Chest
Volume 136, Issue 3, September 2009, Pages 897-903
Journal home page for Chest

Medical Ethics
Disclosing Harmful Medical Errors to Patients: Tackling Three Tough Cases

https://doi.org/10.1378/chest.09-0030Get rights and content

A gap exists between recommendations to disclose errors to patients and current practice. This gap may reflect important, yet unanswered questions about implementing disclosure principles. We explore some of these unanswered questions by presenting three real cases that pose challenging disclosure dilemmas. The first case involves a pancreas transplant that failed due to the pancreas graft being discarded, an error that was not disclosed partly because the family did not ask clarifying questions. Relying on patient or family questions to determine the content of disclosure is problematic. We propose a standard of materiality that can help clinicians to decide what information to disclose. The second case involves a fatal diagnostic error that the patient's widower was unaware had happened. The error was not disclosed out of concern that disclosure would cause the widower more harm than good. This case highlights how institutions can overlook patients' and families' needs following errors and emphasizes that benevolent deception has little role in disclosure. Institutions should consider whether involving neutral third parties could make disclosures more patient centered. The third case presents an intraoperative cardiac arrest due to a large air embolism where uncertainty around the clinical event was high and complicated the disclosure. Uncertainty is common to many medical errors but should not deter open conversations with patients and families about what is and is not known about the event. Continued discussion within the medical profession about applying disclosure principles to real-world cases can help to better meet patients' and families' needs following medical errors.

Section snippets

Case 1: Don't Ask-Don't Tell

A middle-aged man was about to undergo a simultaneous kidney-pancreas transplant. As anesthesia was induced, the surgeon prepared the kidney and pancreas grafts for transplantation on the back table of the operating room by discarding fat, fascia, and accessory tissue. The surgeon implanted the kidney graft without difficulty, and the implanted kidney began producing urine. When the surgeon turned to retrieve the pancreas graft, he realized it was no longer on the back table. An extensive

Discussion

This case represents a clear-cut, harmful error, one that existing guidelines say should be disclosed. Yet most guidelines20, 21, 22 have been silent on what specific information should be conveyed. The standard of The Joint Commission23 with regard to disclosure states that patients should be informed about all outcomes of care, including unanticipated outcomes, and frames the rationale for such disclosure as promoting informed decision making by the patient. However, the standard does not

Case 2: What You Don't Know Won't Hurt You

An 83-year-old longstanding patient at a large medical center presented to the same center complaining of palpitations of 12 h duration. Neither her regular cardiologist nor her primary care physician was available, and she was seen by a covering cardiologist. An ECG showed atrial fibrillation. The finding was presumed to be new; therefore, she was scheduled for electrical cardioversion the following day without antecedent anticoagulation. The cardioversion was successful, and the patient was

Discussion

This patient experienced the following serious medical error: failure to recognize that the atrial fibrillation was not new. Had the covering cardiologist discovered the history of atrial fibrillation, routine anticoagulation before cardioversion would have been recommended, and this would have likely prevented the subsequent fatal embolic stroke. Many arguments could be made to support the decision of the hospital not to disclose the error to the widower. Chief among them might be concern for

Case 3: Shades of Gray

A 60-year-old patient underwent successful coronary artery bypass graft surgery. The attending surgeon left the operating room to speak with the family while the cardiac surgery fellow completed the skin sutures. The perfusionist handed the final bag of cell-saver blood to the anesthesiology resident for administration. Unbeknownst to the anesthesiology resident, the cell-saver bag contained a significant amount of air. The anesthesiology resident started to slowly infuse the blood. The

Discussion

This case highlights how uncertainty may influence the disclosure process. For this injury, several aspects of uncertainty predominated, including whether an error had actually occurred, whether the error had harmed the patient (eg, whether the air embolism was etiologically responsible for the sudden deterioration), and how to characterize the patient's prognosis in the early stages following the arrest when he was not responsive to verbal or tactile stimuli, and long-term recovery therefore

Conclusion

The foregoing cases illustrate three of the central challenges facing health-care providers and architects of disclosure policies today. First, what information must be conveyed in a disclosure conversation? When is an omission misleading, and how much should be left up to the question-and-answer portion of a disclosure conversation rather than to the initial statement by the health-care provider? Second, how does the prospect that the disclosure itself might unproductively distress the patient

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We thank Carolyn Prouty, DVM, and Odawni Palmer for assistance with manuscript preparation.

References (0)

Cited by (37)

  • The law as a barrier to error disclosure: A misguided focus?

    2018, Trends in Anaesthesia and Critical Care
  • Attitudes of dental professional staff and auxiliaries in Riyadh, Saudi Arabia, toward disclosure of medical errors

    2017, Saudi Dental Journal
    Citation Excerpt :

    In situations where no harm or adverse event has occurred, disclosure may not be obligatory (Elder et al., 2006) as it may unnecessarily increase patient stress and anxiety. Gallagher et al. (2009) reported that some physicians believe that if patients do not enquire then error disclosure is unnecessary. Many factors may influence the decision of healthcare providers to disclose medical errors.

  • Disclosure of harmful medical errors in out-of-hospital care

    2013, Annals of Emergency Medicine
    Citation Excerpt :

    Yet implementing error disclosure principles can be difficult. Some disclosure barriers cut across care environments, such as provider concern about litigation, shame and embarrassment, and uncertainty around how to communicate this information to patients and their families.9,11,12 However, EMS providers face special challenges, such as practicing in unpredictable, hazardous, and isolated environments, which complicate the disclosure process.13

  • Professional conduct and misconduct

    2013, Handbook of Clinical Neurology
    Citation Excerpt :

    Research suggests that the failure to disclose medical errors is driven by a variety of factors. These include fear of litigation, lack of training in disclosure, physician’s perception of an error’s severity, perceived responsibility for the error, fear that disclosure might distress the family or patient, and confusion about how much information to disclose (Gallagher et al., 2006, 2009). As Gallagher et al. (2009) describe, where uncertainty exists about whether disclosure is necessary, a physician’s desire for self-preservation naturally can foster nondisclosure.

  • Surgical complications: Disclosing adverse events and medical errors

    2013, Journal of the American Academy of Dermatology
    Citation Excerpt :

    Another challenge in ensuring full disclosure is the issue of timing of disclosure. Although some advocate informing patients and their family members about the error immediately after the event, physicians may be hesitant to discuss the event because of uncertainty about the exact details of what transpired and whether a preventable error had actually occurred.7 Gallagher and colleagues7 favor open communication with the patient and family immediately after the unanticipated outcome while acknowledging that an investigation is underway to obtain additional information.

View all citing articles on Scopus

Funding/Support: This study was supported by the Robert Wood Johnson Investigator Award in Health Policy Research (Drs. Gallagher and Mello) and the Agency for Healthcare Research and Quality (No. 1RO1HS016506) [Dr. Gallagher].

Editor's note: The review addresses the 10th topic in the core curriculum of the ongoing Medical Ethics series. —Constantine A. Manthous, MD, FCCP, Section Editor, Medical Ethics

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

View full text