How to Handle a Medical Mistake

Error in judgment must occur in the practice of an art which consists largely of balancing probabilities.—William Osler

As emergency physicians, we strive for perfection. We strive for quality medical care, diagnostic accuracy, patient safety, and patient satisfaction. However, medical errors are an inevitable reality in the practice of medicine. We focus attention on education and systems to reduce the incidence of medical errors and to manage outcomes after a medical error. Increased attention to medical errors resulted from the Institute of Medicine landmark report “To Err Is Human: Building a Safer Health System” in 2000.¹ In this report, an error is defined as failure of a planned action to be completed as intended (error of execution) or use of a wrong plan to achieve an aim (error of planning). Errors may be classified as serious errors (errors that cause permanent injury or transient but potentially life-threatening harm), minor errors (errors that cause harm that is neither permanent or potentially life-threatening), and near-miss errors (errors that could have caused harm but did not either by chance or by timely intervention).

Errors occur commonly in the ED environment.^2–4 A recent study showed that 56 percent of U.S. physicians have been involved with a serious error, 74 percent have been involved with a minor error, and 66 percent have been involved with a near-miss error.⁵

Patients strongly prefer disclosure of medical errors (up to 98 percent of patients).^6–8 It has been demonstrated that disclosure of errors to patients resulted in increased patient satisfaction, reduced likelihood of changing physicians, lower rate of seeking legal advice, reduced litigation, lower legal expenses, and lower jury awards.^7,9,10 At least 35 states have adopted apology/disclosure laws, which protect providers who disclose medical errors.

According to the American Medical Association ethics opinion “Ethical Responsibility to Study and Prevent Error and Harm,” “physicians must strive to ensure patient safety and should play a central role in identifying, reducing, and preventing health care errors.”¹¹ Physicians should be active in error reporting and disclosure to patients, but they should do so in collaboration with hospital risk management. In addition, The Joint Commission has required multiple safety standards including requirements of attention to safety, staff safety education, reporting systems, and disclosure of errors.

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Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio.

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Reasons to Disclose Medical Errors to Your Attending and the Patient

1. Promote patient safety. Disclosure of medical errors affords an opportunity to implement systemwide solutions.
2. Build patient trust. Patients want you to be honest with them. Honesty is the best policy!
3. Improve your professional skills. Disclosure to your attending physician affords a teaching opportunity. Your attending will help put the error in the proper perspective and develop an action plan to reduce future errors by you and other physicians.
4. Integrity. It’s the right thing to do. It’s as simple as that.
5. Reduce your risk of litigation. Studies have demonstrated that honest disclosure can reduce the risk of litigation related to medical errors.
6. Being found out after hiding something is much worse. The risks to you and your career are significant. Don’t do it.

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ACEP Policy Statement on Disclosure of Medical Errors¹²

Revised and approved by the ACEP Board of Directors April 2010. Originally approved by the ACEP Board of Directors September 2003.

ACEP believes that emergency physicians should provide prompt and accurate information to patients and their representatives about their medical condition and its treatment. In the emergency department, as in other health care settings, patients may experience adverse events as a result of human error or of flaws in the health care system. Human or

system errors can cause significant harm to patients or alter patients’ needs for care. If, after careful review of all relevant information, an emergency physician determines that such an error has occurred in the care of a patient in the emergency department (ED), he or she should provide information about the error and its consequences to the patient, or if the patient is incapacitated, to the patient’s representative in a timely fashion, in accordance with hospital policy on medical error disclosure.

ACEP recognizes that substantial obstacles, including unrealistic expectations of physician infallibility, lack of training about disclosure of errors, and fear of increased malpractice exposure, obstruct the free disclosure to patients of significant medical errors. In order to overcome these obstacles, ACEP recommends the following institutional, professional, and societal initiatives:

• Health care institutions should develop and implement policies and procedures for identifying and responding to medical errors, including continuous quality improvement systems and procedures for disclosing significant errors to patients.
• Medical educators should develop and incorporate into their curricula programs on identifying and preventing medical errors and on communicating truthfully and sensitively with patients and their representatives about errors.

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References

1. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
2. Fordyce J, Blank FS, Pekow P, et al. Errors in a busy emergency department. Ann Emerg Med. 2003;42:324-333.
3. Croskerry P, Sinclair D. Emergency medicine: a practice prone to error? CJEM. 2001;3:271-276.
4. Kuhn GJ. Diagnostic errors. Acad Emerg Med. 2002;9(7):740-750.
5. Garbutt J, Waterman AD, Kapp JM, et al. Lost opportunities: how physicians communicate about medical errors. Health Aff (Millwood). 2008;27(1):246-255.
6. Hobgood C, Tamayo-Sarver JH, Weiner B. Patient race/ethnicity, age, gender and education are not related to preference for or response to disclosure. Qual Saf Health Care. 2008;17(1):65-70.
7. Mazor KM, Simon SR, Yood RA, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med. 2004;140:409-418.
8. Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001-1007.
9. Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356:2713-2719.
10. Boothman RC, Blackwell AC, Campbell DA Jr., et al. A better approach to medical malpractice claims? The University of Michigan experience. J Health Life Sciences Law. 2009;2:125-159.
11. Ethical responsibility to study and prevent error and harm. AMA’s Code of Medical Ethics, 2003. Accessed March 15, 2016.
12. Disclosure of medical errors. Accessed Jan. 26, 2016.