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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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16. Errors
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A careful medical practitioner … before they attempt to administer a remedy to their patient, the medical practitioner must investigate the patient’s malady they wish to cure, the patient’s habits when in health, and the patient’s physical constitution.
~ Marcus Tullius Cicero
Surgical Slip-up
The Importance of Transparency and Accountability
It was a cold winter night when Dr. Smith received a call from the emergency department. His patient, Mr. Johnson, had been admitted with severe abdominal pain. After conducting a thorough examination, Dr. Smith determined that surgery was necessary to remove Mr. Johnson’s inflamed appendix. As the surgery progressed, Dr. Smith realized that he had accidentally nicked Mr. Johnson’s colon, causing a tear. The surgical team repaired the tear and completed the surgery, but Dr. Smith knew he had made a grave error.
Dr. Smith spent the next few days agonizing over what to do. He knew that he had a professional and moral obligation to disclose the error to Mr. Johnson, but he was also afraid of the consequences. He was worried that he might lose his medical license or even face legal action. He confided in his colleague, Dr. Johnson, who reminded him that their duty was to always act in the best interests of the patient.
Dr. Smith ultimately decided to disclose the error to Mr. Johnson and his family. He apologized and took full responsibility for the mistake. Mr. Johnson was understandably upset, but he appreciated Dr. Smith’s honesty and felt reassured that the hospital would conduct a root cause analysis to prevent similar errors in the future.
The root cause analysis revealed that Dr. Smith’s error was due to a breakdown in communication between the surgical team. The hospital implemented new protocols for communication and double-checking surgical procedures to prevent similar errors from happening in the future.
While Dr. Smith faced some consequences for his error, including additional training and supervision, he ultimately learned an important lesson about the importance of transparency and accountability in the medical profession. He realized that he could not let his fear of consequences prevent him from fulfilling his professional and moral obligations to his patients.
Abstract
The patient-practitioner relationship is built on trust and confidentiality of protected health information (PHI). The patient has the right to be informed about all medical errors that may affect their medical care and make an informed consent decision, violating this right is a violation of the patient’s autonomy, legal, professional and moral rights. The practitioner’s professional principles of beneficence (do good) and nonmaleficence (do no harm) require that errors be disclosed in a timely manner to maximize the patient’s best interests. As a matter of justice, the patient has the right to know about medical errors and the practitioner has a duty to report errors to the institution so an institutional root cause analysis can occur. Failure to disclose medical errors and report them to the institution is a legal, professional, moral, and institutional policy violation. The practitioner has a professional and moral obligation to disclose medical errors, apologize, and take responsibility for the error regardless of its impact on the patient’s medical care.
**
Think
[16:1] The patient-practitioner relationship is a social-contract that establishes a relationship grounded on protected health information (PHI), confidentiality, and mutual trust. Honesty and transparency reflect this trust, and lying and not revealing information relevant to the patient’s medical care, such as a medical error, violates this patient-practitioner relationship, which is the very foundation of the art of medicine. Therefore, regardless of the practitioner’s sentiments, the practitioner must inform the patient about all errors that might have a direct medical effect on the patient and communicate all information needed for the patient to make an autonomous informed consent decision.
Assess
Patient: 1) Autonomy
[16:2] Without the knowledge of medical errors, the patient will not be substantially autonomous. The provision of manipulative information, meaning the willful disclosure of only selective information towards the goal of determining a patient’s decision, is a direct violation of “freedom,” a necessary condition of the principle of autonomy or informed consent. Under manipulation conditions, such as concealed errors, the patient’s consent is not substantially informed. Not revealing medical errors is a violation of patient autonomy’s legal, professional, and moral rights.
[16:3] A patient has the negative right of autonomy, meaning that others have an obligation of not interfering with the patient’s informed consent decision-making process. A practitioner not revealing medical errors violates the patient’s negative rights.
[16:4] A patient has the positive right of autonomy, meaning that others have an obligation to provide the patient with information relevant to making informed consent decisions. A practitioner not revealing medical errors violates the patient’s positive rights. The practitioner not revealing medical errors violates the patient’s negative and positive rights to make an autonomous informed consent decision.
