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4
The World Health Organization is grateful to all expert collaborators who contributed to the
conception, design and execution of this report. Their names and affiliations as well as their main
Ethical issues in Patient Safety Research
External Reviewers
Carlos Aibar Zaragoza University, Spain
Ross Baker University of Toronto, Canada
David Bates Brigham & Womens Hospital, USA
Anant Bhan Independent Researcher, India
Hans Van Delden University Medical Center, Utrecht, Netherlands, President, CIOMS
Susan Dovey University of Otago, New Zealand
Ruth Faden Johns Hopkins Berman Institute of Bioethics, USA
Sev Fluss Senior Advisor, CIOMS
Otmar Kloiber World Medical Association
Rieke Van der Graaf University Medical Center, Utrecht, Netherlands
George Liu La Trobe University, Australia
Philippe Michel University Hospital Lyon, France
William Runciman University of South Australia, Australia
Asavaroengchai Santawat King Chulalongkorn Memorial Hospital, Thailand
Claudia Travassos Fundaao Oswaldo Cruz, Brazil
Michel Valloton University of Geneva, Switzerland, Former President, CIOMS
Douglas Wassenaar University of KwaZulu-Natal, South Africa
William Weeks The Dartmouth Institute, USA
5
Systematic Review of the literature
Danielle Whicher Johns Hopkins Bloomberg School of Public Health, USA
9. References ...................................................................................................................................... 34
Appendix 2: Summary of the ethical guidance related to patient safety research .......................... 39
1. Introduction
8
This report responds to a request from patient the burden of unsafe care in developing countries,
safety researchers and research ethics committees where the risk of harm to patients is likely to be
Ethical issues in Patient Safety Research
(REC) for advice on how to interpret existing greater, due to limitations in infrastructure,
research ethics guidelines in the context of patient technologies, and human resources.3 A retrospective
safety research. The report, which was produced analysis of medical records of patients admitted
by the WHO Patient Safety Programme and the to 26 hospitals in eight developing and transitional
WHO ERC Secretariat, builds on the reflections countries estimated an incidence of preventable
of an international expert group and was further harm of almost 1 in 10.4, 5
enhanced by internal and external expert reviews
by research ethics specialists and patient safety Research to understand the causes of unsafe
and quality improvement scientists from across care and to identify potential solutions involves
the world. As explained in the foreword, this is diverse scientific designs and methodologies.
the first version of this report, which will be revised For example, research may be based on a review
to include future input, as evidence and scholarship of medical records, observations, surveys or
in the area of patient safety research evolve. interviews. It may use controlled randomized
designs, allocating different hospitals or clinical
This document is not intended to establish any units to alternative ways of delivering care, or it
new ethical principles. Rather, it represents may use simulations. While patient safety studies
an interpretation and application of existing, share methodologies with many other types of
internationally accepted ethical principles health-related research, some aspects of patient
to specific questions that arise in the context safety research may appear different in ways that
of patient safety activities. It is designed to be can have a bearing on the types and extent of
useful to patient safety professionals, investigators, ethical oversight that may be warranted.6 For
health-care institutions, ethics review committees, example, in patient safety research, the research
health authorities and others aiming to ensure subject who is targeted with a new intervention
ethical conduct of patient safety research activities. may be a health-care provider rather than a patient,
It is hoped that the document will increase the even when outcomes are based on patient-related
attention given to ethical issues around patient information, or the target may be a system
safety research around the world, but particularly in of care rather than an individual. The issues raised
resource poor-settings, where the need for locally by such methods are analogous to those raised
applicable research findings is especially needed. in research using cluster designs.7 In other studies,
researchers identify errors that occurred during
Ethical issues to consider when health-care, errors that may not have previously
conducting patient safety research been known to patients or their families. Some
WHO estimates that tens of millions of patients tensions may arise between a researchers duty
worldwide suffer disabling injuries or death every of care to an individual patient and the aims of
year due to unsafe medical practices and care. the research when clinically therapeutic results
Nearly one in ten patients is harmed due to are withheld from individual subjects, particularly
preventable causes while receiving health care when this information is incidental to the studys
in well-funded and technologically advanced main outcomes measures.8 Patient safety designs
hospital settings.1 Much less is known about may also involve an individual simulating a patient,
the burden of unsafe care in non-hospital settings, for example, someone who buys medicine from
where most health-care services are delivered.2 a pharmacy to determine whether a medicines
Furthermore, there is little evidence concerning formulation is up to standard.
