AMA Journal of Ethics^®

Case

Andy Miller has acute myelocytic leukemia and is receiving chemotherapy. When he was at home after his most recent round of chemotherapy, he developed a fever. He came to the emergency room and was found to be neutropenic, common after the chemotherapy regimen Mr. Miller received.

Joe admitted Mr. Miller after midnight on a busy call night. He wrote the admission orders, including cefipime for the neutropenic fever. A new clerk entered the orders and was unable to read Joe's writing. She was not familiar with the medication and selected cefoxitin from the medication list. Joe was busy on call and post call and did not review the orders.

Mr. Miller continued to have a fever and over the next 24 hours developed low blood pressure and evidence of sepsis, including positive blood cultures. He was transferred to the intensive care unit for management of septic shock. On admission to the ICU, the medication error was noted, and the medication was corrected to cefipime. Mr. Miller required ICU care for 2 days and was on pressors for several hours to maintain his blood pressure. Ultimately he responded to the antibiotics, and he remained in the hospital on antibiotics until his neutropenia resolved.

On rounds Joe and his team discuss Mr. Miller's care and the effect of the mistake. Joe reasons, "If Mr. Miller had received the correct antibiotic he would have remained in the hospital for the same duration, until his white count improved. The effect of the mistake was that Mr. Miller was in the ICU for a few days, which may not have happened if the right medication had been started immediately. Sepsis can be fatal, but in this case it was treated effectively, and Mr. Miller will not have any long-term consequences from the error. I feel terrible, but it was the clerk's error."

Dr. Anderson, the attending physician, asks Joe, "Should Mr. Miller be told about the error, and if so, what should he be told?"

Joe says, "I feel terrible about the mistake, but we're not responsible for the clerical error. No one on the medical team was at fault, and there is no benefit to Mr. Miller from telling him of the error. If it was our mistake I would feel different, but all we will do is upset Mr. Miller and destroy his trust in us when he has a long course of treatment ahead of him. Besides, maybe it wasn't the mistake that caused the problem. He might have become septic anyway."

Sarah, Joe's coresident on the service, thinks Mr. Miller should be told of the error. "An error occurred, and Mr. Miller should be told. We can't decide which errors to disclose and which not to, because then the whole question of disclosure becomes discretionary. We are his doctors—we are responsible for whatever happens to him, whether it is our mistake or not. We erode his trust more by not telling him. He might have become septic anyway, but it seems likely that having him on the wrong antibiotic allowed him to get worse. Since the error could have contributed to the ICU admission, and probably did, Mr. Miller should be told."

Commentary 2

Medical error and patient safety are 2 prominent ethical issues in the profession of health care. As a result of contemporary studies, articles, and books, a paradigm shift has occurred in the reaction to medical error. Prior to widespread attention to studies discussed in the Institute of Medicine report on medical error and patient safety,¹ health care professionals faced with error would often ask the type of question mentioned in the case under discussion. "Was there any real harm?" or "whose fault was it?" as though blame for the event could be assigned in each case to 1 person. Moreover, in the past, the system was seldom investigated as a cause of error. In this case, the prescription was hand-written; a source of many errors. The questions that are posed in this case are as outdated as a suit coat with a belt in the back. Rather, the whole method of writing prescriptions should have been computerized and a fail safe system installed to check whether or not the proper prescription had been filled. To describe the error that occurred in this case as a "clerk's error" is incomprehensible. Computer-based innovations such as physician order entry are systems-based solutions. As cause of frequent error, difficulty with written prescriptions was identified long ago and a mechanism was created to diminish these types of errors. Physicians enter their own orders, thus decreasing communication errors and putting the input responsibility on the person with the knowledge and responsibility.

Moreover, the dialogue of the medical team indicates that they are living in never-never land. "Should the patient be told of the mistake?" Of course he should be told. Even if the mistake is judged to be "not serious," preventing this type of mistake in the future requires a system revision as well as a forthright admission that disposes the team to greater honesty and candor in the future. What medicine has learned from the nuclear energy industry and from the airline industry, is that the only way to limit or eliminate errors is to face up to them. The systems which support patient care should be studied and revised so that dependence upon written instructions and oral commitments is eliminated.