Five years ago, a medical laboratory in Canada made a series of catastrophic mistakes. Lab tests misdiagnosed the estrogen receptor status of almost 400 Newfoundland women with breast cancer – a potentially deadly error because women who are estrogen receptor positive must receive different cancer treatments than women who are ER negative. But it wasn’t until two years later, after the CBC and other national media across Canada ran stories revealing this disturbingly high rate of errors, that the provincial government finally ordered a commission of inquiry to get at the truth. Of those wrongly tested and thus wrongly treated women, 100 are now dead.
Fifty of the women, some of whom had undergone mastectomies, had been told they had advanced breast cancer when they did not.
External audits of the laboratory in question revealed:
- staff incompetence
- poor quality control
- deficient procedures
- frequent turnover of the staff of pathologists
The initial attempts by the province’s Eastern Regional Integrated Health Authority to keep these audits away from public scrutiny led to widespread community outrage and mistrust of the health care system. Some women only learned of their risk through the media.
You might assume that medical errors of this magnitude should have been automatically disclosed to the public – and particularly to patients affected.
But researchers from the University of Washington in Seattle now suggest that disclosure of medical errors should be decided on a case-by-case basis rather than a one-size-fits-all solution. Dr. Denise Dudzinksi and her UW team reported in the New England Journal of Medicine on the Newfoundland case and did describe the ethical analysis of the case as “unambiguous”.
“The magnitude of the risk of harm, as well as the fact that the harm was preventable and involved deviations from standards of practice, clearly warranted disclosure.”
However, the Seattle researchers claimed that there are some instances where disclosure itself may cause harm if anxiety related to worries about what may be only a minimal medical risk outweighs the ethical benefit of disclosure.
Maybe it depends on whether it is doctors or nurses who are doing the disclosing, according to a 2004 Australian study that looked how these two groups tend to report adverse events and near-misses. Researchers at the University of Adelaide found that nurses reported incidents more habitually than doctors did
“…due to a culture which provided directives, protocols and the notion of security, whereas the medical culture was less transparent, favoured dealing with incidents ‘in-house’ and was less reliant on directives.”
Dr. Dudzinski and her colleagues said the ethical justification for disclosing harmful errors to patients is strong, but there’s no consensus about the need to disclose “near-miss” incidents, especially if:
- patients are not physically injured
- they may not benefit from the disclosure
- they may be psychologically harmed
Yet, by withholding information about the error, institutions can’t be sure whether any patient was physically harmed.
Dr. Dudzinski added:
“As these cases illustrate, the ethical obligations to disclose are greatest when the events resulted from preventable errors or system failures, whereas duties to disclose are more ambiguous when the probability of harm is extremely low but the severity of harm is great and there are no definitive diagnostic tests or effective treatments.”
Institutional policies may help guide these deliberations, she added, but they hardly ever cover large-scale adverse events. Thus, responses can be “slow and haphazard.”
Dr. Dudzinski and her colleagues recommended that institutions develop a clear set of procedures for managing the disclosure process, notifying patients, and coordinating follow-up testing and treatment.
Finally, they cautioned medical institutions to assume that media coverage of large-scale adverse medical events is inevitable. Responses to the media should demonstrate the institution’s commitment to honesty and transparency to build public trust.
For a slightly more alarming take on the issue of medical errors, here’s what Johns Hopkins Medical Centre had to say:
- Medical errors are the eighth leading cause of death in the U.S. each year.
- as many as 98,000 hospitalized North Americans die each year—not as a result of their illness or disease, but because of medical errors during their care. That’s 268 a day, also equal to one fully-occupied fatal jet crash every day.
- 84 percent of U.S. adults have heard about a situation in which a medical mistake was made.
- 42 percent of U.S. adults say they were personally involved in a situation where a medical error occurred.
- The total annual cost of preventable medical errors (including expense of additional care, disability, lost income and productivity) in the U.S. is estimated between $17-29 billion.
- Estimates of attributable cost-per-bloodstream infection range between $3,700 and $29,000.
- Ventilator-associated pneumonia (VAP) prolongs length of stay and adds an estimated $40,000 to the cost of a typical hospital admission.
- In the U.S., annual deaths from blood infections related to central line catheters is as high as 28,000.
- Caregivers at one hospital were observed and asked how faithfully they and their coworkers washed their hands after touching a patient. They said: 85 percent for themselves but only 51 percent for their coworkers. According to observers, though, caregivers only washed up 28 percent of the time.
- Infections at surgical sites complicate about 780,000 procedures annually, or more than 1 in 40. For abdominal surgery, the likelihood is even higher: 1 out of 5 procedures.
- Patients with infections are two to three times more likely to die and are hospitalized an average of seven days longer than other patients.
- Antibiotics lose half their potency in two to three hours. If there’s a several hour delay in surgery, a patient could be a candidate for infection by the time he’s rolled into the OR.
- One of every three Adverse Drug Events (ADEs) happens when a nurse administers medications.
- 56 percent of medication errors are related to prescriptions.
- One medication error occurs for every 20 administrations.
- ADEs happen 6.5 times out of every 100 admissions; 28 percent are considered preventable
- Two-thirds of medical errors are preventable.
- One-quarter of ADEs are due to negligence.
- One study found that preventable ADEs in two teaching hospitals caused a 4.6-day increase in length of stay, at a cost of $4,685 for each hospital.
- In emergency health crises, ‘failure to rescue’ accounts for 60,000 deaths each year in Medicare patients under age 75.
- Evidence of clinical worsening is present in 50 percent of codes for many hours prior to code being called.
- ERRORS MADE DUE TO STAFF FATIGUE: “Prolonged wakefulness (e.g., 17 hours without sleep) can produce performance decrements equivalent to blood-alcohol concentration of .05 percent, the level defined as alcohol intoxication.
- Researchers have found that the risk of making an error increased when hospital nurses work more than 12 hours per shift, worked overtime or worked more than 40 hours a week.
- The effects of fatigue include slowed reaction time, lapses of attention to detail, errors of omission, compromised problem solving, reduced motivation and decreased energy to successfully complete required tasks.”
Read the full report from Johns Hopkins, or the entire article from the New England Journal of Medicine.
See also: Why Doctors Get Sued
The Ethical Nag 
“..staff incompetence, poor quality control, deficient procedures, frequent turnover of the staff of pathologists..” ??!!
What is this place, a third world country? Absolutely shocking story here. What possible punishment could be harsh enough for those running this lab given the devastation that they caused so many innocent lives. And where are the government regulators in all this?
So if patients are not physically injured by medical error, may not necessarily benefit from its disclosure, or may be “psychologically harmed” by learning about the errors, doctors and hospitals really don’t have to let us know that they have screwed up? This is typical “hospitalese” mumbo jumbo at its finest.
All they have to do is insist that the public might be “psychologically harmed” if they learn that a bad procedure or test or incompetent doctor may have been involved in their care.
OF COURSE we are going to be “psychologically harmed” by learning about potentially dangerous mistakes in our own health care. So that gets doctors and hospitals off the hook, doesn’t it?
Good work on this – it’s frightening.
Agreed! I don’t trust medical personnel especially doctors any more than a politician because it is now standard protocol to cover their own ass…and to hell with the patient.
We all make our decisions and we all must live with their consequences. I accept responsibility for my decisions and wish that doctors could be so evolved.