Patient safety activities can raise ethical issues research. For example, how can patients privacy
even when those activities are not formally labelled and confidentiality be ensured when examining
as research. For example, quality assurance and records systematically? How can providers be
audit programmes review how care is delivered protected from reprisals when patient safety efforts
and compare it to a set of explicit criteria to result in the documentation of health-care failures?
determine whether standards are being met and (See Box 1) Additional complexities arise when such
how care can be improved. Other programmes, activities, not originally intended as research,
often labelled as quality or patient safety are submitted for publication because the data,
improvement, may implement activities that alter once analysed, appears to be of generalizable
how care is delivered in order to reduce problems relevance. Finally, patient safety improvement
or improve efficiencies. Many of these programmes programmes in hospitals and other health-care
address a defined question, systematically collect settings have purposes that extend beyond
data, and/or evaluate new strategies to examine the immediate interests of the patients directly
whether new approaches actually result in enrolled or affected by them, just as is true 9
improvement.9 Thus, they share several essential for activities more commonly viewed as research.
features with research, even though they may not These patients, too, deserve the health-care
Which patient safety projects should be In particular, under what circumstances, if any, is
considered research requiring Research Ethics deception allowable in patient safety research?
Committee (REC) review? What are the best practices for addressing privacy
What types of risks exist in patient safety and confidentiality issues?
research? Are there any potential direct or indirect benefits
What protections must be in place for patients to, or incentives for, participating in patient safety
and/or providers to reduce the risks from patient research?
safety studies? Under what circumstances, if any, do researchers
Under what circumstances are informed consent have a duty to intervene regarding past or
or other forms of disclosure or permission needed imminent errors?
from research participants?
The application of research
ethics principles to patient
2. safety activities
10
EXISTING GUIDELINES
Guidance point 1
Ethical issues in Patient Safety Research
Dovey S, Hall K, Makeham M, et. al. the ethics review processes applied to exactly the
Seeking ethical approval for an international same research protocol for a study run in Australia,
study in primary care patient safety. Canada, England, the Netherlands, New Zealand,
Br J Gen Pract 2011; 61: 197-204 and the US. Wide variations in ethics review
Seeking ethics committee approval for research responses to the research proposal occurred, from
can be challenging even for relatively simple studies no approval being deemed necessary to the study
occurring in single settings. Complicating factors plan narrowly avoiding rejection. The ethics
such as multicentre studies and/or contentious committees in each country had different concerns
research issues can challenge review processes, about the study protocol they were presented
12 and conducting such studies internationally adds with, which was exactly the same in each country.
a further layer of complexity. This paper drew on The authors experiences demonstrated that ethics
the experiences of the LINNAEUS Collaboration, committees operate in their own historical and
Ethical issues in Patient Safety Research
an international group of primary care researchers, cultural context, which can lead to radically
in obtaining ethics approval to conduct an different subjective interpretations of commonly-
international study investigating medical error held ethical principles, and raised further issues
in general practice in six countries. It describes such as what is research?
EXISTING GUIDELINES
Guidance point 2 The generalizable knowledge
Patient safety activities, even when they do not definition works well for medical
meet the definition of research requiring ethical and behavioural studies pertaining
review, may involve more than minimal risk to
to human health, which are
patients and health-care providers in some situa-
commonly denominated
tions. It is the responsibility of those working in
patient safety activities to be aware of ethical biomedical research to indicate
issues and seek guidance as needed. its relation to health. But
the definition works less well in 13
separating practice from research
in the field of epidemiology.
Pronovost P, Needham D, Berenholz S, et. al. before the implementation of the intervention
An Intervention to Decrease Catheter Related were compared with infection rates after its
Bloodstream Infections in the ICU. implementation. Each ICU was responsible
N Engl J Med, 2006, 355:272. for reporting aggregate infection data back to
This patient safety project was implemented to the project staff. The project staff developed
determine the effectiveness of an evidence-based the intervention and conducted the evaluation
intervention aimed at reducing rates of catheter- but were not members of any of the ICUs involved
acquired bloodstream infections in ICUs. The in the study. The study was submitted to the REC
intervention aimed at improving physicians use of the home institution of the project staff before
of five procedures that have been previously shown implementation.
