Ethical encounter with errors of laboratory and colleagues

Nazafarin Ghasemzadeh

Medical Ethics and History of Medicine Research Center

Tehran University of Medical Sciences

ObjectivesDefinition of medical errorReviewing the incidence of errorEthical encounter with error of colleagues

and laboratoryThe necessity of error disclosureBarriers of error disclosureLearning an effective method of disclosing

medical error to patients

CaseA patient’s breast biopsy was confused with someone else’s

sample by the histopathologist the patient had undergone an unnecessary mastectomy.believing her to be at serious risk of premature deathThe mistake was subsequently suspected by a consultant

oncologist who then contacted the consultant histopathologist and asked him to review the slides.

He did so and found that they showed normal tissue without any evidence of malignancy.

The patient’s GP was informed of this and, after discussion, it was decided that the whole situation should be explained to the patient at the hospital by the surgeon who had operated her, together with two nurses to provide support.

Telling patients that they have undergone unnecessary distress and a superfluous operation is clearly difficult.

patient said that “it was easier to accept the mastectomy when I thought I had cancer because I believed that it was necessary to save my life and I actually felt worse once I knew that it has all been a mistake and unnecessary.

To Err Is Human

Therefore, the occurrence of error in medicine and health care services is inevitable.

However errors are preventable & their occurrence can be reduced.

Unexpected medical Complication Unexpected Complication: Complication associated

with medical practice which can't be anticipated.Adverse event: an injury caused by medical

management rather than the patient’s underlying disease; = harm, injury, complication.

Medical Error: Unexpected medical events which are preventable.

Negligence or professional misconduct: Negative consequences which are caused by intentional or irresponsible practice of medical staff.

Definition of M.E There are various definitions for M.EAmerican medical institute: the failure of a

planned action to be completed as intended or the use of a wrong plan to achieve an aim

“a commission or an omission which has the potential to harm the patient & that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences.”

Non-Preventable

AE

Potential AENear Misses

Medical Error

Adverse Events

(complications)

Errors and Adverse Events Errors and Adverse Events

Negligent AE

Medical Errors & Adverse Events

Medical ErrorsAE

Preventable AE

Non-preventable

NearNearMiss

Incidence of M.EReport of American medical institute (1999): M.E Causes about 44000 – 98000 deaths annually in American

hospitalscauses serious injury to more than one million patientsis the 8th cause of death in American hospitalsAnd costs 29 billion dollars Frequency of deaths caused by M.E is higher than death

caused by motor vehicle accidents (43458), breast cancer  (42297), or AIDS (16516)

Findings of the study(2000-2004): each year about 83000 preventable deaths are caused by M.E occur in American hospital

National American medical institute

From every 500 hospitalized patients one is killed because of M.E v.s the possibility of being killed in airplane accidents in one in every 8 million flights.

M.E causes 37.6 billion dollars of cost for American health system, 17 billion dollars of which is caused by preventable M.E.

In Canadian hospitals

In every 1000 admission 7.3% unexpected medical events occur – 36.9% of which is preventable.

Among preventable events 9% leads to patient death.

Australia

16% of patients experience unexpected medical events- half of which is preventable

IRAN

In our country there is no statistics or information on the rate of occurrence of M.E

Types of M.EDiagnostic errorTreatment errors One of the health care centers which have a

significant role in the occurrence of error is medical diagnostic laboratories. (10%-15%)

Laboratory errors which include errors prior to testing, during

the test, and after testing are mainly related to human and instrument errors and system design flaws and they can lead to diagnostic and treatment errors and consequently cause emotional, physical and financial damage to the patients.

Common Causes of M.EIgnoranceInexperienceFaulty judgmentHesitationFatigueJob overloadBreaks in concentrationFaulty communicationFailure to monitor closely System flaws

Complexity of medical knowledge- probabilistic science

Uncertainty of clinical prognosisTime limitation in decision- makingNeed for decision- making in spite of

uncertain &inadequate knowledge Tension causing factorsMultiplicity of dutiesSpecific characteristics of each patientIndividual characteristics of physician (e.g.

inexperience, ….)

Professional commitment in occurrence of error

Commitment to quality of service providing. Reduction in occurrence of errors (error

reporting system& assessment of error management committee)

Commitment to responsibility: Compensation (treatment, professional liability insurance)

Commitment to honesty: Error disclosure

Error disclosureRespect for autonomyThe right to be informed about the results of

medical practiceIncreasing patient trustInformed consent for treatment of harm

caused by M.EThe right to receive compensation

Occurrence of M.E is not necessarily unethical however not disclosing M.E is considered unethical.

