Medical errors occur and are sometimes unavoidable. Physicians generally, but not always, have ethical and moral obligations to disclose their errors to the patient. Because common medical errors can be expected, physicians are obligated to work within health systems toward reducing systems flaws that promote errors. However, the obligations of physicians to disclose errors made by others are less clear. This article discusses the professional ethics involved in disclosing and preventing medical errors.Errors in medical care are common and have important implications for patient health, physician trust, and institutional integrity. Physicians' moral and professional obligations generally, but not always, support disclosure of errors to the patient. What should a physician or other caregiver do when he or she has made a mistake? What should a physician do if another caregiver's mistake has harmed a patient? How should a physician or caregiver act if he or she is genuinely uncertain about whether a particular adverse outcome is the result of an error?What defines a mistake?Should the physician always tell the truth because patients have the right to know the truth, because patients will find out anyway, to improve the patient-physician relationship, or perhaps to reduce malpractice liability?This essay explores physicians' responsibilities to patients who are involved in medical errors.BACKGROUNDWebster's dictionary defines error as "deviation from accuracy or correctness."The Institute of Medicine defines an error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."Wu et aldefine a medical error as "a commission or an omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences." Errors in medical treatment are common.Some errors cause serious harm; most errors cause insignificant harm. Common reasons for medical errors include limited knowledge or experience, errors of judgment, and carelessness, although more mistakes are made through carelessness than through ignorance.A medical mistake does not necessarily imply negligence. Mal-outcomes, by contrast, are untoward but not unanticipated events that result from correctly instituted interventions. Mal-outcomes tend to be evident to patients, whereas errors, particularly those with little or no adverse consequence, often are inapparent to patients.The American Medical Association's Code of Medical Ethicsstates that situations occasionally occur in which a patient experiences significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. Only through full disclosure is a patient able to make informed decisions regarding future medical care.The American College of Physicians' Ethics Manualstates that physicians should disclose to patients information about procedural or judgment errors made during care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.Statements from these physician organizations suggest that, although physicians should disclose errors of significant consequence to the patient, the obligation to disclose minor errors is not clear. Minor errors are errors without material consequence to the patient's well-being. Conversely, in one study,98% of patients desired disclosure for even minor errors. Such disclosure may reduce the risk of punitive actions by patients.DISCLOSURE OF MEDICAL ERRORSIn considering whether to disclose an error, physicians must balance potentially conflicting personal, professional, and patient-centered interests. These concerns include physicians' maintenance of personal integrity, their professional obligation to prevent error recurrence, the concern that disclosure could jeopardize professional relationships with patients and/or peers, the patient's right to know the truth, and the concern that the patient may suffer more by knowing the event was avoidable.Additionally, disclosure by the physician may be self-therapeutic, because commission of errors causes most physicians great emotional distress and often is shrouded in shame and secrecy.Disclosure of mal-outcomes and errors is important. Disclosure of mal-outcomes preserves trust between the patient and the physician. Disclosure validates the patients' suspicions and is a respectful articulation of what often is self-evident. Discussions of mal-outcome provide patients with a realistic view of the limitations of medicine.Prima facie, all errors, even minor ones, should be disclosed. Disclosure follows physicians' commitment to veracity and respects patients' right to self-determination. The ethical, legal, and risk management considerations of medical errors that harm patients require the treating physician to acknowledge an error by truthful disclosure to the patient. Full and honest disclosure of errors is most consistent with the mutual respect and trust patients expect from their physicians.However, physicians' obligations are not guided solely by patient autonomy. Physicians have obligations to promote patient welfare and to avoid harming patients. Potential benefits of disclosure to both patients and physicians are many (eg, maintain trust through honesty). The potential harms are few, although some may be serious, such as patient distress and legal action against the physician.Physicians' generally receive little training in how