Talking with Patients and Families about Medical Error: A Guide for Education and Practice

9 The Broad Spectrum of Adverse Events and Medical Error

103 Adverse events and medical error occur across a broad spectrum, from those that involve little or no harm to those that are catastrophic . In this chapter we explore how cases vary across a range of variables, such as differences between the inpatient and outpatient settings and between medical, surgical, and psychiatric patients. These cases raise questions such as when is it preferable for a nurse to have the disclosure conversation and when is it clinically justified to withhold information about an error from a patient or family member. The vignettes explore the distinctions between adverse events due to clearly preventable errors, those that are linked to unpreventable complications, and those that involve risks that were disclosed to the patient but that likely could have been avoided had there not been a lapse in concentration. Our approach to exploring these vignettes is drawn from wellestablished methods developed in the field of bioethics. A central problem in moral philosophy is how to reason from abstract general principles to specific cases. A similar problem exists in questions about disclosure of adverse events and medical error in that the general principles that have been developed by organizations to date do not provide much useful guidance for the range of varied and complex situations faced by clinicians in everyday practice. In bioethics, using a methodological approach known as casuistry, we identify particular cases in which we have a high degree of confidence about the right course of action. These serve as “anchors ,” or paradigmatic cases. We then examine the more ambiguous cases and consider the ways in which they are similar to or different from these paradigmatic cases. By “triangulating” between the problematic case NINE The Broad Spectrum of Adverse Events and Medical Error 104 TALKING WITH PATIENTS AND FAMILIES ABOUT MEDICAL ERROR and these anchor points, we can arrive at a way of proceeding that is ethically sound. In this section, we again emphasize the importance of a set of foundational values: transparency, respect, accountability, continuity and kindness—TRACK. In many examples of medical error, these central values are in synch, and the alignment of values suggests a clear and ethically uncomplicated approach. In some cases, however, these principles can be in conflict. Consider, for example, a situation in which a man with an anxiety disorder is admitted for minor surgery. He is written for three doses of cephazolin during the postoperative period. Because of a transcription error, each dose is one gram instead of the prescribed dose of 500 mg. Both of these doses are within in the acceptable prescription range for this purpose, and the patient suffers no identifiable harm. Should the error be disclosed? The value of transparency might lead a clinician toward disclosing the error, but the value of kindness might argue against it, especially if the clinician was convinced that this communication would likely cause the patient needless anxiety at an already stressful time. According to the casuistic approach described above, one could consider comparable cases in which the correct course of action seems to be clear and then triangulate from these to examine more ambiguous cases. So, for example, if the dosing error had been much larger or associated with complications, the value of transparency would clearly prevail. In contrast, if the patient had a paranoid personality along with the anxiety disorder, there might be a clear argument in favor of nondisclosure. Since the example above is somewhere in between these two paradigmatic cases, one needs to reason about whether this situation is more like the case of the serious overdose (arguing for disclosure) or more like the case of the patient struggling with paranoia (which would weigh in favor of nondisclosure). While the process of collectively reasoning about these cases never attains scientific precision, it does provide a practical and systematic approach for finding an appropriate course of action. Unlike the field of bioethics, the practice of communicating about adverse events and errors is still in its developmental infancy, and while consensus can be reached regarding some types of cases, many others reside firmly in the gray zone. As organizations create structures for thoughtfully approaching and learning from these cases over time, they will de- THE BROAD SPECTRUM OF ADVERSE EVENTS AND MEDICAL ERROR 105 velop a portfolio of experience that will serve as a reference guide for managing subsequent cases. Eventually, organizations should develop a measure of collective confidence about the right course...