There is a clear consensus that error disclosure is an ethical obligation of physicians — but what if the mistake was made by another clinician, or at another institution?
“Assuming that both the physician who made a harmful error and another physician who discovered it are the patient’s treating physicians, they both have an ethical obligation to ensure that it is disclosed to the patient,” says Charity Scott, JD, MSCM, Catherine C. Henson professor of law at Georgia State University College of Law in Atlanta.
In reality, many physicians are reluctant to fully disclose their own errors, let alone a colleague’s. “A number of personal, psychological, and institutional ramifications of disclosing someone else’s error can make such disclosures very challenging as a practical matter,” says Scott. She gives the following examples:
- A physician may find confronting a colleague about an error to be an uncomfortable and embarrassing conversation that risks damaging their collegial relationship.
- A physician may be concerned about jeopardizing the colleague’s reputation, or even his or her own reputation if he or she becomes viewed by other physicians as breaking collegial trust.
- A physician may be concerned about prompting an investigation or adverse disciplinary action by the colleague’s institution, or about opening up the potential for a malpractice claim by the patient.
“Professional bonds continue to make many physicians reluctant to ‘call out’ a colleague for a mistake, either to the patient or to others in the colleague’s practice or institution,” says Scott.
Physicians have a duty to put a patient’s welfare and need for information above their own discomfort or potential repercussions from an error disclosure. This is true regardless of whether the error was made by him- or herself or another clinician, says Scott. She says that a consulting ethicist can help in the following ways:
- Suggest to the physician who suspects that another physician has erred in a patient’s diagnosis or treatment that he or she discuss the case with his or her colleague.
This gives each physician a chance to gain a more complete understanding of the situation. “It may be that, with a fuller knowledge of the medical case, they can conclude that either there was no error or that it’s simply a professional disagreement among alternative approaches, all of which are still within the standard of care,” says Scott.
- If the physician still suspects that the colleague made a mistake, the ethicist might next suggest that they request a consultation with appropriate specialists.
If the specialist consultation confirms the error, then the ethicist should recommend that the physicians discuss who should make the disclosure and how, advises Scott.
- Identify appropriate resources within the institution, such as patient safety, quality assurance, or risk management, to help physicians make the disclosure appropriately.
“Some institutions have specially trained personnel who can help to coach the physicians on having the conversation,” says Scott.
- If the physician denies committing an error, or refuses to cooperate in the error disclosure, ethicists can recommend that the physician who discovered the error seek institutional support for making the disclosure.
“While that may appear to ‘up the ante’ from the perspective of the other physician, it seems a necessary step from an institutional perspective to report all adverse events causing harm to patients,” says Scott. It can also provide some institutional assistance and support to the discovering physician who makes the disclosure to the patient.
Ideally, the provider who made the error would be notified, allowing him or her the opportunity to disclose to the patient, says Bryn Esplin, JD, a bioethics fellow at the Cleveland Clinic. “If this is not possible, a disclosure that identifies the error and provides the patient with all pertinent information but does not speculate or ascribe unnecessary blame should still be made,” she says.
Bioethicists can provide experiential training so clinicians can practice these difficult conversations, Esplin suggests.
Sandra Petronio, PhD, senior affiliate faculty at Indiana University Health’s Charles Warren Fairbanks Center for Medical Ethics in Indianapolis, says, “In order for disclosure of mistakes made by others to occur, there are a number of difficult issues that need to be taken into account.”
First, says Petronio, the culture of the healthcare delivery system must address clinicians’ reticence to disclose someone else’s mistake, and also what constitutes a medical error. “Many attempts have been made to isolate the parameters of what constitutes a mistake, without a clear consensus except in the most obvious and egregious cases,” she notes.
One clinician may define something as a medical mistake, while another would not agree. Also, many errors involve a team of clinicians.
“There needs to be a conceptual shift from not wanting to jeopardize reputation of self or others, to making the whole system stronger by learning the best way to indicate the possibility that a medical mistake has occurred,” says Petronio.
- Bryn Esplin, JD, Cleveland Clinic. Phone: (216) 444-8720. Email: firstname.lastname@example.org.
- Sandra Petronio, PhD, Senior Affiliate Faculty, Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis. Email: email@example.com.
- Charity Scott, JD, MSCM, Catherine C. Henson Professor of Law, Georgia State University College of Law, Atlanta. Phone: (404) 413-9183. Fax: (404) 413-9225. Email: firstname.lastname@example.org.