[16:5] Since the patient did not provide an informed consent authorizing the practitioner to commit the treatment error, it follows that all medical errors are a violation of informed consent.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[16:6] The professional principles of beneficence (do good) and nonmaleficence (do no harm) require that the practitioner maximizes the patient’s best interests using the patient’s reasonable goals, values, and priorities. Except for very unusual circumstances, such as placebos for clinical trials, or therapeutic privilege for situations in which the information would cause serious harm to the patient or others, it is professionally expected that all errors that relate to the patient’s medical care be disclosed to the patient in a timely fashion. Being honest and informative about errors is considered professionally necessary to maximize the patient’s best interests.
[16:7] There are therapeutic benefits when the practitioner apologizes for errors made by one or more members of the practitioner’s medical team and when the practitioner takes full responsibility for the error. The art of medicine as a practice of evidence-based medicine, together with its probabilistic uncertainties and complexities, makes it inevitable that errors will happen from time to time. What the practitioner does when such errors occur will reflect the practitioner’s character and ability to behave professionally and not violate the patient-practitioner relationship. Not revealing the error to the patient would be a violation of beneficence (do good) and nonmaleficence (do no harm).
[16:8] A healthy patient-practitioner relationship psychologically results in more open and honest discussions by the patient and physiologically results in better patient medical outcomes, maximizing the patient’s best interests.
Public Policy: 4) Justice
[16:9] As a matter of justice (be fair), the patient has the right to know and be substantially informed of all medical errors related to the patient’s medical treatment. As a negative right, nobody should interfere in the patient gaining truthful information about their medical care. As a positive right, the practitioner and health care team must provide all relevant information to the patient’s care. Anything less than the communication of the error to the patient would be a violation of justice.
[16:10] The practitioner has a duty of nonmaleficence (do no harm) and beneficence (do good) to report any errors to the institution so that a root cause analysis can be conducted and mitigation policies implemented. Root cause analysis is a quality improvement measure that identifies: what, how, and why a preventable error occurred so that the institution can create policies and procedures to prevent similar errors from happening again. Examples of error mitigation procedures are the implementation of checklists, double-checking doses, and armband patient identification.
[16:11] Failure to report a medical error to the patient and the institution would be a legal, professional, moral, and institutional policy violation. Honest communication and personal accountability of medical errors are necessary for the institution, practitioner, and patient’s social-contract.
Conclude
[16:12] There is no equivocation regarding the practitioner’s professional and moral obligation to disclose medical errors, apologize for the error, and take full responsibility for the error regardless of whether or not the error had a negative impact on the patient’s medical care.
[16:13] In summary, disclosing medical errors and addressing them transparently is crucial to preserving the patient-practitioner relationship and ensuring that patients can make informed decisions about their care. Practitioners must prioritize honesty, accountability, and institutional reporting to facilitate quality improvement measures and maintain a high standard of care. Upholding these values demonstrates a practitioner’s commitment to their professional and moral obligations and promotes a fair and just healthcare environment.
**
16. Review Questions
1. Not reporting an error to a patient violates the practitioner-patient relationship, which is the foundation of the art of medicine.
2. A patient has a positive right of others providing information necessary for informed consent and a negative right of others not interfering with the patient’s informed consent decision-making process. A practitioner not revealing medical errors violates both the patient’s negative and positive rights.
3. An error is not a violation of informed consent and should be considered to be part of the probabilistic uncertainties associated with the practice of medicine.
4. Root Cause Analysis:
**
CORRECT! 🙂
[16:1] The patient-practitioner relationship is a social-contract that establishes a relationship grounded on protected health information (PHI), confidentiality, and mutual trust. Honesty and transparency reflect this trust, and lying and not revealing information relevant to the patient’s medical care, such as a medical error, violates this patient-practitioner relationship, which is the very foundation of the art of medicine. Therefore, regardless of the practitioner’s sentiments, the practitioner must inform the patient about all errors that might have a direct medical effect on the patient and communicate all information needed for the patient to make an autonomous informed consent decision.
Wrong 😕
[16:1] The patient-practitioner relationship is a social-contract that establishes a relationship grounded on protected health information (PHI), confidentiality, and mutual trust. Honesty and transparency reflect this trust, and lying and not revealing information relevant to the patient’s medical care, such as a medical error, violates this patient-practitioner relationship, which is the very foundation of the art of medicine. Therefore, regardless of the practitioner’s sentiments, the practitioner must inform the patient about all errors that might have a direct medical effect on the patient and communicate all information needed for the patient to make an autonomous informed consent decision.
