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Clinical Crossroads | Clinician's Corner

A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery:  Review of Medical Error

Thomas H. Gallagher, MD, Discussant
JAMA. 2009;302(6):669-677. doi:10.1001/jama.2009.1011.
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After a life-threatening complication of an injection for neck pain several years ago, Ms W experienced a wrong-site surgery to remove a squamous cell lesion from her nose, followed by pain, distress, and shaken trust in clinicians. Her experience highlights the challenges of communicating with patients after errors. Harmful medical errors occur relatively frequently. Gaps exist between patients' expectations for disclosure and apology and physicians' ability to deliver disclosures well. This discrepancy reflects clinicians' fear of litigation, concern that disclosure might harm patients, and lack of confidence in disclosure skills. Many institutions are developing disclosure programs, and some are reporting success in coupling disclosures with early offers of compensation to patients. However, much has yet to be learned about effective disclosure strategies. Important future developments include increased emphasis on institutions' responsibility for disclosure, involving trainees and other team members in disclosure, and strengthening the relationship between disclosure and quality improvement.

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Expectations and Responses in Medical Error Disclosure
Posted on July 14, 2009
John C. Moskop, Ph.D.
Wake Forest University School of Medicine
Conflict of Interest: None Declared
This case offers an instructive example of patient expectations and provider responses following a medical error. Ms. W expresses multiple common expectations, including prompt acknowledgement of the error, a clear apology, an opportunity to share her own account of what happened and how the error could have been prevented, information about how procedures have been changed to prevent similar errors in the future, and an offer of compensation for her suffering and lost income.(1-7) The timely and clear responses by the attending physician and by hospital representatives were effective in assuaging Ms. W's distress about the error and repairing damage to the therapeutic relationship. Because her desires for clear and honest communication, acceptance of responsibility, expression of concern, and compensation were addressed, Ms. W is unlikely to pursue litigation as a way to express her anger about the error, to learn more about how the error occurred, or to obtain compensation.(3-7) The fact that the error in this case was immediately obvious to the patient may make prompt acknowledgment and apology easier. If an error is not obvious, providers may be tempted not to disclose it, hoping that the patient will never discover that an error occurred and so have no reason to seek legal redress for injuries suffered as a result of the error. The ability of this approach to limit liability is uncertain, but it does clearly compromise an open and honest relationship with the patient.(8) Ms. W expresses regret that she was not given an opportunity to speak with the surgical fellow who mismarked the surgical site. Since the fellow's action played a significant role in the error, it is reasonable that Ms. W would want to discuss this with him or her. The explanation given, namely, that the fellow "was not around any longer," seems highly implausible in light of the fact that the error was promptly acknowledged and the patient later underwent a second surgical procedure. Perhaps a more likely explanation is that the fellow felt ashamed, guilty, fearful, or uncertain about what to say to Ms. W, and the attending physician agreed to "cover" for him or her.(9-10) If that is the correct explanation, it has several major drawbacks. First, it was clearly unsatisfying to Ms. W, since it did not allow her to discuss the error with a provider who bore some measure of responsibility for it. Second, it squandered an opportunity to help the fellow come to terms with understandable negative emotions and to engage in sensitive communication with the patient about the error. Physician-educators have a responsibility to help trainees develop proficiency in acknowledging and disclosing medical errors.(8) If the fellow had been present when the attending physician discussed the error with Ms. W, he or she would have had the benefit of participating in a disclosure and apology process that reassured the patient and would have been able to discuss his or her role in the error with the assistance and support of the attending.
The author has no relevant financial interests to report.
References
1. Mazor KM, Simon SR, Yood RA et al. Health plan members' views about disclosure of medical errors. Ann Intern Med. 2004;140:409-418.
2. Hobgood C, Peck CR, Gilbert B et al. Medical errors-what and when: what do patients want to know? Acad Emerg Med. 2002;9:1156-1161.
3. Gallagher TH, Waterman AD, Ebers AG et al. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001-1007.
4. Cohen JR. Advising clients to apologize. S Cal Law Rev. 1999;72:1009-1069.
5. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131:963-967.
6. Beckman HB, Markakis KM, Suchman AL et al. The doctor-patient relationship and malpractice: lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-1370.
7. Hickson GB, Clayton EW, Githens PB et al. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA. 1992;267:1359-1363.
8. Moskop JC, Geiderman JM, Hobgood CD et al. Emergency physicians and disclosure of medical errors. Ann Emerg Med. 2006;48:523-531.
9. Wu AW. Medical error: the second victim. the doctor who makes the mistake needs help too. BMJ. 2000;320:726-727.
10. Hobgood C, Hevia A, Tamayo-Sarver JH et al. The influence of the causes and contexts of medical errors on emergency medicine residents' responses to their errors: an exploration. Acad Med. 2005;80:758-764.
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