Chest
Medical EthicsDisclosing Harmful Medical Errors to Patients: Tackling Three Tough Cases
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.
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2017, Saudi Dental JournalCitation 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.
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2014, Ethique et SanteDisclosure of harmful medical errors in out-of-hospital care
2013, Annals of Emergency MedicineCitation 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
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2013, Handbook of Clinical NeurologyCitation 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.
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2013, Journal of the American Academy of DermatologyCitation 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.
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).