title: Between a rock and a hard place: disclosing medical errors.
abstract: BACKGROUND
  Healthcare-related errors cause patient morbidity and mortality. Despite fear of reprimand, laboratory personnel have a professional obligation to rapidly report major medical errors when they are identified. Well-defined protocols regarding how and when to disclose a suspected error by a colleague do not exist.
  
  
  METHODS
  We describe a woman with a well documented allergy to sulfamethoxazole who was treated with sulfadiazine that led to toxic epidermal necrolysis. After the patient's death, the laboratory medicine resident was asked by one of the patient's physicians to measure serum sulfadiazine, but only if the results were not reported in the patient's electronic medical record. The case was brought to the attention of a laboratory medicine faculty member and the hospital risk management team.
  
  
  OBJECTIVE
  Laboratorians are patient fiduciaries and are responsible for reporting errors. Most medical associations have codes of ethics that address disclosure of incompetence and errors, although the AACC's Guide to Ethics does not. New types of error, risk management, and root-cause analyses help to shift the focus to system errors and away from individuals' errors. This can lead to a healthcare environment that encourages truth and disclosure rather than fear and reprimand. Disposition: The individuals involved in the presented case fulfilled their fiduciary duty to the patient by reporting this incident. An extensive investigation showed that, in fact, no medical errors or misconducts had occurred in the care of the patient.
authors.affiliation: Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO 63110, USA.
authors.forename: Kimberley G
authors.initials: KG
authors.lastname: Crone
authors.forename: Michele B
authors.initials: MB
authors.lastname: Muraski
authors.forename: Joy D
authors.initials: JD
authors.lastname: Skeel
authors.forename: Latisha
authors.initials: L
authors.lastname: Love-Gregory
authors.forename: Jack H
authors.initials: JH
authors.lastname: Ladenson
authors.forename: Ann M
authors.initials: AM
authors.lastname: Gronowski
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy; D000328:Adult; D000890:Anti-Infective Agents / Q000506:poisoning*; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007755:Laboratories, Hospital; D017056:Medical Laboratory Personnel / Q000592:standards*; D016347:Medical Records Systems, Computerized; D008508:Medication Errors; D012308:Risk Management; D013420:Sulfamethoxazole / Q000506:poisoning*; D014123:Toxoplasmosis / Q000188:drug therapy
chemical_list: D000890:Anti-Infective Agents; D013420:Sulfamethoxazole