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Academy News: July 2003 Medical errors: Disclosure strengthens
doctor-patient trust Dr. K has a very busy clinical practice with many patients on immunotherapy. One day her nurse beckons her to come and see two patients who are having severe reactions to their shots. Upon assessing the situation Dr. K realizes that both patients are having anaphylaxis and begins to rapidly treat them. Much later, once both patients have recovered, she asks her nurse what happened. He indicates that he simply prepared both of the injections at the same time and then gave each patient their shot. Almost immediately thereafter the patients began to get sick. Dr. K asks the nurse to show her the immunotherapy extracts. It becomes clear that the nurse gave the wrong injection to each of the patients. Later that evening one of the patients calls Dr. K and asks what happened and whether he should continue getting his allergy shots or not. What should Dr. K say? This vignette highlights the difficult issue of how to handle medical errors. At first blush it seems obvious that complete disclosure is the best answer—or is it? If you favor disclosure, what type of comment on the error is appropriate? Must the physician admit the mistake? For example, if the patient had just started immunotherapy, would it be acceptable to tell him that he overreacted to the shots, and that things will be okay next time—once the dose is lowered? Since the nurse committed the error, should the nurse explain the blunder to the patient? A pair of recent essays in the American Medical News discussed the issue of medical errors and disclosure. According to Jeremy Fish, MD, one of the major reasons physicians fail to disclose errors is due to fear and uncertainty of reprisal, as well as difficulty in accepting the fact that we have flaws in “an environment that implies physicians must be perfect at all times and in all ways.” Nonetheless, because one of the core components of the patient-doctor relationship is the necessity to put the patient’s needs before that of the doctor’s, Fish argues that disclosure is mandatory—albeit difficult. As he puts it, “living out this ethic is the great challenge of disclosure.” Maurice Sholas, MD, PhD, argues that the first act of disclosure is an “individual internal analysis.” In order for a physician to discuss an error with a patient, he/she must “decide the root cause and his or her bias about the consequences.” It is critical for the physician to recognize his/her feelings about the error, because, as Sholas points out, “guilt, irritation, remorse or the lack of these…will have a profound effect on the body language and word choices used in communicating about the event.” Furthermore, it is “crucial” that the person responsible for the error be the one who discloses this information to the patient. The second act, according to Sholas, is the
actual conversation between physician (or responsible party) and patient.
The goals of this event should be “to provide information, demonstrate
compassion, and remorse and address questions...” The discussion should be
straightforward with a minimum of excuses and mitigation. Fish agrees with
“listening, empathy and apology” being the “essential components of the
disclosure moment.” It is imperative to avoid “skillful obscuration” which
is no more than “cloak[ing] the truth in obscure or esoteric language that
the patient is unlikely to understand”—a “cover-up.” So what should Dr. K have done? Based on this discussion, it would have been most appropriate if both she and the nurse had spoken to the patients immediately after the error was discovered. Once they had accepted responsibility for the mistake, then they could go about developing safeguards to guarantee that this would not happen again. Furthermore, Dr. K probably should inform her risk management (i.e. malpractice) insurer sooner rather than later. The earlier they are involved after any error, the more rapidly they can help with minimizing any risk to the physician’s practice. This discussion was taken from the November 4, 2002, American Medical News Ethics Forum, “Honesty is the best policy when discussing medical errors.” Accessed online on May 6, 2003. http://www.ama-assn.org/sci-pubs/amnews/pick_02/prca1104.htm The Ethics Committee provides these discussions as a way to open a dialogue on the various ethical issues that confront our specialty on a daily basis. These issues are often quite complex and do not have simple “right” or “wrong” solutions. The articles are meant as a way to highlight the various issues that are involved in these ethical dilemmas, they should not be viewed as the Ethics Committee or the Academy’s particular stance on an issue. |
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