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Guest Column: Correcting medical errors: How far do you go?
CMs have a responsibility to monitor errors
By Mindy Owen, RN, CRRN, CCM
Chair, Ethics Committee, Commission for Case Manager Certification and President
Phoenix Health Care Associates
Coral Springs, FL
John Banja, PhD
Assistant Director for Health Sciences
Associate Professor of Clinical Ethics
The occurrence of medical errors made by health care providers against patients has been at the forefront of the media in recent years. Dealing with the occurrence and subsequent outcomes of medical errors is a hazardous part of our jobs, but it is not a new phenomenon as it may appear to health care consumers due to this vast amount of attention.
In fact, very few medical mistakes result in patient harm — that is, an outcome that results in requiring additional medical care, lost time from work or, worst case scenario, a disability or even death.
As a case manager and patient advocate, you have a moral responsibility that goes along with those roles to monitor any errors that could potentially result in harm to the patient.
In general, all health care providers have a duty to practice according to a standard of care, and when a health care provider commits an error, he or she has breached that standard of care.
Essentially, our patients have a right not to be wronged and when they suffer physical, emotional, or psychological harm due to a medical error, they not only have been harmed, but they have been wronged by the health care delivery system.
Secondly, patients have rights to make decisions about their care and to be informed as to why additional care is needed. This is where the disclosure of medical errors becomes important for case managers. If, for example, the patient requires an additional procedure to correct an error that occurred in the initial procedure, that patient has a right to know why the additional medical attention is necessary.
This scenario may take place if, for example, a surgical device was not removed after completing a surgery. If that information is withheld from the patient, he or she is not giving a valid consent to that second procedure because the patient does not truly know why the additional care is required and has, in essence, been wronged by the system.
Furthermore, because most patients who have suffered harm as a result of a medical error do require additional care, it is morally wrong to expect patients to bear the financial burden of the costs associated with the added care.
The silent response’
Not disclosing a medical error committed against your patient often is referred to as a "silent response," and is indeed a moral mistake. But how can you be sure if a medical error has truly occurred? They typically are uncovered while performing routine patient management tasks.
Because of the nature of our jobs, case managers are in step with the day-to-day treatments and care of our patients. Each intervention is carefully monitored, and when additional care is required, it is a natural response for a case manager to question it.
Basically, any error resulting in medical care that was not initially anticipated is a red flag and should be investigated. In fact, the Commission for Case Manager Certification (CCMC) has established a Code of Professional Conduct for Case Managers, which includes a section on ethics. This section mandates that if a medical error occurs during the course of a patient’s treatment in which the case manager is involved, the case manager is ethically obligated to acknowledge and address such errors as a condition of his or her certification. However, this is different from reporting the incident, which may or may not be necessary, depending on the circumstances and outcomes of each individual case.
Getting to the root of the problem
Should you suspect that a potentially harm-causing error has indeed occurred, there are a number of steps to take before confronting the patient:
• Confirm and clarify your suspicions. The best way to begin your research is to discuss your concerns first with the physician who is managing the patient’s treatment. Simply ask, "Was this an error?"
Keep in mind that what happened may sometimes appear to be a medical error on paper, when in fact it was not and there is a good clinical explanation for the subsequent steps that are being undertaken in the patient’s treatment plan. If the error occurred while the patient was hospitalized and you still are not satisfied with the responses you are receiving from the providers, talk with the internal case manager and perhaps the hospital’s risk manager about the case.
Should you discover that a patient was harmed due to a medical error, but those involved have decided not to disclose the information, as a patient advocate, you should attempt to persuade the providers to reveal the information. Should that effort fail, your last resort is the ethics committee of the organization.
Liability is, of course, the core reason many institutions shy away from total disclosure in some cases of medical errors, however, recent research suggests that health care facilities may in fact lower their overall risk of malpractice by implementing policies of full disclosure at all times.
The reason appears to be that, in cases where hospitals have come forward with full disclosures of medical errors that impacted their patients in any way — even in those cases where the patients may not have known an error occurred — the patients were less likely to bring a lawsuit against the facility.
• Document, document, document. Keep copies of records and document conversations with other care providers involved in the patient’s treatment. This way, you will have documented evidence of the proactive steps you have taken to ensure the patient has received the best care possible and that you have worked within the parameters of your case management role to avoid any adverse outcomes as a result of the services the patient received under your care.
• Confront the patient with compassion, but do not advise. Regardless of the outcome of your efforts, case managers have a duty to make information available to their patients. Therefore, the final step, armed with information, is to inform the patient what happened, but not to provide advice regarding legal action or any other possible subsequent actions that may be taken in response to this information.
Those decisions should be left up to the patient and his or her family. For example, say, "Mr. Jones, what happened was this mistake. You need to know that what’s charted here is you received a very high dose of this particular drug. The order was for 10 mg of oxycodone, and you received 100 mg. There is reason to believe that this might have caused all the problems that you had that week in the hospital."
Confronting medical errors can be one of our most wrenching tasks as case managers. However, errors, as in any industry, will continue to happen as well in the health care community. The trick is to keep those errors from causing harm to our patients.