• Vol. 53 No. 4, 272–273
  • 29 April 2024

VOWELS: A communication framework for disclosing medical errors in medical oncology and palliative care


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Dear Editor,

Recognising the impact of medical errors on patients and the doctor-patient relationship has underscored the need for better communication.1,2 For the most part, these efforts are informed by Chafe et al.’s 6 steps that entail: (1) the identification of the error in a timely fashion; (2) determination of the extent of the error; (3) constitution of a workgroup to establish the scope of the review; (4) identification of affected patients; (5) scrutiny of clinical records; and (6) the act of informing patients and other stakeholders.3-6 The apology and open disclosure are then said to be built upon this platform.

Building on our experiences training healthcare teams on the disclosure of false positive HER2 tests for patients with breast and gastric cancers at the National Cancer Centre Singapore (NCCS), these processes need to be timely, empathetic and patient-focused. Our experience suggests that for patients, disclosure extends beyond support of autonomous choice and empowering informed decision making to include a chance to rebuild trust and to be heard and understood.

For the local healthcare team, fear of litigation needs to be overcome, and training with a purpose-built tool is required. Poor experience with a misapplied approach built around the Setting, Perception, Invitation, Knowledge, Emotions and Summary (SPIKES) protocol and failure to effectively attend to cultural sensitivity merely underline calls for a more effective approach.

Here, we forward the VOWELS approach. The acronym VOWELS conveys a commitment or “VOW to be culturally sensitive, to Empathise, Listen and Support”.7 This process draws on strategies represented by the mnemonics “AEIOU”, paying special attention to the demeanour and attitude of doctors involved in the disclosure of medical errors (Table 1).7

Table 1. AEIOU communication strategy.

While our own experiences and feedback using the tool in training residents at NCCS have been positive, further evaluations are proposed.


The authors declare no conflict of interest.

Correspondence: Prof Lalit Kumar Radha Krishna, Division of Supportive and Palliative Care, National Cancer Centre Singapore, 30 Hospital Boulevard, Singapore 168583. Email: [email protected]

This article was first published online on 09 April 2024, and updated on 19 April 2024 at annals.edu.sg.


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  2. Manias E, Street M, Lowe G, et al. Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit. BMC Health Serv Res 2021;21:1025.
  3. Chafe R, Levinson W, Sullivan T. Disclosing errors that affect multiple patients. CMAJ 2009;180:1125-7.
  4. National Patient Safety Agency. Being open: Communicating patient safety incidents with patients and their carers, 2005. https://minhalexander.files.wordpress.com/2016/12/1334_beingopenpolicy.pdf. Accessed 15 November 2023.
  5. Australian Commission on Safety and Quality in Healthcare. Open disclosure standard: a national standard for open communication in public and private hospitals following an adverse event in healthcare, 2008. https://www.safetyandquality.gov.au/sites/default/files/migrated/OD-Standard-2008.pdf. Accessed 15 November 2023.
  6. Canadian Patient Safety Institute. Canadian disclosure guidelines, 2011. http://www.healthcareexcellence.ca/media/v4zni14t/cpsi-canadian-disclosure-guidelines-final-ua.pdf. Accessed 15 November 2023.
  7. Vincent C. Understanding and responding to adverse events. N Engl J Med 2003;348:1051-6.