Case Scenario

My patient, an 82-year-old man who had smoked cigarettes for 60 years, was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). A chest radiograph was obtained the day of his discharge, and a small density was noted by the radiologist. The recommendation was to follow up with a computed tomographic (CT) scan.

One month later, the patient came to our clinic for an appointment. It was a typical hectic day, and I was fatigued because I was on obstetric service and post-call. I readily recognized my patient's face but could not remember all of his medications and was unsure if he had been admitted the previous month for congestive heart failure or COPD. My patient couldn't remember either. The discharge summary and radiology reports from the hospital were not at the clinic. Frustrated, I paged the senior resident from the previous month. Thankfully, from the patient's name alone he recalled the man's medications and the chief diagnosis. With this information, I was satisfied that I had put together the pieces.

I presented the patient to the attending physician and indicated that I remembered the important details of the patient's hospitalization. Because I thought I knew the details, I did not subsequently have the hospital reports sent to me. Meanwhile, I came to know the patient and his son very well. I followed up frequently on the telephone and in the clinic as his COPD worsened, and I arranged for home care needs.

Ten months later, the patient signed in for a walk-in visit following an episode of hemoptysis. A chest radiograph was obtained, and a large lesion was seen in the lung. A follow-up CT showed multiple lesions throughout the lung. I promptly referred the patient to pulmonary and oncology subspecialists. At this point, I still did not remember that a lesion had been seen on a chest radiograph the previous year. To be thorough, I decided to go to the hospital to review the patient's old films and hospital chart. At this point, I read the note I had written just before the patient's discharge, in which I had commented on the radiology report and stated that an out-patient CT scan would be obtained. I now remembered reviewing the report earlier with my attending physician, who had suggested obtaining the CT after discharge. I also remembered discussing this with my patient and explaining that he would need a CT as an outpatient.

Realizing my oversight, I immediately reported it to the residency director. In the next agonizing weeks, I spoke with a psychiatrist on the faculty, as well as with other residents and my advisor. I discussed the situation endlessly with my spouse, recalling every detail and wondering how I could have “forgotten” such a critical detail. At the same time, I skirted the issue with the patient's son, although indicating that something might have been done earlier and that I should have known the diagnosis. I felt the right thing to do was to tell the son the truth, but I was advised that doing so would invite a lawsuit. I felt like a moral failure.

I didn't sleep at all for three days, and then only intermittently. My progress note replayed itself endlessly in my mind. I checked in frequently with my patient to arrange chemotherapy, pain control measures and, ultimately, hospice care. I last visited my patient two days before his death, which was five months after I discovered my mistake. He was sleeping in a warm room in his house. His son and I watched him for a few moments, then we hugged and I left. I will never forget this patient, and I think of him whenever I screen and examine patients, knowing that I don't want to miss another important diagnosis.

Commentary

Virtually all of us have faced the awful realization that we have made a serious error. Almost as chilling is the prospect of telling the patient or family members about the error. This unfortunate case is typical in its features and in the reactions it elicited. The error—the failure of a sleep-deprived resident to follow up on an abnormal finding—was something that “fell through the cracks.” Partly an individual error, this was also a “system error” that resulted from a fragmented and inaccessible database and a care process that did not include a systematic mechanism for checking test results. The patient and the physician fell victim to a mistake waiting to happen.

The resident's emotional reactions, including shock, guilt, remorse and intrusive thoughts, were to be expected. In attempting to cope with the mistake, he did several things right: he talked with the residency director and other residents so they could learn from the mistake, and he met with a psychiatrist, his advisor and his wife for needed support. In the longer term, he made some constructive changes in practice. However, the resident succumbed to the temptation to frame discussions with the patient's son in a way that obscured his mistake. Even though the resident knew the right thing to do was to tell the truth to the son, he allowed himself to be dissuaded by the fallacious advice that disclosure would increase the risk of a malpractice suit. He sought comfort by becoming overly attentive to the patient and his family.

There is a consensus among the medical and legal professions, ethicists and the public that physicians are obligated to disclose medical errors.¹ Ethical theory supports disclosure because it is in the patient's best interest, as well as being part of the physician's duty to the patient. The patient may benefit from knowing that an error occurred because decisions about timely treatment can be made to correct problems resulting from the error; the patient may be able to avoid misdiagnosis or improper action in the future; the patient's course of health may be explained; and, in the case of injury, just compensation can be obtained.

Disclosure of a mistake can promote trust in physicians, whereas non-disclosure (think “cover-up”) is guaranteed to provoke anger over a violation of trust. Statements from professional societies echo this message. For example, the American Medical Association Council on Ethical and Judicial Affairs states, “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 facts necessary to ensure understanding of what has occurred.” Since the mid-1980s, legal scholars and case law have indicated that physicians have a special duty to disclose medical mistakes. Patient surveys confirm that the vast majority of patients would want to be informed if a mistake were made in their care.²

There are, of course, plenty of reasons why physicians are reluctant to disclose mistakes. Foremost among them are shame and fear—of litigation, damage to reputation, poor evaluations or even disciplinary action, as well as the patient's anger or disappointment. However, physicians' fears of litigation are probably exaggerated. Evidence suggests that most malpractice suits are initiated because of a desire for information or because of anger about a perceived cover-up. As illustrated by the recent example³ of the Veterans Administration Medical Center in Lexington, Kentucky, which has adopted a policy of prompt investigation and disclosure of mistakes (including assistance in seeking compensation), candid disclosure of a mistake may actually decrease the likelihood of a lawsuit or, if compensation is awarded, reduce the amount of the settlement.

The bottom line is that physicians have an obligation to disclose to their patients clear-cut mistakes that cause significant harm, especially those that can be fixed or mitigated, and those that are compensable. However, practical issues remain concerning when and how to tell the patient about the mistake. Disclosure should be prompt to avoid any implication of a cover-up. It is useful to think of disclosure of a mistake as a special case of “breaking bad news.”⁴ Physicians should anticipate that patients or family members might become upset or angry. Use of empathic response is crucial, and physicians should take special care to avoid being defensive.

When disclosing an error to a patient, the physician should begin by simply stating that he or she has made a mistake. The events surrounding the mistake should be described and explained in detail, using nontechnical language. The physician should describe the consequences of the mistake and actions that have been or will be taken. It is important to express personal regret and to apologize for the mistake. If the mistake had adverse consequences for the patient, an offer should be made to cancel charges for subsequent care needed to mitigate the impact. Finally, the physician should ask if there are additional questions or concerns, and address them.

As in this case, when a resident makes a mistake, the responsibility is shared with the attending physician. Therefore, it may be most appropriate for the attending physician and the house officer to disclose the mistake to the patient together. In cases involving serious injury, it may also be appropriate to involve hospital risk management at an early stage.

It can be a great relief for a physician to admit that a mistake has been made. In the case of a serious adverse outcome, the patient or a family member may be the only one able to grant forgiveness to the physician. The unexpected pay off is that, when confronted by a distraught and apologetic physician, patients and family members can be astonishingly generous. Despite their own misfortune, many will try to comfort the physician.

Honest disclosure of mistakes is easier when we work to help our patients appreciate the uncertainty that is inherent in medical decision-making and encourage them to participate in decisions about their care. A real opportunity exists to forge closer doctor-patient alliances, as well as to set more realistic expectations on the part of all involved. At the same time, hospitals and practices need to adopt systems that are geared toward preventing, detecting and minimizing the likelihood of errors.