by Timothy Gieseke MD, CMD

I recently cared for a post-acute patient who was seriously ill.  While at our facility, one of the important medicines for a complication of his illness was stopped by computer order entry error, but I and the team didn’t discover it until a week later at which point that complication had objectively, but likely not seriously worsened.  I didn’t have the expertise to know the optimal management of this worsening complication.  The patient was scheduled to go home soon.  Would your team disclose the error to this patient and their partner?

At the time of discovery of this error, we focused on figuring out how it occurred, but then the above question arose in my mind and our management team.  The next morning, I raised the question with our team and felt we should disclose, but also understood the legal and regulatory concerns of those who questioned the wisdom of full disclosure.

Later that morning, I was at another facilities CQI meeting and asked that team what they would do.  They too struggled with the necessity for full disclosure.

At lunch that day, I ran the situation by a trusted colleague who agreed that full disclosure that day was necessary.  I was then able to discuss the situation with another colleague with expertise in this complication, who confirmed my suspicion that the harm was likely minor and manageable in the outpatient setting.

Armed with this information, I was please to discover that the process of full disclosure had already occurred led by our DON.  I then met with the patient and his partner and completed the disclosure from a physician perspective with an emphasis on responsibly managing the complication.  While this event stressed the “trust” in our system, the patient was very gracious and expressed thanks for our honesty and was pleased that we were with him through this error.

This is so fresh that I don’t know if there will be adverse legal or regulatory consequences, but I am sleeping better at night believing our team’s integrity has survived an important test.