Responding to medical errors ethically
Use a 'just culture' framework
Hospital ethics committees need to review their hospitals' policies and approach to medical error reporting to determine whether or not the approach is a principled one, an expert says.
"The key principles that ought to be part of the medical error reporting and response system are that staff and providers have a way to report errors that occur and near misses," says Daniel Hyman, MD, MMM, an assistant professor of pediatrics at the University of Colorado in Aurora. Hyman also is the chief quality officer at the Children's Hospital in Aurora.
Ethics boards might consider reviewing their organizations' approach to medical error reporting and their responses to problems that are discovered, Hyman says. "Adverse events that impact patients should be disclosed appropriately to those patients and their families, and the staff that made the error should be responded to in a principled way," he says.
A good model for this approach is the "just culture" framework devised by David Marx, JD, in a 2001 primer about patient safety. (See resources, below.) "David Marx is a risk management systems analyst who has developed this framework for thinking about an institution's response to error," Hyman says. "The idea is that people make mistakes, and we need to understand that, as in any fundamentally human endeavor, people are going to make mistakes in the course of providing healthcare. The way we respond to those errors should recognize that fact."
Following the just culture model, there are three basic responses to medical errors:
Intentional bad acts.
In these rare cases, a staff person intentionally, recklessly, or illegally does something wrong that leads to a medical adverse event. Taken to the extreme, this category would apply to those headliner cases of nurses who intentionally kill nursing home patients. This category also could apply to medical staff that abuse drugs in the workplace and endanger patients by their habit and subterfuge, Hyman says.
When healthcare administrators discover an instance of someone behaving badly on purpose, they should initiate a thorough investigation and take the appropriate legal actions.
Simple human error.
Most medical errors involve simple human mistakes in which the healthcare provider did not do anything wrong other than make the mistake, Hyman says. "They are a victim of that situation," he says.
These mistakes can be the result of circumstances outside of the individual's control.
In these circumstances, an institution's ethical obligation is to align its response to these types of errors to the root cause and not to the outcome, Hyman says. "Making decisions about how to discipline a staff person on the basis of the outcome of the error is not ethical," he says. "No harm, no foul has no place in this." For example, a staff member could walk into an MRI suite with metallic content in his pocket and forget that this is in the MRI area, despite signage being in place and having completed training, Hyman says.
"The staff member made an honest mistake in this instant," he adds. "This is an opportunity to think about how we educate people in this situation. The ethical response is think about the root causes of the mistake to reduce the likelihood in the future of a recurrence of the error."
In another example involving an honest mistake, the response is inappropriately outcome-based. In this actual case in Cleveland, OH, a pharmacist named Eric Cropp approved a pharmacy technician's mix of chemotherapy solution for a 2-year-old child who was treated at a local children's hospital. The pharmacist had been under pressure to quickly fill the prescription, and he mistakenly thought the experienced technician had drawn the sodium chloride from an empty 250 mL bag of 0.9% sodium chloride located near the bag of chemotherapy, according to a first-hand account obtained by the Institute for Safe Medication Practices of Horsham, PA.
Instead, the technician had drawn from a different bag, and the mixture contained more than 20 times the correct amount of sodium chloride. The child was given the mixture and died within days of receiving the incorrect mixture. The response to this mistake was outcome-based. Because the simple mistake resulted in a death, the pharmacist was stripped of his license, prosecuted in a criminal trial, and spent time in jail, Hyman says.
"Errors in the medication dispensing process are a frequent problem, which are often caught prior to reaching the patient, or they result in no or minimal harm in most cases," he says. "But a child died, so the pharmacist was put in jail. That doesn't make us safer as a society; it's unethical decision-making that doesn't make us safer."
The fact that this particular case resulted in severe harm should not be the determinant of the punishment, he adds.
Policy and procedural breakdown.
In these cases, a staff member makes a choice that involves not following the institution's policies and/or procedures, and this choice can result in a medical error and possibly patient harm, Hyman explains.
"That staff person should be counseled and educated," he adds. "This should be a compact between staff and the hospital leadership where people know how this type of situation will be handled."
Policy and procedural breakdowns include cases in which a nurse gives medication to the wrong patient because the nurse didn't check the patient's ID wristband before administering the medication, Hyman says. "This type of mistake should result in a conversation between the staff person's manager and the staff person about what was going on that resulted in the person making this error and not checking the wristband," he says. "Maybe there were staffing problems, or the lighting was dark, or the staff member forgot the policy."
The response would be to reinforce the policy, highlighting reasons why the policy is in place, providing additional training if necessary, and reiterating the need for employees to follow policies that are in place to protect patients' safety, he adds. "It also should result in correcting any system factors that created the context within which the policy was not appropriately followed," Hyman says.
Hospital ethics committees should review the medical error reporting policies and culture at their own institutions to see whether these create disincentives for medical error self-reports, Hyman suggests. "We don't want to punish people for making mistakes because that only discourages other people from reporting errors," he adds. "We have to understand all of the risks in our systems, and we'll only understand those risks if people tell us about them."
When reviewing an institution's culture regarding medical errors, an ethics committee might collaborate with the hospital's patient safety and risk management staff to learn how they handle these situations and what kind of framework is their guiding principle, Hyman says. "In our department, we use just culture principles in all event reviews we do," he adds. "But it also involves educating staff and managers about these principles so that they respond to errors using this framework. We've done this education for staff and managers in a few departments in our hospital, and we've seen increases in reporting these errors following this work."
Source/Resources
- Daniel Hyman, MD, MMM, Assistant Professor of Pediatrics, University of Colorado, Aurora, Chief Quality Officer, The Children's Hospital, Aurora. E-mail: [email protected].
- For more information about "just culture," visit the just culture web site at http://www.justculture.org or see an April 17, 2001, paper published by Columbia University, titled Patient Safety and the "Just Culture": A Primer for Health Care Executives. The paper is available for a free download at the web site:
http://www.mers-tm.org/support/Marx_Primer.pdf.
- For detailed information about the Eric Cropp phamacy mistake and outcome, visit the Institute for Safe Medication Practices (ISMP) at the web site: http://www.ismp.org/Newsletters/acutecare/articles/20091203.asp.
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