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42 Disclosure of medical errors in anesthesiology practice
The Case
A 45-year-old woman presents for laparoscopic cholecystectomy. She is healthy apart from symptoms related to her cholelithiasis. As is normal practice in this institution, the antibiotics to be administered by the anesthesiologist are hanging on the IV pole on the patient’s stretcher. The anesthesiologist notices the antibiotic that has been sent is cefazolin, despite the fact that the patient’s allergy to cefazolin is clearly documented in the chart. He asks the nurse to replace the cefazolin with an alternative antibiotic. As he is about to take the patient to the operating room, one of his colleagues interrupts him to ask if he will take late call that night. A brief discussion ensues. He is now late bringing the patient into the operating room and the surgeon is making his impatience obvious. The anesthesiologist induces anesthesia and starts the antibiotic infusion.
Fifteen minutes later he notices a rash covering the patient’s body. The airway pressures have increased and the patient is wheezing. The blood pressure falls precipitously. To his dismay he sees that, in his haste to get the patient anesthetized he failed to confirm that the antibiotic had been replaced and he has accidentally administered the cefazolin. He diagnoses acute anaphylaxis and initiates treatment. The patient responds and her condition stabilizes, surgery is abandoned and the patient is admitted to the ICU for further care.
“To err is human; to forgive, divine” Alexander Pope 1688–1744.
A competent anesthesiologist would instantly recognize the classic signs of anaphylaxis. Once diagnosed, prompt treatment of anaphylaxis usually results in a complete recovery.
In contrast to the medical management of this error, disclosure of the error resulting in the anaphylactic reaction is not straightforward; layers of hospital policies, legal precedents, ethical codes and personal biases complicate the correct course of action. A thorough understanding of the issues involved in disclosure of medical errors is important to every anesthesiologist.
Ethical principles involved in disclosure of medical errors
If this incident had happened prior to the modern era, it would be easy to imagine the patient being told that she had experienced a “complication” related to her anesthetic, and perhaps very little else. This reflects the paternalist approach by physicians that dominated medicine until the last half of the twentieth century, and summed up by Oliver Wendell Holmes, the dean of Harvard Medical school from 1847–1853. “The patient has no more right to the truth than he has to all the medicine in the physician’s saddlebag”.1 Many physicians believed it was right to deny the patient the truth for a number of seemingly good reasons.
Modern medical ethics emphasizes four guiding principles; respect for patient autonomy, beneficence, nonmaleficence, and justice. Autonomy refers to the right of an individual to make decisions about one’s life and body without coercion by others. When applied to the disclosure of medical errors, autonomy refers to the patient’s right to possess all the available information about their health necessary to making decisions. In our case, the patient required admission to the intensive care unit, escalation of medical care, and investigation of the anaphylactic reaction. She also needed to have her surgery rescheduled. The patient must understand all the facts related to the case in order to be able to consent to extra treatment. Respect for patient autonomy therefore requires the open and timely disclosure of all the facts, including an admission that the wrong antibiotic was delivered.
The American Medical Association (AMA) Code of Medical Ethics is clear about the ethical duty of physicians to disclose errors:
It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients.… Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician’s mistake or judgment. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. Only through full disclosure is a patient able to make informed decisions regarding future medical care. .….. Concern regarding legal liability which might result following truthful disclosure should not affect the physician’s honesty with a patient.2
Likewise, the General Medical Council of the UK has stated that doctors should:
…offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-term effects.3
In 2009, the National Health Service of the UK announced a new “Being Open” framework as the best practice guide for healthcare staff concerning communication with patients, their families and their caregivers following harm.4
National policies and standards for disclosure of medical errors
In 1999, The Head of the Clinical Risk Unit at the University College London reported that an estimated 40 000 patients die annually in Britain due to medical errors.5 Shortly thereafter in the US, the Institute of Medicine published a landmark report “To Err is Human” making the startling revelation that medical errors accounted for an estimated 44 000 to 98 000 preventable deaths annually.6 This report heralded a significant re-structuring of US healthcare systems aimed at improving patient safety. In 2001 the Joint Commission for Accreditation of Health Care Organizations (JCAHO) in the US issued the first nationwide disclosure standard that required patients to be informed about all outcomes of care, including “unanticipated outcomes.” Since then, guidelines for disclosure have increasingly been used by institutions as well as pay-for-performance programs to promote safer patient care.
A systems-based approach to medical error
It is apparent that a number of problems within the system may have contributed to the error described in our case. These include the delivery of the wrong antibiotic to the patient’s bedside, the distraction by a colleague, and the failure of the anesthesiologist to identify the drug prior to administration. There is also a small chance that the anaphylactic response was due to another drug administered within the same timeframe as the cefazolin. Without investigation of the error, the flaws in the system or the true nature of the patient’s allergy may not be completely revealed. A common response by patients who are the victims of medical errors is a desire that the same thing doesn’t happen again to someone else. The premise of the policies put in place by the quality and safety organizations is that, by encouraging reporting, a greater openness and understanding of medical errors will develop and measures to prevent them can be determined. Hospitals have much in common with the airline and nuclear power industries which are also complex systems in which individuals are rarely solely responsible for serious errors.
In our case, the anesthesiologist clearly has an ethical duty to disclose the error to the patient. The implementation of patient safety and quality policies reinforces this duty. Disclosure respects the patient’s autonomy to be fully informed about their medical care. From a systems perspective, the disclosure of errors allows healthcare systems to identify and eliminate system errors, thereby improving safety for all patients. The ethical principle of justice requires that patients be treated equally, thus patients are entitled to the truth regardless of the views of their physicians or the policies of the institution in which they receive care.
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The use of ethics consultation regarding consent and refusal
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Animal subjects research Part I: Do animals have rights?
Physician conscientious objection in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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