Book contents
- Frontmatter
- Contents
- List of contributors
- Acknowledgements
- 1 Introduction
- Section I Information problems
- Section II End of life care
- Section III Pregnant women and children
- Section IV Genetics and biotechnology
- Section V Research ethics
- Section VI Health systems and institutions
- Introduction
- 32 Organizational ethics
- 33 Priority setting
- 34 Disclosure of medical error
- 35 Conflict of interest in education and patient care
- 36 Public health ethics
- 37 Emergency and disaster scenarios
- 38 Rural healthcare ethics
- 39 Community healthcare ethics
- Section VII Using clinical ethics to make an impact in healthcare
- Section VIII Global health ethics
- Section IX Religious and cultural perspectives in bioethics
- Section X Specialty bioethics
- Index
- References
34 - Disclosure of medical error
Published online by Cambridge University Press: 30 October 2009
Book contents
- Frontmatter
- Contents
- List of contributors
- Acknowledgements
- 1 Introduction
- Section I Information problems
- Section II End of life care
- Section III Pregnant women and children
- Section IV Genetics and biotechnology
- Section V Research ethics
- Section VI Health systems and institutions
- Introduction
- 32 Organizational ethics
- 33 Priority setting
- 34 Disclosure of medical error
- 35 Conflict of interest in education and patient care
- 36 Public health ethics
- 37 Emergency and disaster scenarios
- 38 Rural healthcare ethics
- 39 Community healthcare ethics
- Section VII Using clinical ethics to make an impact in healthcare
- Section VIII Global health ethics
- Section IX Religious and cultural perspectives in bioethics
- Section X Specialty bioethics
- Index
- References
Summary
A 77-year-old farmer with recurring kidney stones visits his urologist for an annual examination. Prior to seeing the patient, the physician is taken aside by her nurse, who tells her the patient had been in the emergency department the previous night with hematuria. A CAT scan had been done, which indicated that the renal tumor seen on last year's CAT scan was larger and there were now lung metastases. The physician cannot remember ever seeing the radiology report from last year. To her complete surprise, it is found filed in the patient's chart. There is no record in the chart that the results were ever shared with the patient. She considers herself extremely meticulous and has never had such an oversight before. The urologist considers what she should tell the patient.
A 12-year-old boy has cataract surgery at a large teaching hospital. At a critical moment the surgeon's hand slips, severely 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.
What is medical error?
Well-publicized reports of harm occurring to patients as a result of their medical care in the USA (Patient Safety Foundation, 1998), Canada (Sinclair, 1994) and the UK (Smith, 1998) have raised public concerns about the safety of modern healthcare.
- Type
- Chapter
- Information
- The Cambridge Textbook of Bioethics , pp. 257 - 265Publisher: Cambridge University PressPrint publication year: 2008
References
Baker G. R., Norton P. G., Flintcroft, V., et al. (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ170: pp. 1678–86 (http://www.ncbi.nlm.nih.gov/entrez/query. fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_ uids=15159366).
, , , et al. (2002). Views of practicing physicians and the public on medical errors. N Engl J Med 347: 1933–40.CrossRefGoogle ScholarPubMed
, , , et al. (1999). Perils, pitfalls, and possibilities in talking about medical risk. JAMA 281: 1037–41.CrossRefGoogle ScholarPubMed
(1979). Lying: Moral Choice in Public and Private Life. New York: Vintage Books, p. 71.Google Scholar
, , , et al. (1991). Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 324: 370–6.CrossRefGoogle ScholarPubMed
, , , et al. (1998). A Practical Guide to Communication Skills in Clinical Practice. [CD–ROM set.] Toronto: Medical Audio Visual Communications.Google Scholar
Canadian Medical Association (2004). Code of Ethics. Ottawa: Canadian Medical Association. (http://www.cma.ca/index.cfm/ci_id/2419/la_id/1.htm) accessed 31 July 2006.
