Question of the Week

For March 14, 2023

Your answer is correct.

Explain that nephrotoxicity is a known side effect of cisplatinExplain the error now, and apologize to the patientPostpone discussion of the error with the patient until a full investigation of the circumstances leading to the error has been completedGet advice from the hospital’s ethics consult serviceAsk the hospital attorney to meet with and apologize to the patient

Key Learning Point View Case Presentation

The proper way to communicate an iatrogenic medical error that causes harm to a patient is to provide an early, open, honest account of the error and apologize formally to the patient.

Detailed Feedback

Although health care providers might be reluctant to disclose errors because they are embarrassed or fear litigation, telling the truth shortly after the error is discovered is ethically obligatory and is the accepted standard of care. Acknowledging a medical error and apologizing for it is only the first step in managing the error; health care systems also need to identify the root cause and address knowledge and system gaps to ensure that the error is not repeated. However, initial discussion with the patient and acknowledgement of the error should not be delayed while the investigation is ongoing.

The National Quality Forum recommends that when disclosing a medical error, the health care provider should provide relevant information surrounding the events, express regret for the unanticipated outcome, and give a formal apology.

Lying or attributing the cause of the error to another etiology is unethical; it is the treating provider’s responsibility to disclose the error and apologize for it.

Although the hospital attorney or risk-management team will usually become involved in cases like this, it is the treating health care provider’s responsibility to acknowledge and discuss the error with the patient.

An ethics consultation might be helpful later on if an ethical dilemma arises, but it is unnecessary at this stage.

Last reviewed Feb 2021.

Citations

Gallagher TH et al. Disclosing harmful medical errors to patients. N Engl J Med 2007 Jun 29; 356:2713. > View Abstract

Surbone A et al. Confronting medical errors in oncology and disclosing them to cancer patients. J Clin Oncol 2007 Apr 20; 25:1463.   > View Abstract

Mansour R et al. Disclosure of medical errors: physicians' knowledge, attitudes and practices (KAP) in an oncology center. BMC Med Ethics 2020 Aug 20; 21:74.   > View Abstract

37 Comments

  1. Mohammed W.Omar March 14, 2023 at 8:28 am - Reply

    A good question thank you NEJM.

  2. Claudio Sandoval, MD March 14, 2023 at 10:32 am - Reply

    Abrahm Lincoln said it best “Honesty is the best policy”.

  3. Ivan N. Sukhikh March 14, 2023 at 10:46 am - Reply

    The patient will definitely ask about the reasons for the situation. The doctor must explain these reasons to the patient. To do this, the doctor himself must first find out these reasons. Therefore, we must first wait for the results of the investigation, and then talk to the patient.
    It should also be remembered that the error is the result of a conscientious delusion, the error is not the fault of the doctor.

  4. D Landau March 14, 2023 at 11:09 am - Reply

    It would be curious to see how this occured. Many of the chemotherapy orders in modern EMRs have the supportive care products build in (i.e. nausea medications, premedications, fluid support). I agree the patient needs to be informed and probably informed as quickly as possible but an investigation into root cause becomes paramount as well.

  5. Dr. Louis.Verardo March 14, 2023 at 11:12 am - Reply

    Good question about a common ethical issue seen in practice.

  6. Mangala Khattar March 14, 2023 at 11:15 am - Reply

    Thank you for the different question!

  7. Dan Henry March 14, 2023 at 11:15 am - Reply

    You apologize for the error and at same time tell the patient we are going to investigate.

  8. T. Sowell March 14, 2023 at 11:15 am - Reply

    Who gives 1000 cc of saline PRIOR to cisplatin in someone with normal renal function??? Was mannitol given?? In how much saline was the platinum given and over how long? This is a rare situation; rare enough to suggest an idiosyncratic reaction….while apologies are certainly in order, not sure where the full blame lies…

  9. donna norquist March 14, 2023 at 11:49 am - Reply

    Excellent!

  10. Dan Henry March 14, 2023 at 11:50 am - Reply

    I was a resident rotating at Sloan Kettering when they were doing studies to see how to prevent cisplatin nephrotoxicity in the late 70’s. Until they found a way to decrease nephrotoxicity many patients died. As a nephrologist you HAVE to give saline before treatment. This is from Goodman and Gilman. Cisplatin is given only intravenously. To prevent renal toxicity, it is important to establish a chloride diuresis by the infusion of 1 to 2 L of normal saline prior to treatment. The appropriate amount of cisplatin then is diluted in a solution containing dextrose, saline, and mannitol and administered intravenously over 4 to 6 h.
    If you do not infuse normal saline AKI is likely even if baseline renal function

  11. Saju Xavier March 14, 2023 at 12:43 pm - Reply

    Although the fact that the patient was not well hydrated , makes him prone for nephrotoxicity, The diagnosis can be confirmed only after ruling out coexistent disease processes like obstructive uropathy and Sepsis. I would rather wait for the urine routine , complete haemogram and USG abdomen report before going to step 2

  12. Rafael Escandon March 14, 2023 at 1:25 pm - Reply

    Thank you for including ethics cases in NEJM Knowledge; as well as the thoughtful reasoning not just behind the right answer, but the incorrect ones as well. A thought experiment here is whether this week’s answer would be (would have been) different 50 years ago (and why).

