Preparing for the worst: Handling an adverse event

The main push in the past decade has been to build systems similar to those used in the aviation industry that catch errors and decrease the chance that they will lead to patient injury (JAMA 1994; 272:1851-7). Systems use buffers and redundancy to catch errors before they lead to adverse events; however, systems are not foolproof, and injuries still occur (AUAUpdate Series 2004; 23:57-64). This article, the second in a series of three examining medicolegal issues in urology, discusses how the physician should respond to adverse events that affect their patients.

We discussed the disclosure of unexpected or unforeseen complications to patients and their families in the first article of this series (Urology Times, September 2008, page 38). Early disclosure of a problem is usually a good idea, as it not only lets patients know that you care about their well-being, but also shows you are on top of the matter (Legal Medicine 2002; 1:35-38). Disclosing errors that do not appear to have harmed the patient is a different matter. While some may argue, "Let sleeping dogs lie," others may counter that patient awareness of a cover-up will lead to hostility at best and a claim at worst. It is true that a plaintiff must have damages in order to have a valid claim; however, extra medical costs stemming from errors and mental anguish may be seen as damages in a medical malpractice suit.

Types of events

Errors are classified as "near misses" or "sentinel events." A near miss is an event that was identified and resolved before reaching the patient and a sentinel (or actual) event is one that reaches the patient and may or may not result in harm to the patient. Depending on the type and severity of the event, notification of hospital personnel may be required.

Examples of sentinel events are:

The hospital risk management department is required by the Joint Commission to report all sentinel events and perform a root cause analysis to identify and help prevent future such events by building a safer system. Near misses are often unreported due to lack of understanding the benefit of doing so and potential embarrassment on the part of caregivers. In aviation, near misses, harmless and harmful errors, and mechanical problems are reported promptly and thoroughly because the system is anonymous and without punishment. These reports are investigated, and the problems and their solutions are then published.

Physicians fear the embarrassment and potential backlash, both professionally and legally, should they report their own mistakes. Morbidity and mortality (M&M) conference is done regularly in academics, but is rarely performed in private practice for the reasons listed above. M&M conference serves a vital role in identifying problems and educating practitioners. We can all learn from other urologists who have encountered similar situations and have experience in dealing with the problems.

Informing the patient and the family of adverse events secondary to medical error is very difficult. While it may seem easier to talk to the patient when the mistake was due to someone else, there are several reasons for caution.