In 2001, JCAHO required hospitals to directly inform patients harmed by the care the hospital provided. There was no definitive guidelines established by the JCAHO, but it was the recommendation that the hospital develop a policy for reporting adverse events.  Studies have indicated that full disclosure reduces and may even eliminate punitive damage awards.  The issue is what to report.  Should “near misses” be reported? Should errors that result in no harm be reported? Adverse events that are preventable and do not result in harm are still errors that need to be corrected and changed. These preventable adverse errors could also have a potential litigation liability associated with the reporting, if the information became public.

            The responsibility of informing the patient should always involve the attending physician and may involve hospital safety personnel (Safety Officer, Nursing, Social Work, Pastoral Care, etc).  It should be noted that disclosure is not an admission of liability. Guidelines should include:

1.      full explanation of event

2.      an apology

3.      an assurance that lessons have been learned and action steps have taken place

4.      documentation of the disclosure noted in the patient’s medical record

Examples of reportable adverse events that may be disclosed to patients.

For discussion: should the following be reported?

1)      Infant receives 0.25 ml of Ranitidine Syrup instead of 0.15 ml. There is no clinical effect on the infant.

2)      A cancer patient receives Adriamycin instead of Idamycin. This happens due to misunderstanding a verbal order. Though the drug is extremely cardiotoxic, there are no apparent clinical effects noted at the time.

3)      A patient is scheduled for a MRI. While waiting she was mistaken for another patient and given a medication that resulted in a hypotensive episode and code. She was resuscitated, stabilized and recovered.       

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