Emergency Physicians and Disclosure of Medical Errors
Abstract & Commentary
By John Shufeldt, MD, JD, MBA, FACEP, Chief Executive Officer, NextCare, Inc.; Attending Physician/Vice Chair, Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Mesa, AZ, is Editor for Urgent Care Alert.
Dr. Shufeldt reports no financial relationship to this field of study.
Synopsis: Examines the issue of disclosure of medical errors and the barriers to error reporting.
Source: Moskop JC, et al. Emergency physicians and disclosure of medical errors. Ann Emerg Med. 2006;48:523-531.
Since the publication of the Institute of Medicine's "To Err is Human," increased attention has been given to medical error reporting. This article reviews medical error disclosure in emergency medicine, suggests the rational for error reporting, and examines barriers to medical error disclosure. Medical error is defined as, "failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." Medical errors do not necessarily mean that the patient has been harmed.
Physicians have a duty of truthfulness. The American Medical Association's "Principles of Medical Ethics" includes the principle that "a physician shall. . .be honest in all professional interactions. . ." What information is owed to the patient? One source of guidance can be found in the legal doctrine of informed consent. This doctrine can be summarized in the following manner. What a reasonable person would need or want to know in order to make an informed decision about his/her medical treatment. This also can be extended to error reporting. What information would a reasonable person want to know about a medical error that occurred during his/her treatment? If the error is minor or quickly identified and corrected, a physician may still want to inform the patient about this inconsequential error and provide reassurance that the error has been identified and that no untoward outcome occurred. This also extends to reporting errors made by another physician. The American College of Emergency Physicians is silent on disclosing errors made by another physician. However, physicians should not simply ignore errors committed by peers. At minimum, they should discuss the situation with the offending physician. If the patient asks specific questions about the reason for complications, the physician should not withhold information.
There are numerous barriers to medical error reporting. The US health system is not designed to reward or encourage error reporting. Both health care institutions and health care providers have a strong interest in avoiding medical liability exposure and, consequently, may view error reporting as a liability risk.
The distinctive environment of the emergency department has its own barriers to error reporting. High patient volume, high acuity, short duration of ED stay, and the episodic nature of the interaction increase the risk of errors and may foreclose their identification and reporting. For a variety of reasons (incomplete or false contact information, out of town visitors, fugitives, and undocumented immigrants), physicians may have difficulty contacting ED patients. Even if the patient is found, physicians may lack the training or skill set to discuss medical errors with patients. Many physicians believe, despite evidence to the contrary, that disclosing errors further erodes patient trust in them, in particular, and the medical profession in general.
The threat of malpractice liability looms large in the physician's mind and is a significant barrier to error reporting. In an effort to overcome any potential liability of a physician's apology, 18 states have enacted statutes making a physician's apology inadmissible in a civil suit. One caution, however, is that most state's "I'm Sorry Statutes," only protect a physician's expression of sympathy for the patient, not an admission of fault.
Disclosure of errors is important but it is only one piece of a comprehensive approach to error reduction in medicine. In addition to disclosing errors, institutions and physicians must work to reduce the number of errors that occur. Administrative staff should promote a culture of error reporting. For example, an institution might establish a safety hotline to encourage error reporting. Once an error occurs, the root cause of the error should be investigated in an effort to prevent reoccurrence.
Physicians should practice disclosing minor mistakes with little or no impact since, by doing so, they will acquire the skills necessary to admit consequential errors. "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 effective professional-patient relationship because relationships cannot endure failures of truthfulness for long."
Commentary
This article is particularly relevant to urgent care (UC) medicine inasmuch as many of the barriers to error reporting in emergency medicine are similar to those that exist in urgent care medicine. For example, many patients in an urgent care environment are treated only one time, spend a short time in the clinic, and may be difficult to follow once care in the center is completed. Moreover, UC physicians often do not have an ongoing relationship with the patient or their family, nor do most errors become visible while the patient is in the UC.
The urgent care setting is a place where errors can occur and a place where the errors of other may be discovered. UC physicians should follow the doctrine of informed consent and respond to errors with the reasonable person perspective; what would a reasonable person want to know about their medical condition or complications that ensue from medical error? By using the legal doctrine of informed consent, UC physicians will respond appropriately and ethically to their medical errors and the errors of others.
Since the publication of the Institute of Medicine's "To Err is Human," increased attention has been given to medical error reporting. This article reviews medical error disclosure in emergency medicine, suggests the rational for error reporting, and examines barriers to medical error disclosure.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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