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Between a rock and a hard place: disclosing medical errors.
Kimberley G Crone1, Michele B Muraski, Joy D Skeel
1Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO 63110, USA.
Clinical Chemistry
|July 22, 2006
Summary
Laboratory professionals must report suspected medical errors despite lacking clear protocols. A case involving a patient
Area of Science:
- Medical error disclosure
- Laboratory medicine ethics
- Patient safety protocols
Background:
- Healthcare errors contribute to patient morbidity and mortality.
- Laboratory personnel have a professional duty to report identified medical errors.
- Clear protocols for disclosing suspected colleague errors are lacking.
Observation:
- A patient with a sulfamethoxazole allergy developed toxic epidermal necrolysis after treatment with sulfadiazine.
- Following the patient's death, a resident was asked to measure serum sulfadiazine, with results only to be reported if not in the electronic medical record.
- The incident was reported to a laboratory medicine faculty member and the hospital risk management team.
Findings:
- Laboratorians act as patient fiduciaries, responsible for error reporting.
- Ethical codes address error disclosure, but specific guidelines vary.
- Focus is shifting towards system errors and away from individual blame through risk management and root-cause analyses.
- The investigation concluded no medical errors or misconduct occurred in the patient's care.
Implications:
- Encouraging a healthcare environment that promotes truth and disclosure over fear.
- Highlighting the importance of established protocols for error reporting in laboratory medicine.
- Reinforcing the fiduciary duty of laboratory professionals to patient safety.