(2000). Disclosing Adverse Events to Patients: CMPA Information Sheet. Ottawa: Canadian Medical Protective Association.Google Scholar
College of Physicians and Surgeons of Ontario (1994). Policies. Professional Misconduct. Toronto: College of Physicians and Surgeons (http://www.cpso.on.ca/Policies/profmisc.htm) accessed 22 December 2000.
, , , et al. (1995). The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 21: 541–8.Google Scholar
, , and , (2003). The Canadian Patient Safety Dictionary. Ottawa: Royal College of Physicians and Surgeons of Canada.Google Scholar
ECRI (2002). Disclosure of unanticipated outcomes. Healthc Risk ContrRA:IRM 5 (Suppl A): 1–27.
ENEAS (2005). Report. National Study on Hospitalisation-Related Adverse Events. Madrid: Ministry of Health and Consumer Affairs Madrid (http://www.who.int/patientsafety/research/RESUMEN.ENEAS_INGLES.pdf) accessed 22 August 2006.
Etchells E., Sharpe G., Walsh, P., et al. (1999). Consent. In Bioethics at the Bedside, ed. . Ottawa: Canadian Medical Association pp. 1–7.Google Scholar
, , , et al. (1997). When a physician harms a patient by a medical error: ethical, legal, and risk–management considerations. J Clin Ethics 8: 330–5.Google Scholar
, , , et al. (1999). The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 126: 66–75.CrossRefGoogle ScholarPubMed
Gerula v. Flores (1995). 126 DLR (4th) 506, 128 (Ont CA).
(1992). The reliability of peer assessments of quality of care. JAMA 267: 958–60.CrossRefGoogle ScholarPubMed
(2006). System failure versus personal accountability: the case for clean hands. N Engl J Med 355: 121–3.CrossRefGoogle ScholarPubMed
, , and (2006). Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?Acad Emerg Med 13: 443–51.CrossRefGoogle ScholarPubMed
Illinois 93rd General Assembly (2005). Patient Safety Act. Bill HB4245. (http://www.ilga.gov/legislation/BillStatus_pf.asp?DocNum=4245&DocTypeID=HB&LegID=8461&GAID=3&SessionID=3&GA=93) accessed 6 July 2006.
, , , et al. (1998). Five times: coincidence or something more serious. BMJ 316: 1736–40.CrossRefGoogle Scholar
(1997). Legal anxieties and medical mistakes: barriers and pretexts. J Gen Intern Med 12: 787–8.CrossRefGoogle ScholarPubMed
, , and (eds.) (2000). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press.Google Scholar
and (1999). Risk management: extreme honesty may be the best policy. Ann Intern Med 131: 963–7.CrossRefGoogle ScholarPubMed
, , , et al. (2003). Hospital disclosure practices: results of a national survey. Health Aff (Millwood) 22: 73–83.CrossRefGoogle ScholarPubMed
(2002). Improving quality through public disclosure of performance information. Health Aff (Millwood) 21: 52–62.CrossRefGoogle ScholarPubMed
Leape, L. L. (1994b). The preventability of medical injury. In Human Error in Medicine, ed. . Hillsdale, NJ: Erlbaum, pp. 13–25.Google Scholar
, , , et al. (1991). The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 324: 377–84.CrossRefGoogle ScholarPubMed
, , , et al. (1998). Promoting patient safety by preventing medical error. JAMA 280: 1444–7.CrossRefGoogle ScholarPubMed
Legislative Assembly of Quebec (2006). R.Q., c. M–9, r.4.1. Section 56.
