 |
|
 |
 |
| |
|
|
| |
| A Dilemma on Honesty and Patient Care: Is It Ever Appropriate Not to Disclose Clinical Error? |
 |
by Kristina Fiore, MedPage Today/ Bob Blumm, MA, PA-C, DFAAPA - September 8, 2010
|
Admitting Clinical Errors Not Always Best Policy
 |
By Kristina Fiore, Staff Writer, MedPage Today
September 03, 2010 |
|
|
Review
Wide-scale disclosure of clinical errors seems intuitively to be ethical choice for hospitals and physicians, but researchers from the University of Washington, in Seattle, suggest that disclosure should be decided on a case-by-case basis rather than a one-size-fits-all solution.
There are instances where disclosure itself may cause harm as anxiety related to worries about what may be only a minimal risk outweighs the ethical benefit of disclosure, Denise Dudzinski, PhD, of the University of Washington, and colleagues reported in a commentary in the New England Journal of Medicine.
Dudzinski and colleagues said the ethical justification for disclosing harmful errors to patients is strong, but there's no consensus about the need to disclose "near-miss" incidents. Often these patients are not physically injured, they may not benefit from the disclosure, and may be psychologically harmed.
Yet, by withholding information about the error, institutions can't be sure whether any patient was physically harmed.
The researchers used three examples to illustrate the disclosure quandary.
In one, a laboratory in Canada misdiagnosed the estrogen receptor status of several hundred women with breast cancer, a key clinical concern since women who were estrogen receptor positive would receive different chemotherapy regimens than women who were ER negative. The center disclosed the findings, but patients faced long delays due to inconsistent attempts at contacting women at risk for incorrect results.
The researchers called the ethical analysis here "unambiguous."
"The magnitude of the risk of harm, as well as the fact that the harm was preventable and involved deviations from standards of practice, clearly warranted disclosure," they wrote.
In another case, the University of Washington Medical Center realized that some endoscopes were not cleaned completely. Risk was likely remote, but the hospital disclosed the finding to all potentially affected patients. It also devoted "considerable time and resources to developing and implementing a process for following up on the disclosure."
Ultimately, there was no infection with blood-borne pathogens and no lawsuits were filed.
But in a third case, a Denver neurosurgery patient was found posthumously to have Creutzfeldt-Jakob disease, and the center subsequently realized that instruments used in the patient's surgery were later used in surgeries of six other patients.
With this particular disease, however, incubation can last anywhere from six months to twenty years, and may never manifest.
"This event is among the most rare and challenging type of large-scale adverse event, since it is difficult to know whether any harm has occurred until decades after exposure," the researchers wrote. "Thus, a duty to tell the truth might be outweighed by a duty of nonmaleficence."
Disclosure could be warranted, they said, but nondisclosure was also justified because of the facts of the case.
"As these cases illustrate, the ethical obligations to disclose are greatest when the events resulted from preventable errors or system failures, whereas duties to disclose are more ambiguous when the probability of harm is extremely low but the severity of harm is great and there are no definitive diagnostic tests or effective treatments," they wrote.
Institutional policies may help guide these deliberations, but they hardly ever cover large-scale adverse events. Thus, responses can be "slow and haphazard."
The Veterans Health Administration Directive on Disclosure of Adverse Events to Patients, however, is an exception, the researchers said. It outlines a "clear and systematic process for disclosure decisions regarding large-scale adverse events."
That includes convening an advisory board and defining a threshold parameter. For instance, disclosure is not obligatory when less than one of 10,000 patients is expected to be affected, or when an event is not clinically significant regardless of the number of patients exposed.
Dudzinski and colleagues recommended that institutions develop a clear set of procedures for managing the disclosure process, notifying patients, and coordinating follow-up testing and treatment.
Finally, they cautioned that part of the institutional disclosure policy should include a media strategy based on conveying truthful and accurate information to the press.
Primary source: New England Journal of Medicine
Source reference: Dudzinski DM, et al "The disclosure dilemma -- large-scale adverse events" N Engl J Med 2010; 363(10): 978-986.
Disclaimer
The information presented in this activity is that of the authors and does not necessarily represent the views of the University of Pennsylvania School of Medicine, MedPage Today, and the commercial supporter. Specific medicines discussed in this activity may not yet be approved by the FDA for the use as indicated by the writer or reviewer. Before prescribing any medication, we advise you to review the complete prescribing information, including indications, contraindications, warnings, precautions, and adverse effects. Specific patient care decisions are the responsibility of the healthcare professional caring for the patient.
