Disclosure of Medical
errors
A medical error is a preventable adverse
effect of care ("iatrogenesis"), whether or not
it is evident or harmful to the patient
Healthcare professionals are generally
professional, dedicated, and caring people
But
“Humans make mistakes”
COMMON ROOT CAUSES OF MEDICAL
ERRORS
COMMUNICATION PROBLEMS
Communication breakdowns are the most
common causes of medical errors. Whether
verbal or written, these issues can arise in a
medical practice or a healthcare system and
can occur between a physician, nurse,
healthcare team member, or patient. Poor
communication often results in medical
errors.
INADEQUATE INFORMATION FLOW
Information flow is critical in any healthcare
setting, especially within different service areas.
Insufficient information flow happens when
necessary information does not follow the
patient when they are transferred to another
facility or discharged from one component or
organization to another. Inadequate information
flow can cause the following problems:
The lack of crucial information when needed to
influence prescribing decisions.
Lack of appropriate communication of test results.
Poor coordination of medication orders for
transfer of care.
HUMAN PROBLEMS
Human problems occur when standards of
care, policies, processes, or procedures are
not followed properly or efficiently. Some
examples include poor documentation and
labeling of specimens. Knowledge-based
errors also occur when individuals do not
have adequate knowledge to provide the care
that is required at the time it is needed.
PATIENT-RELATED ISSUES
These may include inappropriate patient
identification, inadequate patient assessment,
failure to obtain consent, and insufficient
patient education.
ORGANIZATIONAL TRANSFER OF
KNOWLEDGE
These issues can include insufficiencies in
training and inconsistent or inadequate
education for those providing care.
Transfer of knowledge is critical in most
areas specifically where new employees or
temporary help is used.
STAFFING PATTERNS AND WORKFLOW
Inadequate staffing alone does not lead to
medical errors but can put healthcare
workers in situations where they are more
likely to make a mistake.
TECHNICAL FAILURES
Technical failures can include complications
or failures with medical devices, implants,
grafts, or pieces of equipment.
INADEQUATE POLICIES
Often, failures in the process of care can be
traced to poor documentation and non-
existent, or inadequate procedures.
Case 1
A 37-year-old woman with an unremarkable
medical history visits her physician for a physical
examination. As the physician is about to enter
the examining room, she is taken aside by her
nurse, who has just noticed for the first time that
the patient's last Pap smear, done 3 years earlier,
showed adenocarcinoma in situ. The report,
although filed in the patient's chart, is a complete
surprise to the physician as well. She cannot
understand how it was missed because the
patient had been seen several times in the clinic
since the test was done. The physician considers
what she should tell the patient.
Case 2
It was a busy clinic day and getting worse.
Patients were getting impatient. Time was
marching and details were becoming a casualty.
Five year old Madhumita comes in with her
mother. She has asthma and is under your care.
You examine her and adjust your prescriptions
and start your good byes. At that time, her
mother reminds you that she is due for her
booster shots. Oh that, you frown - and tell her to
wait for a few minutes and that you will have the
nurse load the injection and come to the adjoining
room and give the injection.
You ask the nurse to load the injection and
keep it for you over the intercom. You continue
to see patients. After a couple of patients, the
mother knocks indicating that she is getting
late. You get up and go to the next room. The
nurse is not there but you find a loaded
syringe. You quickly administer the injection to
the child and get back to seeing patients.
A few minutes later, the nurse calls back
saying that she has loaded Madhumita’s
injections. You drop everything and go into the
injection room and confront the nurse “But
doctor that was gentamicin I had loaded for
Mrs. Asif” she says
Case 3
A 12-year-old boy has cataract surgery at a
large teaching hospital. At a critical moment
the surgeon's hand slips, rupturing the lens
capsule. The planned implantation of an
intraocular lens has to be abandoned.
Instead, the patient will have to use a contact
lens. The physician wonders what he should
tell the patient and his family about the
surgery.
▪Should the physician tell the parents the
results of the earlier test during this visit? If
so, how should the oversight be
communicated?
Should a formal apology be offered? If not,
why not? If not now, when, if ever, should the
error be communicated to the parents?
If the error should not be reported to the
parents, why not?
ensure that the report of the adenocarcinoma
in situ is accurate and in the right chart
tell the patient, before the examination,
about the report and admit that it seems the
report was not acted upon
False reassurances, blame placed on the
patient for failed follow-up or blame placed
on office staff will not be helpful.
The patient should be offered an immediate
and thorough examination with prompt
retesting and, if needed, follow-up as soon as
possible by an appropriate specialist.
The physician should re-evaluate her office
procedures and inform the patient of what
will be done to prevent similar errors caused
by ineffective data management.
Begin by stating there has been an error;
Describe the course of events, using
nontechnical language;
State the nature of the mistake,
consequences, and corrective action;
Express personal regret and apologize;
Elicit questions or concerns and address
them;
Plan the next step and next contact with the
patient.
Seek assistance from those who might help you with disclosure
(e.g., unit director, risk manager).
Disclose promptly what you know about the event.
Concentrate on what happened and the possible
consequences.
Take the lead in disclosure; don't wait for the patient to ask.
Outline a plan of care to rectify the harm and prevent
recurrence.
Offer to get prompt second opinions where appropriate.
Offer the option of a family meeting and the option of having
lawyers present.
Document important discussions.
Offer the option of follow-up meetings.
Be prepared for strong emotions.
Accept responsibility for outcomes, but avoid attributions of
blame.
Apologies and expressions of sorrow are appropriate.
