A New Approach To Medical Mistakes: Admit It!
The Orlando Sentinel recently reported on a medical malpractice claim against the Veteran’s Administration clinic in Daytona Beach for missing a cancerous tumor on a veteran’s chest x-ray in 2005. When the veteran visited a non-VA doctor in 2006, a follow-up x-ray revealed the large cancerous tumor which was removed along with a large section of the man’s lung. What is interesting about the case is the VA accepted responsibility for its medical error and apologized to the veteran along with advising him of his right to bring a legal claim for the misdiagnosis.
Medical errors kill or injure thousands of people every year, yet very few hospitals and doctors acknowledge their mistakes, even when they are clear cut. Several years ago, our firm handled a medical malpractice case against a radiologist who missed a pituitary tumor the size of a GOLF BALL. The doctor and his insurance company denied that this miss had breached the standard of care. The case was litigated and ultimately the doctor’s policy limits were paid, but he never did acknowledged the error or apologize to his patient.
I salute the Veterans Health Administration for its policy of telling the patient when a medical error occurs. More doctors and hospitals should consider adopting a similar “I’m Sorry” policy. It could well save them money in the long run as patients who are given an explanation and an apology are less likely to hire an attorney and file a lawsuit.
March 15th, 2008 at 11:41 am
Dear Mr. McKenna, I agree wholeheartedly with your post. I have written an unpublished (as yet) article on the issue of which you speak. I would like to share it with you:
The Ethical Responsibility to Disclose Medical Errors by Patricia Brock, RN, BSN, CLCP, LNCC
Not only is it wrong to cover up a medical error, a complete explanation and an apology are warranted and expected by the patient. Healthcare workers are human beings, not machines. Therefore mistakes will be made. The way a mistake is dealt with determines patient satisfaction. When a patient knows that an error has taken place and no one comes forth with a proper explanation, anger starts to build. The adverse event may take a back seat to the fact that no one is dealing with it honestly and openly. Thomas Gallagher in the Archives of Internal Medicine (2006) states, “Ethicists and patient advocates promote full disclosure while risk managers and malpractice insurers often urge restraint”. Gallagher further noted that physicians were less likely to disclose an error that was not evident to the patient.
Basing disclosure on whether or not the patient might know about it is not at all defensible or consistent with Joint Commission of Accreditation of Healthcare Organizations Standards. According to the patient rights and organization ethics chapter in the JCAHO revised standard R1.1.2.2 (2001) “Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.” The intent of this standard is that “the responsible licensed independent practitioner or his or her designee clearly explains the outcome of any treatments or procedures to the patient and when appropriate, the family, whenever those outcomes differ significantly from the anticipated outcomes.”
The relativist theoretical viewpoint does not recognize the idea that an ethical position is either true or false. Everything is relative to what a certain group, society or individual ultimately believes. The deontological theory applies to doing the right thing out of a sense of duty. Teleological theory assesses the consequences of an act. Virtue theories stress the moral relevance of ethical behavior. Narrative ethics requires that everyone’s opinion be heard prior to deciding an ethical dilemma.
The deontological theory is the one that applies to the hypothesis of this paper. Healthcare workers have a strong sense of duty to their patients. They want to do the right thing. Donald Berwick (2003) in the New England Journal of Medicine states that “most bad errors are committed by competent, caring people doing what other competent, caring people would do.”
Deontological theory indicates that a person is acting morally and ethically when they are acting according to duties and rights. Reporting a medical error, disclosing that error to the patient, and apologizing to the patient and/or family for the error is the moral and ethical duty of healthcare providers.
The six-step process of judging the resolution of the dilemma using an example by Banja (2001) is as follows:
1. Gather relevant information:
David, a twelve-year-old male pediatric patient with a diagnosis of lymphoma was admitted to the hospital for a final dose of chemotherapy. He had a favorable prognosis due to the success of the treatment he had received up to this point. He was familiar with his team of caregivers because he had an established relationship of more than a year’s time with them.
David had an extreme fear of needles and had always been sedated with anesthesia and was asleep before his nurse would start the intravenous chemotherapy line. On the final day of his treatment an unfamiliar physician who had never treated David before injected both his sedative and the chemotherapy drug directly into his spine. The label on the chemotherapy drug was clearly marked for intravenous use only. David immediately cried out when the drug was injected. He died several days later after suffering terribly from the effects of the injection.