CORRECT! 🙂
[16:3] A patient has the negative right of autonomy, meaning that others have an obligation of not interfering with the patient’s informed consent decision-making process. A practitioner not revealing medical errors violates the patient’s negative rights.
[16:4] A patient has the positive right of autonomy, meaning that others have an obligation to provide the patient with information relevant to making informed consent decisions. A practitioner not revealing medical errors violates the patient’s positive rights. The practitioner not revealing medical errors violates the patient’s negative and positive rights to make an autonomous informed consent decision.
Wrong 😕
[16:3] A patient has the negative right of autonomy, meaning that others have an obligation of not interfering with the patient’s informed consent decision-making process. A practitioner not revealing medical errors violates the patient’s negative rights.
[16:4] A patient has the positive right of autonomy, meaning that others have an obligation to provide the patient with information relevant to making informed consent decisions. A practitioner not revealing medical errors violates the patient’s positive rights. The practitioner not revealing medical errors violates the patient’s negative and positive rights to make an autonomous informed consent decision.
CORRECT! 🙂
[16:5] Since the patient did not provide an informed consent authorizing the practitioner to commit the treatment error, it follows that all medical errors are a violation of informed consent.
CORRECT! 🙂
[16:10] The practitioner has a duty of nonmaleficence (do no harm) and beneficence (do good) to report any errors to the institution so that a root cause analysis can be conducted and mitigation policies implemented. Root cause analysis is a quality improvement measure that identifies: what, how, and why a preventable error occurred so that the institution can create policies and procedures to prevent similar errors from happening again. Examples of error mitigation procedures are the implementation of checklists, double-checking doses, and armband patient identification.
Wrong 😕
[16:10] The practitioner has a duty of nonmaleficence (do no harm) and beneficence (do good) to report any errors to the institution so that a root cause analysis can be conducted and mitigation policies implemented. Root cause analysis is a quality improvement measure that identifies: what, how, and why a preventable error occurred so that the institution can create policies and procedures to prevent similar errors from happening again. Examples of error mitigation procedures are the implementation of checklists, double-checking doses, and armband patient identification.
16. Clinical Vignettes
1. Ms. Stella Reyes, a 48-year-old network security specialist visits their practitioner for a routine check-up. During the examination, the practitioner realizes that they made a mistake in the patient's previous test results, and the patient has not been informed about it. What is the practitioner's most appropriate course of action?
2. Ms. Lana Ahmed, a 66-year-old lighting designer presents to the clinic for a routine check-up. During the visit, the practitioner realizes that a mistake was made during a previous procedure that could impact the patient's health. The patient has a right to be informed of any medical errors and to make informed decisions about their care, but the practitioner is faced with a dilemma. If the error is disclosed, it could violate the patient's right to make informed decisions because of the lack of trust in the practitioner that might ensue from the disclosure. However, if the error is not disclosed, it would interfere with the patient's positive right to be informed. Which of the following actions is the most appropriate for the practitioner in this situation?
3. Ms. Adriana Temple, a 72-year-old marine engineer presents to the emergency department with severe abdominal pain. The treating practitioner orders a CT scan to evaluate the source of the pain. During the scan, the technologist accidentally injects the patient with a contrast agent intended for another patient. The patient experiences an allergic reaction and requires medical treatment. Which of the following statements best describes the situation?
4. Mr. Isaiah Lee, a 61-year-old surveyor with a history of hypertension and diabetes presents to the hospital with complaints of chest pain and shortness of breath. The patient is diagnosed with acute myocardial infarction. Despite appropriate management, the patient deteriorates and passes away. As per institutional policy, an institutional root cause analysis (RCA) is conducted to identify the causes of the adverse event and implement quality improvement measures. The RCA team found that the delay in the administration of thrombolytic therapy was a significant factor in the unfavorable outcome of the patient. Which of the following best describes the purpose of conducting an institutional RCA?
5. Ms. Kelly Baker, a 29-year-old mobile app developer presents to their primary care provider with complaints of persistent headache and fatigue. During the examination, the practitioner realizes they had made a mistake in the patient's previous diagnosis and treatment plan. Which of the following actions should the practitioner take in response to this realization?