  13. TAREQ BURGAN March 14, 2023 at 1:50 pm - Reply

    Nice question, but the answer depends on where you practice medicine. As it might be the opposite way the reaction of the patient. He will take his own discharge and sue the Dr. and hospital.

  14. Gerard Landais,M.D. March 14, 2023 at 2:38 pm - Reply

    The author of this vignette is testing your ethical knowledge, or if you put it this way, he wants to check your honesty. This is a well
    known fact that finding an honest man on the planet is scarce. An example is the Greek philosopher, Diogenes who was walking iaround in broad daylight with a lantern in hand. When one asks him:
    Diogenes what are-you looking for?
    He answered:
    I am looking for an honest man.
    Thus, you should tell the patient right away about the mistake and apologize.

  15. Mary Louise C. Ashur MD March 14, 2023 at 4:10 pm - Reply

    There are two types of errors:
    1) Errors of omission occur if actions are not taken. This is an example of such.
    2) Errors of the commission occur as a result of the wrong action taken. One could argue that this also happened – as the complex protocol for administering this chemotherapeutic drug to a vulnerable patient was not followed. .

    Typically, doctors and nurses have psychological effects – anger, guilt, depression, feelings of being incompetent, etc. – when errors like this occur We do not go into medicine to hurt anyone. ; Sometimes the anger comes when a trainee is improperly supervised; and bad things happen; these episodes cause nightmares for doctors for decades to come. Is there any wonder there is a high suicide rate among physicians – when there is so much guilt about real and perceived errors? Sadly, even now, scapegoating is still a popular way for hospitals and groups to respond to complex errors.

    In this case, there was an individual error, but also there is a larger system error – There was the failure of a drug to be given with proper protocol, and neglect of logical system safeguards. .JCAHO and others support a complex web to prevent system errors. Who would hang a major drug – or perform a procedure – without a time out and group acknowledgment of the proper procedure – including the patient in the conversation!
    Let’s face it – the system failed both the patient and the ordering doctor; it also failed the public – who trusts that chemotherapeutic drugs will be dealt with by people collaborating in systems to prevent stupid mistakes. This case is a good representation of system failure.
    The only thing a doctor could do to make it worse would be to not acknowledge the error right away. It is part of the continuing care of this patient. Like it or not, the doctor also must ensure that system safety is in place for all orders physicians write, and appropriate reporting of major errors to state and professional accreditation boards occurs.

  16. HUGO ASTI, MD March 14, 2023 at 4:17 pm - Reply

    I deeply agree, honesty first. But what happens if during the patient interview he has questions that you do not know the answer yet ?
    I believe that a precise and complete information is needed together with the recognition of the error.
    A modest opinion.
    Thanks NEJM:

  17. Brian J. Ellinoy, PharmD March 14, 2023 at 6:17 pm - Reply

    Unfortunately patients continue to be subjected to serious preventable medical mistakes like this daily. Healthcare as yet not being able to adequately monitor itself or be monitored satisfactorily in my view requires the involvement of an informed patient advocate (e.g. family member, care giver, friend) at the bedside to help protect the patient from potential harm.

  18. Vaughn Payne March 14, 2023 at 7:59 pm - Reply

    That’s a heady response from a clinician who doesn’t actually “take care of patients”. Meaning a PharmD doesn’t prescribe therapies, order tests, make complicated medical decisions, cut into a body, or even provide solace to a family after a death. There’s no doubt no physician wants to be involved in a preventable medical error, but to carte blanche or project a generality that suggests “the medical system” is at fault is ill-informed. I can say this confidently as both a PharmD and MD.

  19. Eric Feldman March 14, 2023 at 8:48 pm - Reply

    I believe when we look back on 2022 and 2023, a major increase in medical errors will be recorded. Most of us are all dealing with understaffing and the stress of being overworked along with bringing on inexperienced staff to replace those who retired during the pandemic. Good reminder to be upfront and honest with our patients.