Initially it seemed that the error was clearly an example of medical negligence. However, as the case was investigated similarities to the majority of other serious mistakes made at the hospital unfolded. In the article Processes for Disciplining Nurses, M. Johnstone and O. Kanitsaki (2005) indicate, “when errors occur, their causes are likely to be multifactorial rather than individual in nature”. In David’s case a cascade of system/facility errors actually caused the problem. To begin with, He had eaten part of a muffin on the morning of his treatment. When he arrived at the hospital and admitted that he had not remained NPO as ordered, the decision was made to delay giving him the anesthesia because he might vomit and aspirate while sedated. Consequently David was not sent to the anesthesia department as usual, he was sent to a floor where the nurses were unfamiliar with his routine and care. They assumed that David was only to wait the proper amount of time to empty his stomach and they ordered both the chemotherapy drug and the anesthesia drug to be sent to the anesthesia department. When David was finally sent to anesthesia his familiar morning treatment team had left for the day and the afternoon team was in place. An anesthesiologist who had no experience in providing chemotherapy and who did not know David or his history injected both the anesthesia and the chemotherapy drug into his spine. David had an immediate and dramatic reaction to the chemotherapy agent that should have been delivered intravenously.
2. Identify the Type of Ethical Problem:
The anesthesiologist experienced significant ethical distress. He had injected a substance into a patient that was clearly marked for intravenous use only and had caused that patient to die. He possessed the virtues of a compassionate person and had always upheld the value of human life. Therefore he was also experiencing moral distress as a result of his error.
3. Use Ethics Theories or Approaches to Analyze the Problem:
In accordance with the hypothesis of this paper the anesthesiologist chose the deontological approach to the situation. He felt a consuming duty to explain the error to the family and to apologize to them for his error. He displayed moral courage by the disclosure, the explanation and the apology. If he had approached the incident from a Utilitarian position he would have been guided by the desire to mitigate the consequences of his mistake.
4. Explore the Practical Alternatives:
The initial reaction by the anesthesiologist was panic. He realized that there would be no way to hide or diminish the magnitude of his error. Shock, guilt, shame, feelings of incompetence, fear of a lawsuit soon replaced the panic. He counseled with a senior member of the anesthesia team who assisted him in examining what his next step should be. Upon further investigation it was learned that the hospital had experienced similar events in the past and had done nothing to correct the problems that led to the cascade of events in this situation. To be fair, the facility bore a large percentage of the blame. The hospital had allowed a system to exist whereby both of David’s drugs were permitted to go to the anesthesia room where the possibility would exist that they would be injected together. Unfortunately the first inclination when an error is made is to blame the error perpetrator who is usually the last agent in a series of events that contribute each in their own way to the mistake.
5. Complete the Action:
The anesthesiologist met with David’s family immediately after the error occurred. He fully disclosed what had happened. He delivered a heartfelt and sincere apology to them. He promised to investigate fully the events that led up to what had happened and to keep them informed regarding the outcome. The disclosure of this error was a caring and loving act. Families and patients need to be able to trust their health care providers. Trust cannot be established without truth, honesty and respect.
Many physicians are reluctant to admit errors due to malpractice fears.
According to an editorial by R. Lamb (2004) the Veterans Affairs Medical Center in Lexington, Kentucky has shown that “a policy for full disclosure has clearly mitigated the financial repercussions when patients have been harmed.” Other United States hospitals are finding full disclosure policies beneficial to both staff and patients.
6. Evaluate the Process and Outcome:
Considering the horrific event and outcome in the commission of this error it would be simplistic to think that the anesthesiologist disclosed the truth, admitted the error, apologized and was able to put the event behind him. The impact that mistakes have on patients is well documented and reviewed, but healthcare workers who have committed an error feel that they have nowhere to turn. They feel devastated, filled with guilt and remorse.
The process worked for the anesthesiologist in David’s case. The hospital assumed part of the blame for the error and they corrected the situations that allowed the error to occur. Policies were instituted that would protect patients from the same type of harm in the future. As long as human beings are health care providers medical errors will exist. If knowledge is obtained and correction is made as a result of those errors then progress will have been made and patient safety will improve. Open disclosure, honesty and education are the keys to promotion of a culture of safety in the healthcare environment.
References
Banja, J. (2001, February). Ethics news & views. Moral courage in medicine:
disclosing medical error. Retrieved October 18, 2006 from
http://www.ethics.emory.edu/news/archives/000188.html
Berwick, D. (2003, June 19). Editorials: Errors today and errors tomorrow. The
New England Journal of Medicine, 348(25), 2570-2573. Retrieved
October 23, 2006 from https://content.nejm.org/cgi/content/extract/348/25/2570?ck=nck
Gallagher, T. (2006). Choosing your words carefully. How physicians would
disclose harmful medical errors to patients. Archives of Internal Medicine, 166, 1585-1593.
Lamb, R. (2004). Open disclosure: the only approach to medical error. Editorial:
open disclosure of medical errors. Retrieved October 27, 2006 from
http://qhc.bmjjournals.com/cgi/content/full/13/1/3
Nucleus Magazine (2000, January). In Christian medical fellowship.
Retrieved October 22, 2006 from http://www.cmf.org.uk/literature/content.asp?context=article&id=251
Revised Standard R1.1.2.2, Revisions to Joint Commission Standards in Support
of Patient Safety and Medical/Health Care Error Reduction Effective:
July 1, 2001. Retrieved October 27, 2006 from http://www.dcha.org/JCAHORevision.htm