Wrong 😕
Explanation: The most appropriate course of action is to inform the patient about the error and communicate all necessary information for the patient to make an informed decision. It is essential to inform the patient of the mistake, as this could potentially have an impact on their health and well-being [16:1]. The practitioner should explain the error and the potential consequences to the patient, and provide them with all the necessary information to make an informed decision about their care [16:2]. The patient has a right to know about any errors that may affect their health [16:2], and it is the practitioner's ethical and legal responsibility to inform the patient of the mistake [16:6]. Keeping the error a secret would be a violation of the patient's rights and could lead to further harm [16:9]. Similarly, only informing the patient if they ask is not sufficient, as the patient may not be aware of the mistake and may not think to ask about it. It is also not appropriate to shift the responsibility to someone else. Therefore, the most appropriate course of action is to inform the patient directly and provide them with all the necessary information to make an informed decision [16:1].
CORRECT! 🙂
Explanation: The most appropriate course of action is to inform the patient about the error and communicate all necessary information for the patient to make an informed decision. It is essential to inform the patient of the mistake, as this could potentially have an impact on their health and well-being [16:1]. The practitioner should explain the error and the potential consequences to the patient, and provide them with all the necessary information to make an informed decision about their care [16:2]. The patient has a right to know about any errors that may affect their health [16:2], and it is the practitioner's ethical and legal responsibility to inform the patient of the mistake [16:6]. Keeping the error a secret would be a violation of the patient's rights and could lead to further harm [16:9]. Similarly, only informing the patient if they ask is not sufficient, as the patient may not be aware of the mistake and may not think to ask about it. It is also not appropriate to shift the responsibility to someone else. Therefore, the most appropriate course of action is to inform the patient directly and provide them with all the necessary information to make an informed decision [16:1].
CORRECT! 🙂
Explanation: The practitioner needs to disclose the error to the patient, apologize for the mistake, and provide all necessary information for the patient to make an informed decision [16:6][16:7][16:9][16:12]. While it is understandable that the practitioner may be hesitant to disclose the error due to concerns about damaging the patient's trust, it is essential that the patient be informed of any errors that may impact their health [16:2][16:3][16:4]. This allows the patient to make informed decisions about their care and to take any necessary steps to address the error [16:6]. Additionally, withholding information about the error can be seen as a violation of the patient's right to be informed [16:9]. Disclosing the error but emphasizing that it is not the practitioner's fault, is not appropriate, as it can be seen as an attempt to shift blame or avoid taking responsibility for the error [16:7]. Similarly, not disclosing the error at all, is not appropriate, as it violates the patient's right to be informed [16:2][16:3][16:4][16:9]. Consulting with a colleague before making a decision to disclose may be appropriate in some situations, but ultimately it is the practitioner's responsibility to inform the patient of any errors that may impact their health [16:6][16:7][16:9][16:12].
Wrong 😕
Explanation: The practitioner needs to disclose the error to the patient, apologize for the mistake, and provide all necessary information for the patient to make an informed decision [16:6][16:7][16:9][16:12]. While it is understandable that the practitioner may be hesitant to disclose the error due to concerns about damaging the patient's trust, it is essential that the patient be informed of any errors that may impact their health [16:2][16:3][16:4]. This allows the patient to make informed decisions about their care and to take any necessary steps to address the error [16:6]. Additionally, withholding information about the error can be seen as a violation of the patient's right to be informed [16:9]. Disclosing the error but emphasizing that it is not the practitioner's fault, is not appropriate, as it can be seen as an attempt to shift blame or avoid taking responsibility for the error [16:7]. Similarly, not disclosing the error at all, is not appropriate, as it violates the patient's right to be informed [16:2][16:3][16:4][16:9]. Consulting with a colleague before making a decision to disclose may be appropriate in some situations, but ultimately it is the practitioner's responsibility to inform the patient of any errors that may impact their health [16:6][16:7][16:9][16:12].
CORRECT! 🙂
Explanation: The medical error violated informed consent because all medical errors violate informed consent. Informed consent is a fundamental ethical and legal principle that requires healthcare providers to inform patients of the risks and benefits of medical interventions and to obtain the patient's agreement before proceeding with any treatment or diagnostic procedure [16:1]. In this case, the patient consented to the CT scan but did not consent to being injected with contrast agent intended for another patient [16:5]. The medical error resulted in an allergic reaction and required medical treatment, which is an adverse outcome that the patient did not consent to. Therefore, the medical error violated informed consent, as the patient was not informed of the risks associated with the injection of contrast agent intended for another patient [16:1]. The fact that the patient consented to the CT scan does not justify the violation of informed consent related to the injection of the contrast agent intended for another patient. The fact that the patient did not experience any permanent harm from the reaction does not justify the violation of informed consent. Errors are not an inevitable part of medicine and do not excuse the violation of informed consent. Healthcare providers have a responsibility to take all necessary steps to prevent medical errors and to inform patients of any risks associated with medical interventions [16:1].