to conduct a relationship with the patient after an injury sustained from a medical error.Commonly, admission of errors is difficult for physicians.Historically, physicians in residency have trained in a culture where disclosure to peers is a sign of weakness. Instead, skill in "roundsmanship" is valued, that is, creative and contemporaneous responses to cover deficiencies or errors when reporting to more senior physicians. Physicians who accept responsibility for errors and discuss these errors with other physicians are more likely to make constructive changes in their practice of medicine.Barriers to disclosure must be overcome and should start with physician training and role modeling. Practical issues include who decides whether to disclose a mistake, when the disclosure should be made, and who should disclose the mistake.NONDISCLOSURE OF MEDICAL ERRORSConsequentialist theory supports behavior that maximizes net good. Application of consequentialist theory requires specification of harms and benefits and identification of the moral reference group, that is, the parties on whom the benefits and harms fall. Situations exist where harm from disclosure may exceed harm from nondisclosure and may exceed harm directly pursuant to the error. For example, consider the patient given a stool softener by error. The patient experiences one diarrheal stool but no other untoward physical effect. If the patient learns of the error, the ordering physician or administering nurse may lose the patient's confidence. The loss of confidence, if appropriate, will afford the patient the opportunity to seek more capable health care practitioners. The patient, learning of the error, may be reassured by knowing that no new (diarrheal) illness is developing. Alternatively, psychological harm to the patient from disclosure may be significant, undermining a plan of care. The physician or nurse risks significant and unfavorable notoriety if the hospital's medication error mechanism is triggered. However, the hospital may benefit from a root cause analysis following reporting of the error. As this example illustrates, harms and benefits may be evaluated from the perspective of patient, patient and staff, and patient, staff, and organization. How the harms and benefits are identified and weighted often is case and context specific. Considerations of benefit for persons other than the patient are generally, but not always, inappropriate.The management of medical errors also may be examined through deontologic theory or principalism. The principles in tension are respect for patient autonomy and nonmaleficence or the obligation to not cause harm. Normative behaviors in our culture are consistent with a strong obligation to individual autonomy. In this context, a principled basis for nondisclosure is one where disclosure of the error causes harms to the patient that are greater than harms to patient autonomy from nondisclosure.Nondisclosure may be ethically appropriate when the error is inconsequential and disclosure does not empower the patient, when disclosure would likely distress the patient, or when disclosure is likely to result in unwarranted diminution of patient trust. In these instances, promotion of autonomy may not be the overriding obligation. A patient's interests may lie in maintaining a therapeutic relationship with the physician and remaining free of emotional distress. Making such a determination follows a series of judgments about the likelihood and degree of each element in this equation. An underlying concern is that this determination may cover unjustified paternalistic behavior.PHYSICIANS' OBLIGATIONS WHEN RECOGNIZING THE ERROR OF ANOTHERHow should a physician proceed when another physician's error in patient care has been observed? For example, a primary care physician learns that a consulting pulmonologist has performed a thoracentesis on the nonaffected hemithorax before repeating the procedure on the correct side. The patient experiences a clinically inapparent pneumothorax, and the pulmonologist does not disclose the error to the patient. The pulmonologist is obligated to disclose to the patient the commission of the error and should be encouraged by the primary care physician to do so. However, if the consultant is unwilling to disclose, the primary care physician nevertheless is obligated to keep the patient fully informed. The staff member involved in the error should be identified to the patient at the patient's request. The physician is also obligated to inform hospital quality assessment mechanisms so that problems with systems and substandard practitioners are addressed.Should a physician commit and not disclose an error, house staff, nurses, and other personnel should inform the appropriate supervisor. These supervisors should approach the physician for clarification of the purported error. Supervisors should report suspected error nondisclosure to the department chief or medical staff office. To encourage and support physician disclosure of error, peer error committees or discussion groups should adopt nonpunitive responses to reporting errors and provide anonymity outside the committee deliberations.PHYSICIANS' OBLIGATIONS AND INSTITUTIONAL LIABILITY CONCERNSPhysicians' ethical