Profiles in patient safety: when an error occurs.
Medical error is now clearly established as one of the most significant problems facing the American health care system. Anecdotal evidence, studies of human cognition, and analysis of high-reliability organizations all predict that despite excellent training, human error is unavoidable. When an error occurs and is recognized, providers have a duty to disclose the error. Yet disclosure of error to patients, families, and hospital colleagues is a difficult and/or threatening process for most physicians. A more thorough understanding of the ethical and social contract between physicians and their patients as well as the professional milieu surrounding an error may improve the likelihood of its disclosure. Key among these is the identification of institutional factors that support disclosure and recognize error as an unavoidable part of the practice of medicine. Using a case-based format, this article focuses on the communication of error with patients, families, and colleagues and grounds error disclosure in the cultural milieu of medial ethics.
Hobgood
Cherri
C
Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA. hobgood@med.unc.edu
Hevia
Armando
A
Hinchey
Paul
P
D000085:Acetates / Q000627:therapeutic use; D000368:Aged; D000588:Amines; D000700:Analgesics / Q000627:therapeutic use; D000927:Anticonvulsants / Q000627:therapeutic use*; D003509:Cyclohexanecarboxylic Acids; D003929:Diabetic Neuropathies / Q000188:drug therapy*; D004334:Drug Administration Schedule; D004635:Emergency Medicine / Q000379:methods*; D005260:Female; D000077206:Gabapentin; D006801:Humans; D007022:Hypotension / Q000139:chemically induced; D000860:Hypoxia / Q000139:chemically induced; D008508:Medication Errors / Q000517:prevention & control; D010146:Pain / Q000188:drug therapy; D010672:Phenytoin / Q000627:therapeutic use*; D016896:Treatment Outcome; D005680:gamma-Aminobutyric Acid
D000085:Acetates; D000588:Amines; D000700:Analgesics; D000927:Anticonvulsants; D003509:Cyclohexanecarboxylic Acids; D005680:gamma-Aminobutyric Acid; D010672:Phenytoin; D000077206:Gabapentin