14 to reduce infections. These procedures include
proper hand washing, full barrier precautions during Indeed, confusion by experienced professionals
insertion of the catheter, cleaning the patients about whether projects like this should be classified
Ethical issues in Patient Safety Research
skin with chlorhexidine, avoiding the femoral site as research vs. quality improvement practice led
if possible, and removing unnecessary catheters. to public controversy around this particular case,
Agreement to participate was obtained from and questioning from government authorities,
108 ICUs from 67 hospitals in the state of Michigan, highlighting the need for clearer guidance around
United States. Each of the ICUs implemented when projects such as this should be subject
the evidence-based intervention, and infection rates to ethical oversight and when they should not.
EXISTING GUIDELINES
The distinction between research
and practice in public health does
not correlate with the extent
Figure 1. Suggested flow diagram
to which an activity carries risks
for individuals and communities
or otherwise raises ethical issues Patient Safety Patient Safety
that would benefit from Activity Research
a prospective review process.
The distinction has no bearing if poses a greater
if not
either on the ultimate question than minimal risk
of whether a particular public
health response is scientifically
and ethically justifiable. Review by No Review ERC
Third Party needed Submission
Despite the conceptual problems
of distinguishing between research
if poses a greater
and non-research, the distinction than minimal risk
if not
is deeply ingrained in many
countries regulatory structures
and is unlikely to be changed
ERC No Review
any time soon. However, this does review needed
not mean that all research must
undergo full REC review, nor does
it mean that activities that fall
outside local or international
definitions of research should
escape ethics review entirely.
WHO Technical Consultation on
Research Ethics in International
Epidemic Response
Understanding risk
3. in patient safety research
Social risks: Social risks are the risks that research participants For all epidemiological research
encounter due to how others might treat them as a result of their involving human subjects,
participation in a study. While there may be minimal social risks for
the investigator must ensure
patients who take part in patient safety studies, medical providers or
that potential benefits and harms
institutions may be concerned about social risks if they participate in
research that exposes their own system failures or ineffectiveness. For are reasonably balanced and risks
example, research documenting the factors associated with significant are minimized.
health-care incidents that occurred in the past or rates of particular CIOMS International Ethical Guidelines for
types of errors runs the risk that the providers involved with these Epidemiological Studies, 2009 Guideline 8
incidents, or the institutions themselves, could suffer reputational and
professional harm. The risks to which research
subjects may be exposed have
Psychological risks: Psychological risks include the possibility that been classified as physical,
research participants will become emotionally distressed, fearful or psychological, social, and
anxious as a result of their participation. For example, studies that economic.
interview patients or families about harmful incidents that occurred OHRP Institutional Review Board
previously or about their perceptions of the quality of care may cause Guidebook
them to question the quality of their medical providers and to become
anxious. Also, health providers may become anxious if they believe
that researchers are evaluating their professional performance,
particularly if they fear that the results may result in reprisals.
Guidance point 3
Patient safety research may be considered of mini-
mal risk if all of the following factors are present:
The intervention does not modify clinical management
or the treatment plan for the patient;
Data are not individually identifiable, or adequate
protections against breaches of confidentiality of
EXISTING GUIDELINES data are in place;
Minimal risk refers to risk that The intervention is unlikely to divert staff from
16 existing responsibilities in ways that are likely to pose
is no more likely and not
a risk to patient wellbeing and safety;
greater than that attached to
Nothing in applicable laws, or institutional rules, or
Ethical issues in Patient Safety Research
Cullen DJ, Sweitzer BJ, Bates DW, et. al. the hospital staff involved in providing the patient
Preventable adverse drug events in hospitalized with the medication were interviewed by a peer
patients: a comparative study of intensive care and asked to describe the circumstances
and general care units. surrounding the incident, to describe how the event
Crit Care Med, 1997, 25:1289-1297. had occurred, and to self-assess their competency
A patient safety project was implemented at and skills, decision-making style, openness to
11 different ICUs and general care units in two change, duration in the service or job, the amount
tertiary care hospitals in the United States, and quality of supervision they had received,
with the objective of understanding the causes and the relationship of the incident to the timing
of adverse drug events (ADEs) resulting from of their shift. Consent was not obtained from
18 human errors in drug use, so that they might be patients within the unit. Project staff reported
prevented in the future. Data on all ADEs that that several of the medical staff who had made
occurred in any of those 11 units over a six-month errors did not want to discuss those errors with
Ethical issues in Patient Safety Research
period were included in the project. Data on ADEs interviewers because they were scared about
were collected in several ways: all nurses and being reprimanded for their mistake. As stated
pharmacists in those 11 units were asked to report by the project staff member, We had to reassure
all ADEs to nurse investigators involved in the them about the confidentiality issues and
project, a nurse investigator visited each unit it worked most of the time. The project was
twice a day on weekdays to obtain information approved by the REC at each of the two hospitals.
