Ethical obligations to disclose medical errors in the pediatric setting are very similar to those involving competent adults, says Robert D. Truog, MD, Frances Glessner Lee professor of medical ethics, anaesthesia, and pediatrics and director of the Center for Bioethics at Harvard Medical School in Boston.

“Close attention should be paid to the unique needs of children at different stages of development,” says Truog.

Pediatric settings frequently have access to child life specialists, pediatric social workers, psychologists, and psychiatrists. These experts can provide guidance on how to frame information about a medical error in ways appropriate to the developmental, emotional, cognitive, and spiritual needs of each child.

“I see the role of ethicists as primarily one of making sure that these sources of expertise are explored and utilized,” says Truog. “Failure to handle this well could result in lasting harm to the child.”

Robust Systems Needed

Philip M. Rosoff, MD, MA, professor of pediatrics and medicine at Duke University’s Trent Center for Bioethics, Humanities & History of Medicine in Durham, NC, says ethical obligations are similar for error disclosure in children and adults who have lost decision-making capacity and have surrogate decision-makers.

“The error would then involve another layer of complexity,” Rosoff explains. This is because the interventions associated with the error would have necessarily been approved during the informed consent process by the surrogate or parent.

Errors involving people who have capacity primarily affect them and, secondarily, affect their loved ones, notes Rosoff. In contrast, errors with children and adults without capacity “also seem to integrally include the authorized decision-maker as an ‘accessory,’ if you will,” says Rosoff. “They would be the people legally and morally acting in the patient’s stead.”

Rosoff says institutions should have robust systems for disclosure, regardless of the age of the patient involved.

“Of course, due to the special cultural sensitivity involved with children — especially if the error produced an injury — institutions should be sensitive to the needs of the pediatric population and their parents,” says Rosoff.

Many, but not all, hospitals have error disclosure policies in place. “If some administrators are not already attuned to the modern understanding of what should happen after an error is discovered, there is now a large literature on this issue,” says Rosoff. The process includes the following:

  • Full disclosure without hiding anything for the fear of legal liability. “It has been demonstrated that honest disclosure lessens liability,” says Rosoff.
  • An admission of responsibility;
  • an apology;
  • a promise to try and understand what happened (and why);
  • follow-up.

“Ethicists can play a major role if the powers that be need to be educated in both the instrumental and moral benefits of this approach,” says Rosoff.

SOURCES

  • Philip M. Rosoff, MD, MA, Professor of Pediatrics & Medicine, Trent Center for Bioethics, Humanities & History of Medicine, Duke University, Durham, NC. Phone: (919) 668-9025. Fax: (919) 668-1789. Email: philip.rosoff@dm.duke.edu.
  • Robert D. Truog, MD, Frances Glessner Lee Professor of Medical Ethics, Anaesthesia, and Pediatrics/Director, Center for Bioethics, Harvard Medical School, Boston. Phone: (617) 355-7327. Email: Robert_Truog@hms.harvard.edu.