When a medical error leads to patient harm, it’s hard to argue that no one is more upset than the patient’s family. However, it’s often overlooked that the doctors or nurses who caused that error also may be devastated.
“One of the most difficult experiences for any doctor or nurse is when they realize that they have made a mistake that has harmed a patient,” say the authors of an ethical discussion in the current issue of Pediatrics.
What should a doctor do when they realize a mistake has led to pain and suffering, or worse? While the answers may seem clear, there are many ethical and, unfortunately legal, dilemmas a provider must consider prior to disclosing such sensitive information.
“In the past, mistakes were seldom disclosed to patients,” said the authors, led by Sigall K. Bell, MD, of Beth Israel Deaconess Medical Center, Boston. “The prevailing ethos was one of professional silence, secrecy, and shame. That has begun to change.”
The authors present the case of a four month old, former 23 week preemie; several weeks of high-frequency oscillating ventilation and vasopressor infusions; multiple operations for complications of necrotizing enterocolitis; docs suggested, but mother refused DNR. Following slight improvement, condition worsened. Evaluated for sepsis, started antibiotics, back on ventilation. Baby went into cardiac arrest.
A radiologist noted, on a chest radiograph taken during the resuscitation, that SP’s central line was in her aorta and not in a central vein as it should have been….[Baby’s] decline over the past several days and her cardiac arrest were likely the result of arterial emboli from her central line and the administration of medications directly into her arterial system….consistent with severe hypoxic ischemic injury.
Should the docs have recommended the DNR? And how much should they tell the mother about the misplaced line?
“What matters for the patient is the clinical reality of the situation, not the path by which that reality came to be. As such, the advice and recommendations of the clinical team to the mother should be same as would be given to the parents of any infant with this condition, regardless of whether an error occurred,” said Dr. Bell and Robert Truog, MD, Division of Medical Ethics, Harvard Medical School and author of Talking with Patients and Families about Medical Error: A Guide for Education and Practice. “Although patients and family members are clearly at the sharp end of errors, such experiences also can have devastating effects on providers.”
Disclosure of medical errors “leads to improved trust from families,” said Keith J. Mann, MD, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, Kansas City. “When done effectively and coupled with an effective claims management model, it may lead to fewer lawsuits and overall less of a financial burden on hospitals.”
“In this case, [the] mother should be told that the central line was misplaced and that the clinical team believes there is a connection between the misplaced line and [the baby’s] clinical deterioration,” said Dr. Mann.
John D. Lantos, MD, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, Kansas City, said that failure to disclose information to patients is not always about ethics. “When disclosure does not occur, it is simply because such disclosure is psychologically difficult for doctors to do.”
What would you do?
(Photo by Melimama via Wikimedia Commons)