Group assignment Law
docx
keyboard_arrow_up
School
Canada College *
*We aren’t endorsed by this school
Course
1108
Subject
Medicine
Date
Feb 20, 2024
Type
docx
Pages
7
Uploaded by JusticeBoar4027
The Incorrect
- Disclosure of Error
Healthcare Law
Content
Background:
0
A 12-year-old boy from London went to see his pediatrician for the school physical
when he was supposed to get a Hepatitis B vaccination. He was a little weak in his
immunization record, especially for Hepatitis B. Other than that, he had no medical
history of note and was otherwise doing fine. During the appointment, boy's father
and doctor agreed to close this gap by giving him the Hepatitis B vaccine. Sadly,
though, an error occurred, and the Hepatitis A vaccination was given instead.
As soon as the doctor understood what had happened, he informed the father. He
clarified the confusion surrounding it and its side effects. The father was angry and
would not allow any more vaccines, despite being assured that the Hepatitis A vaccine
alone could cause no ill effects at all-- indeed it might even protect further. After the
event was brought to light, it made the doctor feel guilty for betraying a patient's
confidence and not administering that specific vaccination.
Facts about Case:
Rationale for Disclosing Harmful Errors to Patients:
Ethical precepts such as integrity, openness and respect for patient autonomy provide
the starting point from which to tell patients of dangerous mistakes. Openness in
discussing errors promotes a cooperative approach toward minimizing their effects.
Safety and confidence between healers and patients are also enhanced. Also,
admitting mistakes helps patients play a role in their treatment and is important for
informed choice.
In this case, the upholding of honesty and respect for liberty led him to quickly tell
Daddy that the vaccination had gone wrong. (Thomas H. Gallagher & Wendy Levinson, 2004)
Specific Information Patients Want Disclosed Following a Harmful Error:
This is what patients want to know. What went wrong? How big an effect did it have?
Here's why It happened, and how we can fix it; here are safeguards for the future so
this won't happen again-that kind of stuff. They want frank, candid contact--and an
apology when it's needed. Furthermore, patients emphasize the importance of
compassion and that their needs always have priority.
Here the father may seek to know why Hepatitis A vaccination, possible side effects
and a plan for future care. (Armutlu, 2009)
1
Disclosure Gap and Barriers: The term disclosure gap refers to the disparity between what patients think has been
made known to them after a mistake and what doctors tell their patients. The
provider-patient bond, a lack of communication skills training, and the hierarchical
structure are some examples. And then there is also worry about legal repercussions if
you screw up. The shame of medical errors can also become a culture of silence.
If this is the case, then with his angry response the father calls attention to an apparent
mismatch between expectations on either side of what should be in disclosure.
(McLennan, 2014)
Emotional Effects on Healthcare Professionals:
Health care professionals may feel many kinds of emotions, such as guilt, shame, and
fear after making an error. The Ordeal of Truth Surface Creating a culture of
transparency and openness to mistakes depends on acknowledging that working in the
healthcare field imposes emotional costs.
This case is a good example of how the doctor felt responsible for losing confidence.
Healthcare professionals go through a variety of emotions after making an error.
Feelings that influence communication and decisions such as guilt, shame, or anxiety
may damage the disclosure process (Doctor 'cautioned' after boy receives wrong vaccine twice
at Cambridge clinic, 2019)
Steps to Enhance Disclosure:
Education and Training: o
Give the medical staff in-depth instruction on emotional intelligence,
disclosure procedures and communication skills.
Creating a Supportive Culture:
o
Build an environment of openness, learning from errors and helping
doctors in need.
Standardized Protocols:
o
To ensure consistency across all healthcare facilities, implement clear-
cut procedures for reporting mishaps.
Legal Protections:
2
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
o
To reduce the threat of lawsuits, support legislative frameworks that
protect healthcare practitioners from disclosing errors.
Involving Patients in Solutions:
o
As you bring them into the resolution process, ask patients for their
opinions about what preventative actions could be taken and how
healthcare can be further improved. (Geoffrey H. Gordon, 2005)
Continuous Quality Improvement:
o
To avoid repeating the same problems, we must make procedures for
continuous evaluation and development possible in response to errors
that are discovered.
(Berthold, 2014)
Discussion Questions:
Q1. Now What doctor will tell the nurse, family, and patient once he recognized about the mistake? Ans: The doctor should discuss about this problem once with his nurse, what are
reason of happening and measures to correct it. Moreover, it is responsibility of the
doctor to apologize and reveal about an error and inform the patient and family clearly
what is done regarding the mistake. The doctor must listen carefully, put any doubts
to rest, and detail the follow up treatment plan.
(Petronio, 2013)
Q2. What possible action can the medical professionals do to understand the
error occurred and changes necessary to avoid it future?
Ans.
The medical professionals should do root cause analysis to do full detail
assessment of the mistake. This would include testing medicine administration
procedures, examining communications techniques and searching for system
imperfections. If you want to change the course, adjustments can be made by
strengthening staff training or adding more checks and balances. Communication
channels also must improve dramatically so that problems like these will never
happen again.