from hospital staff on any ADEs that had recently During the review process, it was decided that if,
occurred, and each day, the nurse investigator during the course of the project, staff identified
also reviewed all medical charts to collect patterns of care that were harmful to a patient,
information on reported and potential ADEs. it was the duty of the project staff to immediately
All data were then reviewed by two physicians. inform the hospital staff and the appropriate
These physicians judged the severity of the ADE authorities so that the recurring error could be
and whether or not it had been preventable. corrected, but without retribution to any individual
For each ADE judged to have been preventable, employees.
Minimizing social and psychological risk in patient safety
studies
Baker GR, Norton PG, Flintoft V, et.al. possible to uncover some possible evidence of
The Canadian Adverse Events Study: intentional harm or incompetence, the researchers
the incidence of adverse events among hospital set up a safety committee of recognized experts
patients in Canada who agreed to provide back-up to the researchers
CMAJ 2004; 170 (11): 1678-1686 and review data and make a decision about possibly
This patient safety project involved the analysis for informing the hospital or other relevant personnel
adverse events in a sample of 20 hospitals spread about potential risks or unsafe providers. The
across five provinces in Canada. In this large and researchers had to use the committee in one instance
complex study, which involved the review of more where a patient had been injured and provider
20 than 3 700 medical charts, and where it would be actions were deemed worthy of further review.
Ethical issues in Patient Safety Research
General disclosure about the conduct of aspects of the behaviour of providers. Those
and findings from patient safety research conducting interviews with patients and families
Institutions with more positive patient safety must anticipate, and be prepared for such
cultures are more likely to be open to the conduct events and should have adequate responses and
of research studies that aim to improve patient mechanisms in place in the form of referral
safety. General awareness of patient safety or counselling for those that become distressed,
principles in the institutions where research will as appropriate. Referral sites should be contacted
take place can help to increase understanding in advance to ensure that they are willing and
of the issues involved and decrease concerns prepared to respond to requests.
and stress related to the research study. Disclosing
general details about the way the study will be Anticipating risks from interviewing or observing
conducted and disseminated may contribute providers
to reducing anxiety. This sharing of information Providers may be interviewed as part of patient
also demonstrates respect for the individuals safety research, to understand how systemic issues
involved in the research. can contribute to harmful incidents. In the course
of these interviews it is possible that providers
Anticipating risks from interviewing patients may be questioned about their colleagues, their
or their families supervisors or hospital management. In such
Some types of patient safety studies involve circumstances, providers may feel that they are
interviewing patients or family members after at risk of repercussions if the information provided
adverse incidents have occurred. These interviews by them is not treated confidentially. In such cases
are designed to learn more about the patients they must know where they can ask questions,
and families experience and understanding of and feel comfortable with the interview, including
the events that occurred, as well as about the the possibility that they can withdraw at any time
background conditions associated with the or skip any question. Sometimes, providers may be
incident.This information may provide important distressed by the recollection of a harmful incident
insights that can be useful for future prevention during the conduct of an interview, and it may be
strategies. In some cases, patients or family necessary to facilitate counseling or psychological
members may become distressed during such support. On other occasions, research studies may
interviews, either because they are asked to recall involve the direct observation of provider behaviour
the harm that occurred, or they learn about or and performance. Observing providers, even in the
come to suspect errors or problems that had not context of a research study, can often be perceived
been fully apparent to them previously. In other as a threat to the authority or the competence of
instances, patients may be asked about their the providers. In all of these cases, the research
doctors performance (even in the absence of team must be sensitive to the concerns that may
an incident) and this might lead to mistrust, arise in these types of studies and anticipate such
concern or fear about the care they are receiving. an event, having firewalls and referral mechanisms
Researchers should reassure participants that in place, and explaining the purpose of observations
the information provided in the context of in advance. Referral sites should be contacted in
the research will be treated with the utmost advance to ensure that they are willing and
confidentiality. Despite this, patients may still feel prepared to respond to requests.
