Ethics/conceptEmergency Physicians and Disclosure of Medical Errors
Introduction
With the publication of the Institute of Medicine report To Err is Human in 2000, error in medicine became a high-profile national issue.1 As a result, physicians, patients, and the general public are more aware than ever of the incidence of medical error. Responding to this increased awareness, scholars and policymakers have offered a variety of proposals for addressing the problem of medical error.2, 3, 4, 5, 6, 7, 8, 9, 10, 11
Emergency physicians are no strangers to medical error. One recent study in a busy academic emergency department (ED) identified 18 errors per 100 ED patients.12 In September 2003, the American College of Emergency Physicians approved a new policy statement, titled Disclosure of Medical Errors, that directs emergency physicians who discover an error to inform the patient promptly about the error and its consequences.13 The policy recognizes that substantial obstacles, such as unrealistic expectations of physician infallibility, lack of training in communication techniques, and fear of liability, hinder the free disclosure to patients of medical errors. The policy therefore recommends several initiatives to encourage error disclosure, including the development of institutional policies on this subject, continuing education programs on error disclosure, and appropriate tort reforms and system-based changes.
This article will examine the issue of disclosure of medical errors in the context of emergency medicine. It will review the concept of a medical error, propose the professional duty of truthfulness as a justification for error disclosure, examine barriers to error disclosure, suggest system changes to address the issue of medical error, offer practical guidelines to promote the practice of error disclosure, and discuss the issue of disclosure of errors made by another physician.
Section snippets
Defining medical error
Greater attention to patient safety has resulted in a significant increase in academic discourse about what constitutes a medical error. The Institute of Medicine defines medical error as the “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”1 In some cases, the application of this definition is unambiguous. In symmetry errors, for example, a procedure is performed on the wrong side14; in medication errors, a dosing protocol or route is
Medical error and the duty of truthfulness
Truthfulness is widely recognized as a central professional responsibility of physicians. The American Medical Association’s “Principles of Medical Ethics” include the principle that “a physician shall … be honest in all professional interactions …”18 Similarly, the American College of Emergency Physicians’ “Principles of Ethics for Emergency Physicians” direct that “Emergency physicians shall communicate truthfully with patients …”19 In pledging to be truthful with their patients, physicians
Barriers to error disclosure
For a variety of reasons, many physicians have sought to avoid the difficult topic of medical error.27 Recent studies of the frequency of medical errors, however, have forced institutions and individual professionals to confront this problem directly. One obvious way to respond to medical errors is to identify them when they occur, to disclose them promptly to interested parties, and to seek out and correct the causes of errors. There are, however, a number of barriers to implementing a
Creating a culture that promotes patient safety and disclosure of errors
Disclosure of errors is an important practice, but it is only one part of a comprehensive approach to error in medicine. The task of disclosing errors will be less onerous if health care institutions and physicians are able to reduce the overall number of errors. Thus, in addition to disclosing errors when they occur, institutions and individual professionals should seek out ways to prevent errors though improved training, staffing, support, design, and equipment. Department chairs, directors,
Practical guidelines for error disclosure in emergency medicine
In fulfilling the obligation to disclose medical errors, a good place to start is to develop the habit of error disclosure at every appropriate opportunity. Smith and Forster26 have stated this eloquently: “The virtue of truthfulness is the habit of telling the truth even when it is inconvenient or involves some personal risk. When professionals develop a habit of telling the truth, every truth told strengthens their inner selves … the virtue of truthfulness is ultimately essential for an
Disclosure of errors made by another
Physicians bear primary responsibility for the medical care they provide or direct and for medical errors that occur in the course of that care. We have argued that this responsibility extends to informing patients about significant medical errors made by the physician or under the physician’s direction. Does it also extend to informing patients about medical errors that the physician believes were made by a previous physician?
Emergency physicians often discover errors that occurred in care
Conclusion
After a long period of neglect, the issue of medical error has in recent years captured significant public and professional attention. The ED is the locus of a variety of errors, and emergency physicians must therefore be prepared to identify errors and respond to them appropriately. Physicians have a professional responsibility to communicate truthfully with their patients; that responsibility includes disclosure to patients of errors that occur in their care. Barriers imposed by health care
References (64)
- et al.
Strategies for the prevention of medical error in pediatrics
J Pediatr
(2003) - et al.
Coping with medical mistakes and errors in judgment
Ann Emerg Med
(2002) - et al.
Errors in a busy emergency department
Ann Emerg Med
(2003) - et al.
To Err Is Human: Building a Safer Health System
(2000) - et al.
Improving patient safety: five years after the IOM report
N Engl J Med
(2004) - et al.
Five system barriers to achieving ultrasafe health care
Ann Intern Med
(2005) Turning the Titanic: changing the way we handle medical mistakes
HEC Forum
(2001)- et al.
The roles and responsibility of physicians to improve patient safety within health care delivery systems
Acad Med
(2002) - et al.
When is “good” enough?the role and responsibility of physicians to improve patient safety
Acad Med
(2002) - et al.
What practices will most improve safety?evidence-based medicine meets patient safety
JAMA
(2002)
No-fault compensation for medical injuries: the prospect for error prevention
JAMA
Residents’ suggestions for reducing errors in teaching hospitals
N Engl J Med
Profiles in patient safety: sidedness error
Acad Emerg Med
Profiles in patient safety: medication errors in the emergency department
Acad Emerg Med
The importance of cognitive errors in diagnosis and strategies to minimize them
Acad Med
Diagnostic errors
Acad Emerg Med
Professional boundaries in the physician-patient relationship
JAMA
Informed consent
Health plan members’ views about disclosure of medical errors
Ann Intern Med
Medical errors: what and when: what do patients want to know?
Acad Emerg Med
How do patients want physicians to handle mistakes?a survey of internal medicine patients in an academic setting
Arch Intern Med
Patients’ and physicians’ attitudes regarding the disclosure of medical errors
JAMA
Morally managing medical mistakes
Camb Q Healthc Ethics
Facing our mistakes
N Engl J Med
Emergency medicine resident errors: identification and educational utilization
Acad Emerg Med
Discussion of medical errors in morbidity and mortality conferences
JAMA
Emergency medicine: a practice prone to error
Can J Emerg Med
Profiles in patient safety: emergency care transitions
Acad Emerg Med
Crossing the Quality Chasm: A New Health System for the 21st Century
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ED overcrowding is associated with an increased frequency of medication errors
2010, American Journal of Emergency MedicineCitation Excerpt :The severity of these errors in our institution included medication confusion (ie, ketorolac administered instead of ketamine), inappropriate medication administration (ie, ziprasidone given intravenously instead of intramuscular route), and incorrect dosing (ie, tissue plasminogen activator administered at 40% supratherapeutic dose). These types of errors in medicine appear to be common [11,12,22-45]. Factors contributing to the occurrence of errors probably include those related to the patients themselves, as well as to the physicians and the environment, to name a few [23,26,44,46].
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Supervising editors: Robert Silbergleit, MD; Robert K. Knopp, MD
Funding and support: The authors report this study did not receive any outside funding or support.
Reprints not available from the authors.