Ethical and Practical Aspects of Disclosing Adverse Events in the Emergency Department

Errors and emergency medicine

The emergency department (ED) will never be an error-free environment. All practicing clinicians make mistakes, and any clinician who sees many patients will be involved eventually in an incident where a patient suffers an adverse event caused by medical care error. An adverse event is defined here as an injury to a patient resulting from medical care [1]. An error is defined as an act not completed as intended, or the use of the wrong plan of action to achieve a specific aim [1]. A medical

Emergency medicine and disclosure

The patient–physician relationship is unique in EM in its duration, intensity, and character. Patients who use ED services usually have little or no choice regarding selection of hospital, and even less choice of medical providers upon arrival. This lack of choice affects the nature of the patient–physician relationship. Most encounters in the ED represent the initial and final meeting between patient and physician. It is rare that an EM physician will develop a longitudinal relationship with a

The ethical duty to disclose

Ethical arguments supporting full disclosure of adverse events include fiduciary obligations, autonomy, truth telling, respect for patients, and professional standards. Arguments can be made for and against disclosure of errors that do not cause harm; this will be addressed later. The following discussion of ethics pertains to errors resulting in adverse events, or preventable adverse events.

The role of the fiduciary can be traced back to Roman law, where a second party became the fiduciary of

Barriers to disclosure

Despite an ethical duty to disclose, and growing consensus that disclosure is in the best interest of the patient, physician, and medical profession, it does not always occur, and may even occur only rarely. Even when it does occur, disclosure is often incomplete; details may be altered [14], or pertinent facts omitted, leaving the patient with only part of the story. This may be done in an attempt to present the involved individuals in a better light, or to obscure responsibility. In either

How to disclose

Despite ample support for medical error disclosure, there is very little instruction or training available. There are a few training materials, such as The American Society for Healthcare Risk Management's Patient Safety Curriculum's session on “Adverse Event Disclosure” and its Monograph series on disclosure [23], [24], [25]. Recently, Johns Hopkins University developed the training package, “Removing Insult from Injury: Disclosing Adverse Events,” in which the disclosure process is explored

The disclosure process

It is helpful to approach the disclosure process as a special case of breaking bad news [27]. More important is to view the disclosure of an adverse event as a part of the ongoing dialog between the patient and physician about the patient's condition and what is occurring in his/her health care.

Once an error has been recognized, or its effects are noticed, steps should be taken immediately (if possible) to prevent or rectify any harm caused by the error. This process is illustrated in Fig. 1.

When should an adverse event be disclosed?

An adverse event should be disclosed as soon as possible after it has been recognized. This initial notification should be viewed as part of routine communication within the patient–physician relationship. However, if there is a serious adverse outcome, then talking to a risk manager or counselor experienced with the disclosure of adverse events, before notifying the patient, can provide the physician with support, and make the disclosure process less painful for all concerned. Many adverse

Who should disclose the adverse event?

The health care professional whom the patient perceives as being responsible for his/her care should be the person to disclose the error. In the ED, this is generally the supervising attending physician or the physician who cared for the patient. If others were involved in the error, or are in a good position to explain what happened, they may also participate in the initial disclosure. An administrative representative, such as a risk manager, may be useful to the patient later in the

Where should the disclosure take place?

The disclosure of an adverse event is emotionally difficult for both the patient and the physician, and the location of the disclosure should respect this. Privacy is paramount. The best location for disclosure is a private room or quiet space in the ED, or a physician's office if possible. When these options are not available, the physician should make every effort to conduct the disclosure with as much privacy as possible. The ED poses unique challenges related to crowding and close quarters,

What should be disclosed?

An initial disclosure should include everything the physician is certain of at the time of the discussion. The story generally emerges over time. If information regarding the error is unknown or unclear, the physician should say so, and should not speculate about what might have occurred. The patient should be assured that as information is obtained through the investigation, it will be shared with him/her. Patients appreciate the honesty and willingness to have an ongoing dialog.

Apology

When asked, patients usually mention three things they want and expect to hear in a disclosure: a description of what happened, an assurance that the problem will be investigated and fixed, and an apology [20], [31], [32]. Understanding that someone regrets and feels bad about a situation can help a patient to cope better with the incident. Although a full disclosure with a sincere apology conveys respect for the patient and allows for forgiveness to occur, the physician should keep in mind

Advice for conducting disclosure discussions

Every instance of disclosure is in some ways unique, and no guideline can provide all the instruction a physician may need when disclosing an error. However, some basic communication strategies should be kept in mind when conducting disclosure discussions. It is important to try to make the patient feel comfortable in a situation where one is likely to feel powerless. It is helpful for the physician to begin by making eye contact with the patient, and adapting to be as close to the patient's

After the initial disclosure

The initial notification of the error is only the first step in the disclosure process. The physician or other appropriate person must plan for future contacts with the patient and family, and follow through with those plans. The health care team should clarify which clinician or hospital administrator will be the primary contact person for the family and patient.

Together, the physician and patient should develop a list of priorities and come up with a plan to address them. This process

Summary

Disclosure is difficult in any field of medicine. Environmental factors in the ED that make disclosure even more difficult are the same factors that make a well-conducted disclosure paramount. Communicating an adverse event clearly to the patient or family is in line with the ethical duty to disclose, maintains patient trust, enables patient safety improvements, and may even help avoid a lawsuit. Learning how to disclose and communicate effectively with patients will help make full disclosure