uncomfortable or fear retribution when disclosing
4. Informed consent
EXISTING GUIDELINES
People have a right to know that
their medical records or biological
specimens may be used for
research. . Investigators should
not initiate epidemiological
research involving human subjects
without first obtaining each
subjects informed consent, unless
Waivers of informed they have received explicit
21
Donchin Y, Gopher D, Olin M, et al. A look all encounters between the patient and his or
into the nature and causes of human errors her immediate bedside surroundings, including
in the intensive care unit. any human errors that occurred.
Qual Saf Health Care 2003, 12; 143-147
In a single hospital in Israel, a patient safety project In a published article describing this project,
was conducted to understand the causes of human the project team members indicated that all hospital
errors in the intensive care unit (ICU) so that ICU staff were informed about the project and
these errors could be prevented in the future. its objectives and were excited to participate.
Data on human errors were reported by the In addition, project team members indicated
hospital staff immediately after they were that the need for ethical approval for this project
discovered. Information that was reported included was waived because all that was done was
the time that the error occurred, the time the error observation. Names of hospital staff members
was discovered, the profession of the person and patients were not collected as part of this
who committed the error (physician, nurse, etc.), project. Data collection took place over a period
the profession of the person who reported the of four months, during which time 554 human
error and a short description of what happened errors were reported by hospital staff. The results
and the presumed cause. Individuals involved in of this project cannot be directly applied to other
the project rated the severity of each of the error ICUs at other hospitals, as the errors reported in
reports on a five point Likert scale. In addition, this setting were almost certainly unique to this
to understand the number of activities that occur setting and the staff employed there. However,
in the ICU on a daily basis, 46 randomly selected the project staff published this project because
patients were observed continuously for 24 hours the methods used to complete it were innovative
by outside trained observers from the Israeli and it was felt that similar studies could be easily
Institute of Technology. The observer recorded carried out in other settings.
5. Privacy and confidentiality
25
EXISTING GUIDELINES
Guidance point 8
Research relating to individuals
reviewing medical records may come across an error an error occurred. They were also instructed
or probable error that they believe was never to intervene when errors that could cause harm
reported. In such situations researchers must decide to patients were made.
when, if ever, they should intervene.19, 20 In general,
the role of the researcher is different from the role
of a clinician or hospital manager: researchers
primary role is to document the occurrence and
nature of some features in order to identify better
strategies in the future, or to measure rigorously
whether new approaches to preventing harm are
systematically better than older strategies. To
intervene whenever they see a problem would
almost certainly negate their ability to collect sound
data, which are necessary for making more
widespread progress in improving patient safety.
Indeed, in some cases, part of the patient safety
researchers job is to document the rate and nature
of substandard or unsafe practices in order to
develop programmes to improve care. At the same
time, researchers, as human beings and as
professionals, cannot simply witness egregious,
preventable, and imminent problems without
intervening. Research teams must anticipate
this problem and plan for the types of situations
that may occur in studies, given their own
methodology, setting, and population. In general,
the expectation is that the above criteria would
very rarely be met and researchers would very rarely
be intervening. In rare cases, when researchers
are qualified to assess risk, and if the risk of harm
seems imminent, if the harm would be severe
and irreversible, and if interfering could prevent
the harm, then researchers should indeed intervene.
To facilitate this process, the information sheet
given to providers must mention the possibility
of the observer commenting and intervening
in such circumstances.
For incidents identified through chart reviews, or The purpose of patient safety research is to improve
through any other mechanism, which are generally patient safety; therefore it is mandatory that
conducted retrospectively, any harm associated the results of the research, in aggregate, be reported
with the error is less likely to still be reversible. back to the hospital or department leadership
It may also be unclear from medical records alone so that appropriate corrective steps can be taken
whether the event was ever reported, whether at the system level. The reporting back of research
others were aware of the event, whether any should be in aggregate form and be anonymized so
interventions have already occurred or whether, that there is no way to identify individual providers
indeed, a harmful incident actually occurred. There or patients, as the purpose of reporting results is
will be a relatively small number of cases where not to assign blame to individuals. Similarly, units
intervention, after the fact, can change the clinical participating in a study should have the opportunity
course. However, in such very rare cases, and if to request that their units data not be reported
the patient can still be located, the hospital should to hospital leadership separately from the overall
be informed so that the patient can be contacted findings of the whole study. When publishing
for further evaluation. the outcome of such research, investigators should
be particularly careful in situations where the
Nevertheless, researchers are not best placed specificities of the setting are so unique that even
to make judgements or take any action based on without the use of identifiers the health facility
the findings of the research. Some groups have is easily identifiable.