obligation to patients to disclose errors is far broader than the imperative to disclose within a risk management framework. If one accepts the conclusion that full disclosure as a rule decreases liability risk, then no conflict should exist between physician obligation and institutional interests. However, in a particular situation, disclosure of an error to an unsuspecting patient may create a real liability risk. In this case, professional ethical behavior may conflict with institutional objectives. The institution should view such a situation as an opportunity for quality improvement and accept liability risk as the cost of improvement. An ethical institution chooses to support professionalism, even at a price. These judgments are considered in the literature on organizational ethics.PHYSICIANS' ROLE IN ADDRESSING SYSTEM PROBLEMSAlthough many medical mistakes are due to human error, organizational or adverse work conditions may be at least partially responsible. Such conditions may include high workload, inadequate supervision, poor communication, and rapid change within an organization. Thus, a framework of risk factors allows a systematic approach to safety and error reduction.Within the framework of current methods of hospital quality appraisal, attribution of error has historically focused on the caregiver and not the system. Yet, unless detected and corrected, system faults persist and create circumstances of errors waiting to happen.Some authors propose social policy reforms to address the following topics: Which medical errors are innocent, even though severely damaging, and which are culpable? Does the harm that results from medical error warrant compensation? Does the error that causes harm warrant sanctions? What are the relationships among culpability, harm, compensation, and sanctions?In the past, medical errors have been addressed by a problem-solving approach so that the human cause of the error is identified and corrected. Root causes, such as underlying systems failures, were rarely pursued. Strong recommendations have been made regarding errors and deviations not as human failures but as systems failures.Errors can be viewed as variations in processes that are part of quality management. Systemic change, at both clinical and organizational levels, involves a commitment to safety and quality, a fact long recognized by proponents of total quality management.The paradox of modern quality improvement is that only by admitting and forgiving error can its rate be reduced. The science of error prevention must be used to improve the practice of medicine.Various recent initiatives address the issue of error reduction or prevention. In September 1998, the Joint Commission on Accreditation of Healthcare Organizations issued a systematic approach to reducing medical errors.The introduction of computerized physician order entry in a large tertiary care hospital decreased the rate of nonintercepted serious medication errors by more than half.In another large teaching hospital, a computer alert system was developed and implemented to prevent injury from adverse drug events.The Veterans Health Administration has banned concentrated potassium chloride from all its hospitals.The Institute for Safe Medication Practices issued special alerts on the use of lipid-based drugs and on the improper dilution of albumin.In 1997, the American Medical Association created a National Patient Safety Foundation. A year earlier the American Medical Association, the Joint Commission, and the American Association for the Advancement of Science held the first multidisciplinary conference on errors in health care at the Annenberg Center for Health Sciences, Rancho Mirage, Calif. The medical imperative that emerged from that conference is as follows:To make health care safe we need to redesign our systems to make errors difficult to commit and create a culture in which the existence of risk is acknowledged and injury prevention is recognized as everyone's responsibility. A new understanding of accountability that moves beyond blaming individuals when they make mistakes must be established if progress is to be made.Experts in this field conclude that the goals of systems changes are to prevent, detect, and correct errors before they do harm. To accomplish these goals, our medical culture must be changed to support error recognition, accountability, honesty, and rapid and fair settlement of injuries, addressing the risk of harm as a systems problem and preventing the problems from occurring again in that or similar settings.CONCLUSIONThe special obligations of the physician who harms a patient through a medical error require an honest disclosure, including an apology to the patient and, under certain circumstances, financial compensation. Full disclosure is in the patient's best interest. Honesty and apology are ethically obligatory and appropriate. Truth telling should not be the mark of the heroic physician but rather a distinguishing feature of all decent physicians. Physicians must continue to act as their patients' advocates yet recognize their own fallibility. 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JAMA Internal Medicine – American Medical Association
Published: Jul 24, 2000