Received on April 28, 2006
Accepted on June 9, 2006

Case Conference

Between a Rock and a Hard Place: Disclosing Medical Errors

¹ Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
² Patient Safety and Quality, Barnes-Jewish Hospital, Saint Louis, MO
³ Department of Psychiatry, Medical University of Ohio, Toledo, OH

^* To whom correspondence should be addressed. E-mail: Gronowski{at}wustl.edu.

Background: Healthcare-related errors cause patient morbidity and mortality. Laboratory personnel have a professional obligation to rapidly report major medical errors when they are identified despite fear of potential reprimand. Well defined protocols regarding how and when to disclose a suspected error by a colleague do not exist.

Patient: 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 contacted 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 of risk management.

Issues: 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 American Association for Clinical Chemistry'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.