DISCLOSURE WITH ADVERSE OUTCOMES

AAOS Ethics Committee

Kyle J. Jeray, MD

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Objectives

• Define a medical error

• Identify disclosure obligations to patient and family

• Identify responsible parties relating to disclosure

• What is the purpose of an apology and why do they sometimes fail?

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40,000 Americans die every year because of medical errors.

How do we define an error?

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Errors

Acts

Omissions

May or may not result in harm/undesired outcomes

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Case 1

A 56 year-old undergoes a lumbar spinal fusion

and during the case a pedicle screw is placed into the vertebral foramen. Stockbyte/Thinkstock.com

It is recognized and changed during the case. Postoperatively the patient has a foot drop.

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What is the responsibility of the attending surgeon?

What is the responsibility of the resident physician?

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Do you apologize?

What constitutes a successful apology?

Why do apologies fail?

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What are the ethical issues?

What are the practical issues?

Altered lifestyle? Bracing? Future surgery? Etc.

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Who is responsible for increased cost?

What are the medicolegal issues?

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What if the resident was left to close the wound and a sponge is left in the patient that is recognized on a post-op film Stockbyte/Thinkstock.com

in the office at 2 weeks?

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Is there a change in responsibility?

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Case 2

During a routine decompression

for a herniated disc, the surgeon inadvertently tears the dura. Medioimages/Photodisc/Thinkstock.com It is a small tear easily

repaired and does not change the post op course.

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Is this error different?

Does the surgeon have a responsibility to disclose?

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Case 3Your office nurse calls you about a post-op wound that looks infected, and you ask him to begin antibiotics. The nurse writes a iStockphoto/Thinkstock.com

prescription for a sulfonamide antibiotic. The patient gets it filled and did not

recognize that he is allergic to the medicine as he has a documented sulfa allergy. He ends up in the ER, is treated, released, and changed to an appropriate antibiotic.

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What is the responsibility of:

The physician?

The medical system (i.e. pharmacist)?

The nurse?

The patient?

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Summary

The decision to admit or acknowledge an error should be based on ethical guidelines.

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Disclosure is often difficult, but failure to do so can damage credibility and compromise integrity destroying the physician-patient relationship.

By learning from and admitting errors, the quality of medical care is enhanced for all. 17

ReferencesAmerican Academy of Orthopaedic Surgeons: Code of Ethics and Professionalism for Orthopaedic Surgeons, I.A., I.F., II.A., II.B. Adopted October 1988, revised 2011.http://www.aaos.org/about/papers/ethics/code.asp

American Academy of Orthopaedic Surgeons: Standards of Professionalism on Providing Musculoskeletal Services to Patients, Mandatory Standard 4. Adopted April 18, 2005, amended April 24, 2008.http://www3.aaos.org/member/profcomp/provmuscserv.pdf

American Academy of Orthopaedic Surgeons: Communicating Adverse Events or Poor Outcomes, Information Statement 1028. Adopted 2004, revised 2011.http://www.aaos.org/about/papers/advistmt/1028.asp

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American Academy of Orthopaedic Surgeons: Wrong-Site Surgery, Information Statement 1015.Adopted 1997, revised 2008.http://www.aaos.org/about/papers/advistmt/1015.asp

Kohn L, Corrigan J, Donaldson M, (eds). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000.

Gallagher T, Studdert D, Levinson W: Disclosing harmful medical errors to patients. N Engl J Med 2007;356:2713-2719.

Blendon R, DesRoches C, Brodie M, et al: Views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:1933-1940.

 

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Lo B: Resolving Ethical Dilemmas, A Guide for Clinicians. Philadelphia: Lippincott Williams & Wilkins, PA; ed 4; 2009.

Gallagher T, Garbutt J, Waterman A, et al: Choosing your words carefully: How physicians would disclose harmful errors to patients. Arch Intern Med 2006;166:1585-1593.

Lazare A: Apology in medical practice: An emerging clinical skill. JAMA 2006; 296:1401-1404.

Zimmerman R: Doctors’ new tool to fight lawsuits: saying “I’m sorry.” Wall Street Journal. May 18, 2004:A1.

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Gertner R: The art of apologizing takes hold in the legal world. St Louis Daily Record. December 22, 2005.

Lazare A: On Apology. New York, NY, Oxford University Press, 2004.

Ring D, Herndon J, Meyer G: Case 34-2010: A 65—year-old woman with an incorrect operation on the left hand. N Engl J Med, November 11, 2010.

Council on Ethical and Judicial Affairs: Code of Medical Ethics, Opinions 8.12, 8.121,9.032. Chicago, IL, American Medical Association,

ed 2010 – 2011.

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