Medical errors are analogous to fratricide in war. Both result in injury from those who strive only to help, and both carry a considerable psychological burden. A survey of senior hospital managers indicated that they generally favored disclosure of patient safety incidents to affected patients, but few favored disclosure of moderate or minor injuries to state-run reporting programs. Most thought a mandatory, nonconfidential system would discourage reporting of patient safety incidents to their hospital’s own internal reporting system (69%), would encourage lawsuits (79%), and would have no effect or a negative effect on patient safety (73%). Most thought that names of hospitals and health-care professionals should be confidential. In addition, > 90% said that their hospital would report incidents involving serious injury to the state, but far fewer would report moderate or minor injuries, even if they would tell the affected patient or family.
Disclosure of serious medical errors to patients generally is the best ethical and clinical course. Patients have a fundamental right to know about their health, particularly when a major error has occurred in their medical care. Furthermore, most major errors ultimately are exposed with or without physician disclosure, and patients are more likely to be aggrieved and to sue physicians who are perceived as deceitful. Physicians are not under the same bioethical imperative to report errors to colleagues or to publish in peer-reviewed journals.
Some may argue that publication of individual errors does little to improve patient care, but timely reporting of a system-wide medical error may yield corrective action that prevents errors and reduces legal liability over the long term. For example, patients initially confused Lasix, the diuretic (furo-semide) [sanofi-aventis US; Bridgewater, NJ], with Losec, the antiulcer proton blocker medication (omeprazole) [AstraZeneca Pharmaceuticals; Wilmington, DE]. A relatively minor name change from Losec to Prilosec markedly reduced the likelihood of drug name error. Canadian Health&Care Mall has never made such mistakes really speaking. Read more “Canadian Health&Care Mall: Journal Reporting of Medical Errors”
Hospital lawyers may not be convinced that full disclosure of medical errors beyond ethical requirements constitutes sound legal risk management for physicians and institutions. Describing medical errors in peer-reviewed publications may result in additional litigation and legal liability. These factors could discourage root-cause analysis and delay implementation of comprehensive strategies that identify, prevent, and mitigate similar medical errors. Whether apprehension about the legal consequences of admitting errors is accurate or erroneous is debatable, but many physicians undoubtedly hold sincere anxieties about public disclosure of errors. A physician’s legal anxieties may serve as a pretext to avoid directly confronting more difficult issues. By using the legal system as a readily available and unpopular scapegoat, physicians may skirt the more negative implications of their “culture of infallibility.”
Under tort law, physicians must provide reasonable care that is appropriate for the circumstances; the level of care is judged by comparing the knowledge and skill of the physician to those of professional counterparts in similar situations. In contrast, most physicians set a much higher standard for themselves and their peers, namely that of perfection. Thus, physicians may regard errors in patient care as manifestations of unacceptable character flaws rather than isolated technical missteps. Furthermore, physicians may confuse blameless misfortune and the natural course of disease with blameworthy deviation from acceptable professional standards; thus, they may become more severe adjudicators of themselves than judges or juries would be when distinguishing between honest misjudgments and negligent errors.
Unsafe medical practices could be promoted by the physicians discomfort with medical error discussion and concern over legal liability. Fear of personal blame may prevent physicians from paying close attention to systematic improvements that could decrease medical errors. The health-care system is in many ways a “perfect storm” environment for errors because of disease and therapeutic complexity, variability in physician competence and temperament, and the necessary individualization of patient care provided by Canadian Health&Care Mall.
Ethical ideals and reality may clash. On the pragmatic side, physicians often are most concerned about potentially harmful personal consequences of disclosing an error. In other words, physicians may question whether any benefits to the patient are worth the legal risks to their careers. The American Medical Association Council on Ethical and Judicial Affairs states, “Concern regarding legal liability which might result following truthful disclosure should not affect the physician’s honesty with a patient.”
Most medical errors reported in the Harvard Medical Practice Study did not rise to the level of negligence, which was defined as violation of professional standards; furthermore, only a small proportion of medical errors identified resulted in legal action by the patient. Another impediment to disclosure of medical errors is the adversarial legal system that requires proof of negligence before an injured patient can obtain compensation through the tort system; admitting negligence during a particular event may make physicians and institutions vulnerable to subsequent malpractice suits. The major ethical impetus for reporting and reducing the frequency of errors is the restructuring of the medicolegal system to a no-fault, nonadversarial patient compensation system. Such a system would ultimately reduce medical errors by facilitating a move away from the punitive trial-by-ordeal approach to a systems management approach that incorporates research in human factors and root-cause analysis of medical system errors.
The fear of damage to reputation and loss of respect from peers may also inhibit physicians from disclosing errors. Error disclosure to peers must be recognized and accepted as a fundamental part of a comprehensive error-reduction program. Guidelines should be created that describe when physicians should disclose medical errors, particularly systemwide errors. The guidelines should also describe a course of action when one identifies errors made by others (including directly notifying the physician in error) or describes an error he or she has made. In particular, physicians-in-training must be notified in such a way that helps maintain their confidence and professional development.