established reference groups or safety
committees to provide advice on the adequate
course of action in situations that may develop
during patient safety research and where
researchers may not have the expertise and capacity
to manage the situation, as has been described
under guidance points 4 and 5 (Case Study 4).
These committees may constitute a good resource
for researchers.
7. Withholding information
30
Researchers have a commitment to telling the truth, not informing them of the true purpose of the
but omission of some information (e.g. the specific research, not informing them which behaviours
purpose of the study) is considered acceptable in or interventions are being studied, or taking on
some situations. In general, the type of information a false identity in order to gain additional research
that is withheld from participants may include information. Such withholding of information from
not informing participants that they are in research, research participants is allowable in exceptional
circumstances, where projects are low risk, for their children when they didnt really have
where it is necessary for obtaining the relevant a sick child, and the researchers then examined
data, where the project could significantly advance the pharmacological make-up of the products
the field of patient safety, and where it does not they were given. This study design was allowed
change the overall risk profile of the study. by the local REC, because this was considered
For instance, in a study to determine the extent to be the only way of obtaining access to
of a problem of fake or substandard quality drugs the pharmaceutical products actually being sold
being sold by pharmacists, mystery clients were to patients and the study posed very few risks,
asked to go to public marketplaces for remedies if any, to those involved.
33
The protection of research participants from harm of research and therefore not usually under
caused by the conduct of research studies has the oversight of ethics review committees.
34
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Appendix 1:
How this guide was developed
35
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of healthcare system quality improvement: The conflict
generally be obtained. However, the requirement the consequences of the incident are of direct
of obtaining individual informed consent from severe or irreversible harm;
patients can be waived by an REC if Where sufficient expertise and experience to
The research does not directly inform or alter interpret the situation is not present, staff should
individual patients therapeutic or medical seek advice from more experienced professionals.
treatment plans; and
Risks to the provider are minimal (see Guidance Guidance point 11
Point 3); and Those involved in patient safety research
The research could not practicably be carried have a duty to report the study results
out with the consent of providers. back to hospitals and units once the project
In cases where individual informed consent is complete.
from providers will not be sought, general
disclosure to providers about patient safety
Guidance point 12
activities is highly recommended.
Patient safety researchers who propose to
withhold information from potential research
Guidance point 8 participants as part of their research must do
Staff involved in the conduct of patient
all of the following:
safety research and patient safety activities
Demonstrate to a research ethics committee
should be aware of the principles and
that no other research method will suffice;
methods related to preserving privacy
and confidentiality. Persuasively argue that significant advances
could result from the research either for the local
setting or more broadly;
Guidance point 9
Consider whether asking participants to consent
Individuals involved in patient safety research
to participate, without disclosing the nature or
may, occasionally, observe practices that may
precise timing of the intervention, is reasonable;
put patients at risk. Researchers observing clinical
encounters have a duty to intervene to protect Ensure that withholding information itself will not
these patients if all of the following are present cause a study to involve greater than minimal risk.
and the research staff observing these events have
sufficient expertise and experience to interpret Guidance point 13
these situations appropriately: In those cases where a research ethics
they are highly suspicious that an error is committee approves an activity where
imminent; information has been withheld from
they believe it is highly likely that the error will the participants, the committee must also:
result in direct, severe or irreversible harm; Ensure that nothing has been withheld that,
their immediate action or intervention will if divulged, would cause a reasonable person
prevent or reverse some of the negative effects to refuse to participate;
of the error; Determine if debriefing of those who participated
Where sufficient expertise and experience to is possible or appropriate;
interpret the situation is not present, staff should Ensure that a general disclosure of the type of
seek advice from more experienced professionals. research that is proposed is in place, if possible.
World Health Organization
20 Avenue Appia Email: psresearch@who.int
CH-1211 Geneva 27 Please visit us at:
Switzerland www.who.int/patientsafety/research
Tel.: +41 22 791 5060