, , , et al. (1997). Physician–patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 277: 553–9.CrossRefGoogle ScholarPubMed
, , , et al. (1991). Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med 325: 245–51.CrossRefGoogle ScholarPubMed
, , , et al. (2004). Health plan members' views about disclosure of medical errors. Ann Intern Med 140: 409–18.CrossRefGoogle ScholarPubMed
, , , et al. (2005). Health plan members' views on forgiving medical errors. Am J Manag Care 11: 49–52.Google ScholarPubMed
, , , et al. (2003). The quality of health care delivered to adults in the United States. N Engl J Med 348: 2635–45.CrossRefGoogle ScholarPubMed
(1996). The emotional impact of mistakes on family physicians. Arch Fam Med 5: 71–5.CrossRefGoogle ScholarPubMed
Oklahoma State Legislature (2004). Act Relating to Public Health and Safety. SB 1592. Oklahoma City: State Printing Office.
(2005). Patient Safety in Ontario: An Overview of Patient Safety Policies in Select Ontario Academic Hospitals. Toronto: Ontario Hospital Association.Google Scholar
Patient Safety Foundation (1998). Tale of Two Stories: Contrasting Views of Patient Safety. North Adams, MA: Patient Safety Foundation (http://www.npsf.org/exec/report.html).
and (1996). Legal Liability of Doctors and Hospitals in Canada, 3rd edn. Toronto: Carswell, pp. 170–2.Google Scholar
(1987). Fraudulent concealment and the duty to disclose medical mistakes. Albert Law Rev 25: 215–23.Google ScholarPubMed
, , , et al. (1992). Watching the doctor-watchers. How well do peer review organization methods detect hospital care quality problems?JAMA 267: 2349–54.CrossRefGoogle ScholarPubMed
(2003). Delivering Doctor Miranda: The Story of a Gifted Young Obstetrician's Mistake and the Psychiatrist who Helped Her. New York: Harmony Books.Google Scholar
Shobridge v. Thomas (1999). BCJ no. 1747 (SC. online: QL (BCJ).
(2004). No Moral Conscience: The Hospital for Sick Children and the Death of Lisa Shore. Toronto: Trafford.Google Scholar
Sinclair, M. (1994). The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Centre in 1994. Winnipeg: Manitoba Health (http://www.pediatriccardiacinquest.mb.ca).
, , , et al. (1997). Peer review of the quality of care. Reliability and sources of variability for outcome and process assessments. JAMA 278: 1573–8.CrossRefGoogle ScholarPubMed
(1998). All changed, changed utterly. British medicine will be transformed by the Bristol case. BMJ 316: 1917–18.CrossRefGoogle Scholar
Stamos v. Davies (1985). 21 DLR (4th) 507 (Ont HC).
UK Department of Health (2000). An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS. London: The Stationery Office (http://www.dh.gov.uk/assetRoot/04/06/50/86/04065086.pdf) accessed 31 July 2006.
VA Healthcare Network (1998). Integrated Patient Safety/Risk Management Program. New York: Veterans Health Administration (http://www.va.gov) accessed 22 December 2000.
Vasdani v. Sehmi (1993). OJ no. 44 (Gen Div) online: QL (OJ).
, , and (1994). Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 343: 1609–13.CrossRefGoogle ScholarPubMed
, , , et al. (1999). Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract 5: 13–21.CrossRefGoogle ScholarPubMed
Walton, M. For the Clinical Practice Improvement Unit (2001). Open Disclosure to Parents or Families After an Adverse Event. A Literature Review. Sydney: Clinical Practice Improvement Unit (http://www.nsh.nsw.gov.au/teachresearch/cpiu/CPIUwebdocs/WebversionLiteratureReview.pdf) accessed 31 July 2006.
, , , et al. (1992). Identification of preventable trauma deaths: confounded inquiries?J Trauma 32: 45–51.CrossRefGoogle ScholarPubMed
, , , et al. (1995). The Quality in Australian Health Care Study. Med J Aust 163: 458–71.Google ScholarPubMed
, , , et al. (1996). How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med 156: 2565–9.CrossRefGoogle Scholar
, , , et al. (1997). To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 12: 770–5.CrossRefGoogle ScholarPubMed