  20. Jason Cabot March 15, 2023 at 12:27 am - Reply

    I agree with the assessment and telling the patient ASAP. However, I have seen several cases of patients receiving proper care with Cisplatinum where the creatinine rises to a certain level (usually 4-5 mg%), the urine output is normal with s.g. in the 1010-1015 range, stays there for a certain time and then slowly returns to normal after a few weeks with no sequella. We never have been able to determine the exact cause of this problem.

  21. Sebastiao March 15, 2023 at 7:02 am - Reply

    Attention in prior hidration is very important in this case.

  22. missana March 15, 2023 at 1:00 pm - Reply

    We commonly find the ethics questions/dilemas in our daily clinical works, however its difficult to deal with them.
    Thanks NEJM for the ideal way to deal with these ethical challenges

  23. William Mattry March 15, 2023 at 1:53 pm - Reply

    Good case and excellent teaching service and submitted comments. Thank you NEJM.

  24. Marvin L. Manzanero March 15, 2023 at 1:57 pm - Reply

    This is a rather interesting question and places into perspective, a key issue that we clinicians tend to shy away from routinely.

    Thanks for the explanations given in reference to the other options provided.

  25. David Moran March 15, 2023 at 7:49 pm - Reply

    >> telling the truth … is the accepted standard of care.

    priceless

  26. J VASWANI March 16, 2023 at 4:55 am - Reply

    What happened after the doctor accepted the error & apologies

  27. TomGore March 16, 2023 at 1:19 pm - Reply

    Thank you Eric for this helpful perspective. It puts puts this unfortunate mishap into the existential context we are in. Regarding the phenomenon of guilt, as a psychiatrist with a religious background I have a different understanding of guilt: while we always need to critique our actions, it’s another error to sit in judgement over ourselves. We all fall short. But, with physicians we’re likely dealing with perfectionists, oc personalities who are likely egocentric: it seems to me that it is mostly the persons who needs praise who is also vulnerable to guilt. The practice of medicine is its own reward: we don’t need the praise or approval of anyone else. Humans make mistakes. No matter our intellectual abilities, we are far from perfect. So, it’s not one’s personal fault or the fault of the system; but the unpredictable contingensies of life itself. We do our best. We try to do no harm.

  28. Praveen Kulkarni March 16, 2023 at 11:50 pm - Reply

    In developing countries, acceptance of error will be disastrous. Good question & ideal answer, but sometimes, as we deviate from guidelines, in such situations, one may prefer not to disclose error and continue the care and try to save/recover the patient from illness. If pt is discharged in good health without any residual damage then that’s what pt wants. All well that ends well. Yes, investigations to avoid repeatation of error is must.

  29. Stavroula March 17, 2023 at 2:30 am - Reply

    Excellent thanks you very much!!

  30. Richard D. Blythe, R.Ph. March 17, 2023 at 3:17 am - Reply

    Nice that this question brought into review the importance of adequate hydration but they should have emphasized a chloride diuresis with 1 to 2 liters of normal saline prior to treatment.

  31. Dr. Rajasekaran A March 17, 2023 at 1:42 pm - Reply

    Excellent. It is an eye-opener to check on adequate pre cautionary measures especially important on administration of chemo therapeutic agents. Cysplatin itself a high nephro toxic drug. Patient education as well health care provider education both plays, a vital role to avoid such errors. Prior education of the patient on the consequences of the Cisplatin therapy will make things easy to face post chemo therapy side effects if any occur.

  32. Carlo Benedetti . Retired infectious disease doctor March 17, 2023 at 2:23 pm - Reply

    The first thing to do is to recognize the error. And at the same time talk to the patient to let him know. Apologizing for what happened. Immediately set up the necessary correction explaining it to the patient, obtaining his cooperation.

  33. Carlo Benedetti . Retired infectious disease doctor March 17, 2023 at 2:36 pm - Reply

    In my previous comment, the statement acknowledging the error means ” becoming aware of the error ” to communicate it immediately to the patient, apologizing.
    It does not mean investigating what happened and then communicating it to the patient.

  34. Mario Bonilla March 17, 2023 at 7:42 pm - Reply

    Thanks, for treating ethical issues. This makes us more cautious before acting.

  35. Josh Grossman M.D., F.A.C.P March 17, 2023 at 9:31 pm - Reply

    Outstanding case and most importantly outstanding discussion comments. Merci Beaucoup!
    I cannot thank you enough! Doctor Josh

  36. Jacqui Serbeh March 20, 2023 at 9:15 am - Reply

    Honesty is always the best policy, outstanding case study, thanks

  37. Arnold Vera March 21, 2023 at 11:34 am - Reply

    Thank you very much NEJM excellent clinical case and display of ethical professional health are responsibilities .
    Arnold Vera,MD.,MSc

Leave A Comment

Go to Top