Wrong 😕
Explanation: The medical error violated informed consent because all medical errors violate informed consent. Informed consent is a fundamental ethical and legal principle that requires healthcare providers to inform patients of the risks and benefits of medical interventions and to obtain the patient's agreement before proceeding with any treatment or diagnostic procedure [16:1]. In this case, the patient consented to the CT scan but did not consent to being injected with contrast agent intended for another patient [16:5]. The medical error resulted in an allergic reaction and required medical treatment, which is an adverse outcome that the patient did not consent to. Therefore, the medical error violated informed consent, as the patient was not informed of the risks associated with the injection of contrast agent intended for another patient [16:1]. The fact that the patient consented to the CT scan does not justify the violation of informed consent related to the injection of the contrast agent intended for another patient. The fact that the patient did not experience any permanent harm from the reaction does not justify the violation of informed consent. Errors are not an inevitable part of medicine and do not excuse the violation of informed consent. Healthcare providers have a responsibility to take all necessary steps to prevent medical errors and to inform patients of any risks associated with medical interventions [16:1].
Wrong 😕
[16:5] Since the patient did not provide an informed consent authorizing the practitioner to commit the treatment error, it follows that all medical errors are a violation of informed consent.
CORRECT! 🙂
Explanation: The RCA team needs to identify areas for improvement in patient care so that such events do not happen again [16:10]. The purpose of conducting an institutional root cause analysis (RCA) is to identify the underlying causes of adverse events [16:10], such as delays in treatment [16:10], errors in communication [16:10], or system failures [16:10], in order to implement quality improvement measures to prevent such events from happening again. The RCA team investigates the event by examining the sequence of events leading up to the adverse event, identifying contributing factors, and developing recommendations for improvements [16:10]. The ultimate goal of an RCA is to identify areas for improvement in patient care and to implement changes to prevent future adverse events [16:10]. To assign blame to individual practitioners, is not a correct answer because the RCA process is not intended to be a punitive exercise [16:11]. The focus is on improving the system, not on blaming individuals. To comply with regulatory requirements, is not a complete answer because while regulatory requirements may mandate conducting an RCA, the primary purpose is to identify areas for improvement in patient care, not simply to comply with regulations. To assess the cost-effectiveness of care delivery, is not correct because while cost-effectiveness is an important consideration in healthcare, it is not the primary purpose of an RCA [16:10].
Wrong 😕
Explanation: The RCA team needs to identify areas for improvement in patient care so that such events do not happen again [16:10]. The purpose of conducting an institutional root cause analysis (RCA) is to identify the underlying causes of adverse events [16:10], such as delays in treatment [16:10], errors in communication [16:10], or system failures [16:10], in order to implement quality improvement measures to prevent such events from happening again. The RCA team investigates the event by examining the sequence of events leading up to the adverse event, identifying contributing factors, and developing recommendations for improvements [16:10]. The ultimate goal of an RCA is to identify areas for improvement in patient care and to implement changes to prevent future adverse events [16:10]. To assign blame to individual practitioners, is not a correct answer because the RCA process is not intended to be a punitive exercise [16:11]. The focus is on improving the system, not on blaming individuals. To comply with regulatory requirements, is not a complete answer because while regulatory requirements may mandate conducting an RCA, the primary purpose is to identify areas for improvement in patient care, not simply to comply with regulations. To assess the cost-effectiveness of care delivery, is not correct because while cost-effectiveness is an important consideration in healthcare, it is not the primary purpose of an RCA [16:10].
