title: John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center.
abstract: BACKGROUND
  After the Veterans Affairs Medical Center (VAMC) in Lexington, Kentucky, lost two major malpractice cases in the mid-1980s, leaders started taking a more proactive approach to identifying and investigating incidents that could result in litigation. An informal risk management team met regularly to discuss litigation-prone incidents. During one in-depth review, the team learned that a medication error had caused the patient's death. Although the family would probably never have found out, the team decided to honestly inform the family of exactly what had happened and assist in filing for any financial settlement that might be appropriate. This decision evolved into an organization wide full disclosure policy and procedure.
  The Lexington VAMC's policy on full disclosure includes informing patients and/or their families of adverse events known to have caused harm or injury to the patient as a result of medical error or negligence. The disclosure includes discussions of liability and also includes apology and discussion of remedy and compensation.
  
  
  RESULTS
  Full disclosure is the right thing to do and the moral and ethical thing to do. Moreover, doing the right thing actually seems to have mitigated the financial repercussions of inevitable adverse events that result in injury to patients. As reported in 1999, Lexington VAMC was in the top quarter of medical centers for number of tort claims filed but was in the lowest quarter for malpractice payouts resulting from these torts.
authors.affiliation: Veterans Affairs Medical Center (VAMC), 1101 Veterans Drive, Lexington, KY 40502.
authors.forename: Steve S
authors.initials: SS
authors.lastname: Kraman
authors.forename: Linda
authors.initials: L
authors.lastname: Cranfill
authors.forename: Ginny
authors.initials: G
authors.lastname: Hamm
authors.forename: Toni
authors.initials: T
authors.lastname: Woodard
mesh_terms: D001363:Awards and Prizes; D035881:Compensation and Redress; D006787:Hospitals, Veterans / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D007049:Iatrogenic Disease; D007324:Institutional Management Teams; D007629:Kentucky; D007857:Leadership; D016365:Liability, Legal; D008318:Malpractice; D019300:Medical Errors; D016134:Organizational Policy; D010344:Patient Advocacy; D017751:Safety Management / Q000592:standards*; D014342:Truth Disclosure