PERIOPERATIVE GRAND ROUNDS

Duty to Disclose Someone Else’s Error?

(continued on page 381)

The Case:

A healthy 4-year-old boy came to an emergency de-

partment after three days of vomiting, lethargy, and

fever. He had been exposed to another child with

Streptococcal pharyngitis the previous week but had

been well until the symptoms began. On evaluation in

the emergency department, practitioners found that he

had a low-grade fever, was a little sleepy, and had some

redness in his throat. A computed tomography (CT) of

his head was interpreted as normal. A rapid test for

Streptococcal pharyngitis was positive.

The child was admitted to the hospital and given IV

hydration and antibiotics. During the next 24 hours, the

child became increasingly confused, disoriented, and

lethargic. The following morning, he had a respiratory

arrest. He was placed on a ventilator and transferred to the

intensive care unit. There, he developed fixed and dilated

pupils. A repeated CT revealed severe cerebral edema

with herniation of the brain through the base of the skull.

He was transferred to a tertiary care center. Further

testing revealed a diagnosis of venous sinus thromboses,

which caused the edema and herniation. Unfortunately,

the brain damage was advanced. When it was clear that

the child could not survive, the pediatricians met with

the parents to explain that their child was brain dead.

Angry and upset, the parents asked repeatedly, “How

could this happen? How could the CT scan have been

normal and then be so bad in less than 48 hours?”

This content is adapted from AHRQ Web M&M (Morbidi

from the Agency for Healthcare Research and Quality. Th

Gallagher, MD, and was adapted for this article by Nancy

Collaborations, San Antonio, TX. (Citation: Gallagher TH.

M&M [serial online]. http://webmm.ahrq.gov/case.aspx?c

2013.) Dr Girard has no declared affiliation that could be

the publication of this article.

434 j AORN Journal � October 2013 Vol 98 No 4

As part of their routine evaluation, the neurosurgical

teams and radiologists at the tertiary care center re-

viewed the CT from the original emergency department.

Although the findings were subtle, they found that the

original scan was not normal but demonstrated clear

evidence of cerebral edema. The initial hospital team

had not recognized these findings and, therefore, did no

further workup for the cause. The neurology and neuro-

surgical team members thought that if the brain swelling

had been recognized, the child could have been trans-

ferred earlier, received surgical management, and might

have survived.

Because of concerns of legal liability, the hospital

administrators and the risk management personnel at the

tertiary care hospital instructed the physicians and other

providers not to disclose the misinterpretation of the

original CT and not to comment on the initial care in

any way. Therefore, the parents were never told that an

error had been made that may have contributed to their

child’s death.

Discussion:

Few conversations strike as much fear in physicians’

hearts as talking with patients about medical errors.1

Health care workers strongly favor being open

with patients but find disclosing errors extremely

ty & Mortality Rounds on the Web) with permission

e original commentary was written by Thomas H.

J. Girard, PhD, RN, FAAN, consultant/owner, Nurse

Duty to Disclose Someone Else’s Error? AHRQ Web

aseID¼239. Published May 2011. Accessed June 1,

perceived as posing a potential conflict of interest in

http://dx.doi.org/10.1016/j.aorn.2013.07.015

� AORN, Inc, 2013

(continued from page 434)

PERIOPERATIVE GRAND ROUNDS www.aornjournal.org

challengingdespecially when they perceive that

someone else may have been responsible for the error.

Thus, patients and their family members often do not

learn about tragic errors, as in this case.

There is research that patients want to learn about

harmful errors.2,3 A combination of disclosure programs

and early offers of monetary compensation can help

resolve cases involving error.4,5 Despite this, studies

document a substantial gap between patients’ desire for

disclosure and clinicians’ ability to meet these expec-

tations.6 The rationale favoring disclosure is strong.7

Disclosure allows patients to make informed health care

decisions, signifies truth telling, and demonstrates re-

spect for patient autonomy.

This case is complicated by the fact that the disclosing

physicians would not be the physicians who made the

error. Clinicians are reluctant to speak critically of other

providers. In a recent survey of 1,900 US physicians,

17% had direct personal knowledge of a physician

colleague who was incompetent, but only 67% reported

this colleague to authorities.8

Power and self-interest also complicate these situa-

tions. Fear of retaliation occurs if the person disclosing

an error is subordinate to the person who made the error.

A provider may also choose limited disclosure, hoping

that colleagues who might be involved in a future case in

which “we” made an error would show similar discre-

tion. Lastly, disclosing another health care worker’s

error may precipitate a malpractice suit.9

For cases inwhich a potential error occurred under other

providers, the critical first step is to speak directly with the

referring care providers. These discussions require careful

planning with quality and risk management specialists at

both hospitals, and are critical to starting a formal root

cause analysis process. This situation becomes more

complicated if all agree that there was a clear-cut harmful

error, but the physicians at the referring hospital choose

not to disclose to the patient. There is no consensus on

what situations merit mandatory disclosure of another

health care worker’s error. One important realization

emerging from ongoing work in disclosure is that leaving

disclosure decisions completely to the discretion of the

involved clinicians may be problematic. Ideally, orga-

nizations would have a neutral third party (eg, ethics

committee) involved in disagreements among providers

about whether and how disclosure should occur.

In this case, the two hospitals should have had an open

dialogue. If they determined that a clear error occurred,

then the providers should have disclosed the error openly

and honestly to the parents. This outcome would have

been ethical, collaborative, and patient centered.

Perioperative Points:

n Patients strongly favor hearing about medical errors

in their care.

n Clear disclosure of medical errors is ethical, respects

patient autonomy, and may allow for better-informed

decision making.

n Optimal strategies include full collaboration of all

parties if an error occurs, with investigation and joint

disclosure.

n Hospitals should institute disclosure policies

with neutral third parties to mediate disclosure

cases.

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3. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ,

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