Not disclosing information is considered as deception & can reduce trust to medical community.

It also considers nondisclosure of error as threatening professionalism and potential risk for patients.

Being informed by a source other than the responsible physician.

Ethical management of Lab error based on principles of autonomy, beneficence,

nonmaleficence and justice disclosure of error to patient and health system is considered as one of absolute rights of patients and as a requirement to trust medical profession in community.

Besides it considers error disclosure as a measure in prevention and decrease of future error .

Creating a culture supportive of error reporting is the starting point in reducing future medical errors.

Since errors can be expected, systems must be designed to prevent and absorb them.

Barriers of error disclosureuncertain if “event is an error”has “No useful purpose , point”increased patients’ pain and sufferingdecreased patients’ confidence in MD &

system patients will avoid future caredifficult to admit , confess “no one taught us how”Expectations: Medical profession should be

infallible , perfect

FearLoss of reputation, statusLimiting professional advancementLoss of authorityLitigation ( legal action )

Uncertainty: What do the patients want?

The Essentials of Disclosure

• Why disclose?• What types of events should be disclosed?• What should be said?• Who should disclose?• To whom ?• When and where should the disclosure take

place?• And how should it be done?

WhyPatient Has Right to Know about the Condition and

Make Health Care DecisionsImproves Doctor/Patient RelationshipRebuilds TrustQuality of CareProfessional Code of EthicsStandards on Patient Safety and Error ReductionMay Be Required by Hospital Staff, By-Laws, Medical

Group Policies andProcedures, Health Plans, and Health Care

Organizations

WhoHealth Care Provider Involved in the Unanticipated

OutcomeProvider With Responsibility for Ongoing CarePerson With Ability to Answer QuestionsPersons Involved in Disclosure Discussion May Need

Assistance inPreparing, Coordinating or Conducting Discussion,

Depending Upon:· Communication Skills· Rapport with Patient and Family· Language Barriers

WhatAcknowledge that the event occurredGive the facts, in order, simplyTake responsibility and apologizeCommit to finding out whyExplain what impact the event will have on

the patient now and in the futureDescribe steps being taken to mitigate the

effects of the injuryDescribe steps being taken to prevent a

recurrence

WhenAs soon as practicable after immediate

Health Care Needs Addressed Consider patient’s physical and emotional

readinessIdeally within 24 hours after the event is

recognizedMake sure the proper people are present Ongoing communication may be required

as more information is availableFollow up may be requiredPatient’s permission needed to discuss care

with family

WhereConsider privacy and health needsIn a quiet and private areaHave water and tissues

To whom andwhich error

M.E resulting in no injury Patients do not understand if physician do not disclose Patients understand if physician do not discloseM.E resulting in trivial and treatable injury Patients do not understand if physician do not disclose Patients understand if physician do not discloseM.E resulting in severe and incurable injury Patients do not understand if physician do not disclose Patients understand if physician do not disclose

HowExpress EmpathyCommunicate Only “Known Facts”Avoid Speculation and BlameSolicit and Respond to Patient’s/Family’s

Feelings and QuestionsRespond to Patient’s ComplaintsRespond to Patient’s Questions About

Remedies and Refer Settlement DemandsVerify Patient’s/Family’s Understanding of

Outcome and PrognosisPlan for Follow-up Care and More

Discussions and Communicate the PlanMaintain “open body language”

Practical approach to disclosure of error to patients

When error occurs notify your medical insurer.Seek assistance from those who can help you in error

disclosure.Take the lead in disclosure. Don't wait for them to ask.Describe the event using non-technical language.Address all questions &concerns of the patient.Express regret and also apologize.Ensure the patient that you will do your best to compensate

for the error.Plan for patient care, compensation and prevention of the

recurrence of error &also inform the patient about it.Offer to meet patient's family.Document all discussions & disclosure in medical record.Be prepared for patient's strong emotional expression.Take responsibility for the consequences of your error but

don’t blame your self. Systematic approach

Ethical encounter with colleague’s error

Identification of the errorDiscussion with the person who commits the

error:educating the prior physician presents an

opportunity to improve the quality of care received by other patients that should not be overlooked.

Could say “I believe I have discovered an error in your diagnosis of a patient that I would want to know about if it were my error.”

Disclosure of error to patient and health system respecting the colleague, keeping patient’s trust, and patient’s confidentiality.

Finallyto encourage physicians to report error to the

error management and patient safety committees by winning physicians’ trust and supporting them.

This will enable health system to develop a database of medical errors in the country and to employ them in training health professionals and also use them in error prevention plans to improve health care quality and patient safety.

Thank you for your attention