Q3. Explain barriers make full disclosure challenging in medicine?
Ans. No fix standards for error disclosure, legal liabilities about harm to doctor-
patient relationship, and a hierarchical culture are the obstacles. Another reason is the
shame that comes with medical blunders.
3
Q4. What are the Consequences of disclosure on:
o
Relationship of doctor and patient?
The doctor and patient relationship may strengthen or weakens after
disclosure. Whether transparency and honesty build trust depends on how
the disclosure is handled.
o
The relationship in the medical care system and patient?
In general, we can say it will impact the patient appraisal. And
handling it gracefully will show desire of improvement and
responsibility which will enhance the trust of all. (Ryan Murphy, 2021)
o
The members of the medical professional relationship?
Open communication among members of the medical team is
important. Taking a blame-free approach to the disclosure of error,
there is an opportunity for problems being discovered earlier and team
members not falling out.
Q5. Is it necessary to disclose problem completely if caused impact? Why?
Ans. Trust is built on transparency and patients should be informed of any change in
the standard of treatment. Also, to continue making progress we need to learn from
every mistake--even a big one.
Q6. Disclosure means an apology for the error. If yes, explain how the apology be
phrased to the family?
Ans. Yes, an apology is must for full disclosure. The apology should reveal remorse
for the mistake happened, reiterate on patient care, and tell any emotional problems. It
should be written in a caring and sensitive way.
Q7. Do you have training to practice complete disclosure to your patients? If yes,
explain training has helped you? If not, what preparation required?
Ans. How much healthcare professionals prepared to disclose errors? Training for
communication, specific protocols for disclosure and empathy can contribute to the
4
professional's confidence with such situations. Further training can include
communication workshops, simulations and ethical guidelines courses.
(Disclosing harm from healthcare delivery: Open and honest communication with patients, 2015)
Conclusion:
But due to a mix-up, the doctor mistakenly gave him an injection of Hepatitis A
vaccine. The doctor immediately told the boy's father about this mistake, detailing
what happened and saying that Hepatitis A vaccination was safe. But the father was
beside himself, refused any further shots and reported to the clinic administration
what had occurred. Thinking responsible for the trust breach and the opportunity
missed to administer the immunization, the psychological aftermath of incident. The
importance of disclosing errors to patients, the information that patients request
following such incidents, the existence of a "disclosure gap" in the healthcare sector,
the psychological impact that errors have on medical staff, and the necessity of
institutional measures to improve error disclosure are all highlighted by this example.
References
1.
Armutlu, M. (2009, August). The Ethics of Disclosure of Adverse Health Events
. Retrieved from
www.central.bac-lac.gc.ca: https://central.bac-lac.gc.ca/.item?
id=MR66059&op=pdf&app=Library&oclc_number=777303417
2.
Berthold, B. J. (2014, June). Disclosing medical errors the right way
. Retrieved from www.acpinternist.org: https://acpinternist.org/archives/2014/06/errors.htm
5
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3.
Disclosing harm from healthcare delivery: Open and honest communication with patients
. (2015). Retrieved from www.cmpa-acpm.ca: https://www.cmpa-acpm.ca/en/advice-
publications/browse-articles/2015/disclosing-harm-from-healthcare-delivery-open-and-
honest-communication-with-patients
4.
Doctor 'cautioned' after boy receives wrong vaccine twice at Cambridge clinic
. (2019, June 06). Retrieved from www.cbc.ca: https://www.cbc.ca/news/canada/kitchener-waterloo/doctor-cautioned-college-boy-wrong-
vaccine-cambridge-1.5165037
5.
Geoffrey H. Gordon, M. (2005, August). Disclosing Error to a Patient: Physician-to-Patient Communication
. Retrieved from www.journalofethics.ama-assn.org: https://journalofethics.ama-assn.org/article/disclosing-error-patient-physician-patient-
communication/2005-08
6.
McLennan, S. R. (2014, August). MEDICAL ERROR COMMUNICATION:
. Retrieved from www.edoc.unibas.ch: https://edoc.unibas.ch/38856/1/1.%20PhD%20thesis_McLennan
%20edoc.pdf
7.
Petronio, S. (2013). Disclosing Medical Mistakes: A Communication Management Plan for Physicians
. Retrieved from www.ncbi.nlm.nih.gov: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662285/
8.
Ryan Murphy, S. G.-J. (2021, May 18). How to Disclose Medical Errors and Unanticipated Outcomes
. Retrieved from www.accelerate.uofuhealth.utah.edu: https://accelerate.uofuhealth.utah.edu/improvement/how-to-disclose-medical-errors-and-
unanticipated-outcomes
9.
Thomas H. Gallagher, M., & Wendy Levinson, M. (2004, June 01). The Wrong Shot: Error Disclosure
. Retrieved from www.psnet.ahrq.gov: https://psnet.ahrq.gov/web-mm/wrong-
shot-error-disclosure
6