CORRECT! 🙂
Explanation: The most appropriate course of action is to apologize to the patient, take responsibility for the error, and take steps to prevent similar errors from occurring in the future. In the case of a medical error, it is important for healthcare providers to acknowledge the error, take responsibility for it, and apologize to the patient [16:1]. This can help to build trust between the patient and provider and demonstrate a commitment to transparency and honesty. The practitioner should explain the error to the patient, apologize for any harm caused by the mistake, and discuss any necessary changes to the treatment plan [16:6]. The practitioner should also take steps to prevent similar errors from occurring in the future [16:10]. Denying responsibility for the error and continuing with the previously prescribed treatment plan, is not appropriate as it ignores the impact of the error on the patient's health and well-being [16:7]. Waiting for the patient to bring up the error before acknowledging it, is not appropriate as it does not demonstrate a commitment to transparency and honesty [16:1]. Blaming a colleague for the mistake and offering no apology or corrective action, is not appropriate as it shifts the responsibility for the error to someone else and does not address the impact of the error on the patient's health and well-being [16:7].
Wrong 😕
Explanation: The most appropriate course of action is to apologize to the patient, take responsibility for the error, and take steps to prevent similar errors from occurring in the future. In the case of a medical error, it is important for healthcare providers to acknowledge the error, take responsibility for it, and apologize to the patient [16:1]. This can help to build trust between the patient and provider and demonstrate a commitment to transparency and honesty. The practitioner should explain the error to the patient, apologize for any harm caused by the mistake, and discuss any necessary changes to the treatment plan [16:6]. The practitioner should also take steps to prevent similar errors from occurring in the future [16:10]. Denying responsibility for the error and continuing with the previously prescribed treatment plan, is not appropriate as it ignores the impact of the error on the patient's health and well-being [16:7]. Waiting for the patient to bring up the error before acknowledging it, is not appropriate as it does not demonstrate a commitment to transparency and honesty [16:1]. Blaming a colleague for the mistake and offering no apology or corrective action, is not appropriate as it shifts the responsibility for the error to someone else and does not address the impact of the error on the patient's health and well-being [16:7].
**
16. Reflective Vignettes
1. Ms. Jane Smith, a 45-year-old kindergarten teacher, was admitted to the hospital with symptoms of dehydration, including fatigue, dizziness, and dry mouth. The attending practitioner conducted a physical examination and ordered an IV drip to rehydrate Ms. Smith. However, when filling out the prescription, the practitioner made a typo and inadvertently under-dosed the prescription. A nurse, Nurse John, who was reviewing the orders, noticed the error and immediately informed the practitioner.
The practitioner acknowledged the mistake and thanked Nurse John for her vigilance. Nurse John corrected the dosage error, and the medication was administered to Ms. Smith without any harm done to the patient. Details of the event were recorded in the medical records, the patient was fully informed, and the incident was reported to the hospital's quality improvement department, conducting a root cause analysis, and implementing corrective actions to prevent similar incidents in the future..
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Ms. Sarah Johnson, a 75-year-old retired nurse, was under hospice care due to a terminal illness. She had a DNAR order in her medical records, which meant that healthcare providers were not to perform CPR if her heart stopped. The attending practitioner was administering an IV drip to Ms. Johnson when they inadvertently made an error, resulting in Ms. Johnson going into cardiac arrest. The differential diagnosis for Ms. Johnson's cardiac arrest could include factors such as anaphylaxis, pulmonary embolism, or severe electrolyte imbalances. However, in this case, it was clear that the cause of the cardiac arrest was due to the practitioner's medication error. What should the practitioner do, and what are the various consequences that could befall the patient and the practitioner based on each option, and outcomes?
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
16c*
Mr. Charles Cody, a 70-year-old retired mechanic with multiple medical problems, had been admitted to the hospital four times in the last month due to a worsening of his overall condition. Hospice had been recommended for Mr. Cody, but his offspring wanted aggressive management. During the current admission, the attending practitioner accidentally gave Mr. Cody a dose of medication that was too high, resulting in cardiac arrest and his subsequent death. The differential diagnosis for Mr. Cody's multiple medical problems could include conditions such as heart failure, chronic obstructive pulmonary disease (COPD), and renal failure. However, in this case, it was the medication error that ultimately led to his death.
- A. Do not report the error. The patient had less than six months to live, and no harm was really done.
- B. Do not report the error. The medical liability consequence is so much worse than the consequence to the patient.
- C. Report the error to the patient’s family and the hospital administration. The family has a legal and moral right to know, and the hospital administration needs to know so that they can perform a root cause analysis.
- D. Report the error to hospital administration so they can prevent future errors. It is not necessary to inform the family.
- E. Report to the family if they are willing to keep the disclosure secret from the hospital administration.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