I guess that administration is winning the war relating to legal and human effort, based upon the ultimate finding in the situations. Why should we bother to expect that all instrumentation that is being place down our esophagus or in our bronchus or up our large colon be at least cleansed of the former debris, whether it is e-coli or c-diff or just plain mucus from a cancer patient? There are standards that have been written by the AORN, The Endoscopic Nurses, The CDC and the Epidemiology Society that clearly describe the types of microorganisms and how they should be eradicated prior to utilization on the next patient. I trust the AORN guidelines because, after forty years in this field, they are the ones that stand as the last barrier of protection from the hospital/surgeon to the patient. This new methodology of ruling what should be communicated is atrocious and destroys the level of trust between patient and health care provider. Apathy and lack of focus are the culprits here and they should be dismissed along with those that practice them. We still have over 100,000 patients killed each year because of Hospital Associated Infections, and if we are dishonest and unethical in our reporting, the numbers will continue on an upward trend.
Human life is important, and if our actions are responsible for just one loss of life, we have failed. Honesty in reporting keeps us diligent. If the VA Hospitals have taken an en mass attitude of "no tell," what type of care are we providing to veterans who went into harm’s way for their country? I hope that a maniac with wrong info wrote the preceding article because it demonstrates the unhealthy and immoral state of medical care in 2010.
Bob Blumm
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
|
RECOMMEND THIS ARTICLE
You must be logged in
to recommend articles
|
 |
|
|
| Bob blumm (Amityville, NY) |
on 17 Sep 2010 at 2:09 pm |
|
How Not To Handle A Retained Sponge
by Jeff Reinke, editorial director
In the September print edition of Surgical Products, our editor, Amanda McGowan, talked about the benefits of an honest and upfront approach to those surgical mistakes that, despite everyone’s best efforts, can occasionally take place.
In the September print edition of Surgical Products, our editor, Amanda McGowan, talked about the benefits of an honest and upfront approach to those surgical mistakes that, despite everyone’s best efforts, can occasionally take place.
“Often, no matter how big or small the mistake, an apology is a good start to remedying the situation. Still, it seems to be human instinct to try to cover up the mistake, not talk about it or deny that it happened whenever possible,” she wrote. As if to further illustrate her point, let’s examine how the reaction to a retained sponge in England made a bad situation even worse.
Recently, a British woman lost part of her bowel after doctors accidentally left a surgical sponge inside her body during a routine hysterectomy. The Daily Mail reported that Susan Misiewicz had internal bleeding and a lot of pain after her initial surgery, and was given antibiotics. A second surgery attempted to correct the problem, but to no avail. A CT scan finally revealed the real problem – an 18” surgical sponge wrapped around her bowel. A third surgery finally remedied the error.
Misiewicz said no one is coming forward to take responsibility for the mistake. Officials at the hospital where the error occurred said the incident is still under investigation, and seeing as how treatment shifted between two different facilities, neither is willing to step up and acknowledge the obvious error.
Granted, this incident takes place in a country with a national health care system that is funded by taxpayers, so the competitive factors that propel individual hospitals to react to such matters more passionately are not in play, but should that matter? It seems in this instance ego and potential financial retribution is preventing the surgical team responsible for the initial mistake from stepping forward, especially at this point.
If a CT scan was able to pinpoint the problem several months after the initial surgery, imagine how much easier it may have been able to find it, without compromising the woman’s bowel in the process, if clinicians had swallowed their pride in at least considering the possibility of a retained object. Instead, to avoid acknowledging their potential error, antibiotics and even another surgery simply prolonged the process and further alienated this patient, as well as the entire community. Now the facility is also under greater governmental scrutiny.
In the midst of this past baseball season Detroit Tiger pitcher Armando Galarraga was on the verge of one of sports most difficult accomplishments – a perfect game. This means he was able to get every single Cleveland Indian hitter out without giving up a hit or walk. On a close play at first the 27th batter was erroneously called safe by umpire Jim Joyce. This meant Galarraga would not register the elusive accomplishment and although he and his team still won the game, it would forever carry that single blemish. The reason this game garnered so much extra attention is that the “safe” call was clearly wrong. Video of the play showed the runner was clearly out.
After the game Joyce watched the replay and admitting to blowing the call, taking away Galarraga’s perfect game. The response wasn’t outrage towards Joyce. He’s human. He made a mistake. Galarraga even said so. The public’s response - let’s move on.
Granted, there is no comparing the significance of outcomes between a baseball game and a surgical procedure, but there is takeaway value in a man standing up to the scrutiny of millions of people and admitting his mistake. Joyce worked in the very next game and throughout the season. He’s still considered one the best, and not just for what he did, but what he continues to do at a very high level – and much of that has to do with him saying he was sorry.
Surgical Products |
|
|
|
|
| |
|
|
 |
 |
|
 |
 |
 |
|
