors influence them.
Conclusion
Mrs. R. deserves to hear, clearly and soon, that an error harmed her, what the hospital is doing about her care and what it will change. Research shows that patients want exactly this, that clinicians need support to provide it and that honest disclosure programs can reduce rather than increase liability. A clear policy turns good intentions into consistent practice.
References
Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA, 289(8), 1001-1007. https://doi.org/10.1001/jama.289.8.1001
Kachalia, A., Kaufman, S. R., Boothman, R., Anderson, S., Welch, K., Saint, S., & Rogers, M. A. M. (2010). Liability claims and costs before and after implementation of a medical error disclosure program. Annals of Internal Medicine, 153(4), 213-221. https://doi.org/10.7326/0003-4819-153-4-201008170-00002
Mazor, K. M., Simon, S. R., & Gurwitz, J. H. (2004). Communicating with patients about medical errors: A review of the literature. Archives of Internal Medicine, 164(15), 1690-1697. https://doi.org/10.1001/archinte.164.15.1690
What the IHP 315 Module 5 instructions ask for
The IHP 315 disclosure assignment generally asks you to explain what disclosure of medical errors involves, why it matters, what barriers stand in the way and how an organization should handle it, often applied to a case. Two to four APA 7 pages with at least two or three scholarly sources is common. Describe what patients want from disclosure, name the barriers clinicians face, report what disclosure programs have shown and propose a concrete plan or policy. Keep the patient at the center, and be specific about who says what and when, because vague commitments to transparency tend to score lower than a clear, practical sequence of steps. A short table of policy elements works well.
How this IHP 315 Module 5 disclosure short paper example is built
This paper applies disclosure research to a heparin dosing error that caused bleeding in a 72-year-old woman who had not yet been told. Gallagher and colleagues show that patients want an explicit acknowledgment, an explanation, a care plan, prevention steps and an apology, while physicians tend to soften their words. Mazor and colleagues find broad support for disclosure but inconsistent practice. Kachalia and colleagues show claims and costs fell after the University of Michigan adopted disclosure with compensation. A plan specifies who meets the patient within a day and what they say, and a policy table covers scope, timing, team, content, support and resolution. Peer support for the nurses involved is included.
Where the IHP 315 Module 5 rubric puts the points
Disclosure papers in IHP 315 are typically graded on understanding what disclosure requires, use of evidence on patient preferences and clinician barriers, accurate reporting of disclosure program outcomes, the practicality of the proposed plan or policy, patient-centeredness, scholarly support and APA 7. The strongest papers turn research into specific steps, address liability concerns with evidence and include support for clinicians involved in errors. Papers lose points when they describe disclosure only as a legal risk, when plans are vague about timing and roles or when the apology and prevention steps patients value most are left out entirely. Attention to clinicians involved in the error adds depth.
IHP 315 Module 5 help: the mistakes that cost points
In IHP 315, disclosure papers often lose points for treating disclosure as optional, for ignoring what patients say they want, for overstating what one institution's results prove and for plans with no timeline. Another gap is forgetting the clinicians involved, who need support after an error. Center the patient, cite evidence on preferences and program results, specify who discloses what and when and include clinician support. If your section uses a particular case or state disclosure law, add it to your IHP 315 notes and the paper will address those specifics directly. Be specific about roles and timing. Plain, compassionate language matters in any sample script.
Get IHP 315 Module 5 written to your instructions
Send the IHP 315 disclosure prompt and the case you are working with. The paper will explain what patients want, address clinician barriers and liability with evidence, set out a concrete disclosure plan with roles and timing and propose policy elements, within 24 to 48 hours, free the first time. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
More IHP 315 papers and related BS Healthcare Administration samples
- IHP 315 Module 1 Discussion: How Often Hospital Care Harms Patients
- IHP 315 Module 2 Safety Culture Short Paper: Reading and Improving Safety Culture
- IHP 315 Module 3 Reporting Systems Short Paper: Why Staff Stop Reporting
- IHP 315 Module 4 Project One: Adverse Event Analysis of a Heparin Dosing Error
- IHP 315 Module 6 Technology Short Paper: How Health IT Creates New Kinds of Error
- IHP 315 Module 7 Project Two: A Surgical Safety Checklist Improvement Plan
- IHP 315 Module 8 Discussion: What Administrators Owe Patient Safety
- IHP 310 Module 1 Cell Injury Discussion
- IHP 420 Module 5 Malpractice Case Milestone Two
- IHP 430 Module 4 Final Project Milestone Two
- IHP 450 Module 3 Final Project Milestone One
IHP 315 Module 5 questions, answered
Where can I find a free IHP 315 Module 5 Disclosure Short Paper sample?
Read the whole paper on this page: disclosing a heparin dosing error, what patients want and what disclosure programs have shown, with a plan and policy.
What do patients want when a medical error occurs?
An explicit statement that an error happened, an explanation, how its effects will be handled, what will prevent recurrence and an apology.
Does disclosing errors increase lawsuits?
A study of the University of Michigan program found claims, lawsuits and costs fell after disclosure with compensation became standard.
Who should disclose a medical error?
Usually the attending physician, supported by nursing and patient safety staff, in a private meeting soon after the event.
Why do clinicians hesitate to disclose errors?
Common reasons include fear of liability, uncertainty about what to say and the emotional difficulty of admitting harm.