Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

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Disclosing Mistakes and Errors to a Patient

By Douglas L. Totten, O.D.

Case Study #4

Your paraoptometric approaches you in the hallway and says she thinks a mistake might have occurred with your next patient. She suspects that this 6-year-old patient may have had glasses prescribed and provided by your office with the right and left lenses reversed in the spectacle prescription. The patient's history includes the diagnosis of refractive amblyopia with three diopters of anisometropia and he is returning for a doctor requested encounter.

The pretesting and examination confirm that the lenses were switched in the glasses dispensed three months ago. The mother reports that the child complained that he couldn't see clearly after receiving the glasses. She insisted he wear them until they were lost a short time later. Since then, he hasn't been wearing glasses.

The doctor is not sure if the patient or mother even know a mistake had occurred. Yet it seems the mother might be a bit uneasy after some of the discussion during the pretesting today and may have heard some of the hushed conversation in the hallway.

The best corrected acuity remained at the same level as the previous exam. The doctor was faced with the decision to tell the mother about the mistake or not.

What are the ethical considerations in this case or in the situation where an error has been made and discovered? Should the patient be informed? Or should the information be withheld?

Discussion

Mistakes will happen and no person or facility is exempt. And fortunately, some errors don't result in adverse outcomes.

In a case when a patient might not realize an error has occurred or it causes no harm, some believe it's better for the patient not to know. Fear of lawsuits has also fueled the attitude to hide mistakes. These approaches have been named: "deny and defend." 2

Yet, there can be negative consequences for withholding information. A patient can lose confidence in a provider if he or she believes the care delivered has not been satisfactory or later learns that an error had been hidden. Without disclosure, an opportunity can be missed to look at the processes that led to the mistake and for corrective measures to occur.

There seems to be an appropriate "paradigm shift in the reaction to medical error" with the approach moving from considering if any harm has occurred and withholding information to the idea that disclosure of error is the proper response.2 This mindset especially focuses on the consideration that a patient is the most important stakeholder in most health care situations.

Studies have shown that lawsuits might be less likely when a sincere apology for a mistake is given. When subjects were asked what could have been done to avert a lawsuit, 37 percent of respondents said an explanation and an apology would have made the difference in preventing a suit against a provider. 3 In addition to the ethical benefit of disclosing a significant error, there appears to be a financial benefit to providing a practical alternative to hiding mistakes. 2

Considering patient autonomy, errors should be disclosed to a patient and/or family. Patients generally want to know three pieces of information when a mistake occurs: what happened; will they be OK or did the mistake cause harm; and what is the doctor or organization going to do to remedy the situation.

The AOA Standards of Professional Conduct includes a section stating that telling the truth is a necessary component of a trusting optometrist-patient relationship. From an ethical standpoint, there are two levels of truthfulness, veracity and candor. Simply put, veracity is "telling the truth" and candor is "telling the whole truth." Optometrists should always practice veracity and strive to tell the whole truth as patients have the right to know the truth of their own past, present or future medical conditions.

To aid in truth telling, some states have enacted "apology" laws which allow a physician to make an apology and disclose medical error without it being considered an admission of guilt. Colorado enacted the country's first "apology inadmissibility law" in 2003. Other states have followed suit with the intent to reduce medical error and malpractice litigation. 4

Conclusion

The doctor-patient relationship is to be respected and includes ethical obligations to disclose significant error. Transparency of mistakes can lead to the enhanced health of the patient or the general delivery of care in a system. It can also be required from a legal standpoint. Disclosing error should always be considered even if a provider will not benefit in the exchange.1

While full candor or truth telling is usually required from an ethical standpoint, exceptions are only justifiable out of kindness to the patient or to protect the overall best interests of the patient, especially if the patient has specifically asked not to be told of any details. Since breaching candor would be a violation of the basic principle of patient autonomy, it should only be considered after careful reflection and weighing the alternatives.

In this case, the mother and patient were advised of the error. The patient has returned for follow-up care and the mother has expressed gratitude for the concern and respect given by sharing the truth of the mistake.

REFERENCES

1. Wu, A., Cavanaugh, T., McPhee, S., Lo, B., & Micco, G. (1997). To Tell the Truth: Ethical and Practical Issues in Disclosing Medical Mistakes to Patients. Journal of General Internal Medicine, 12(12), 770-5.

2. Boothman, R., Blackwell, A., Campbell Jr. D., Commiskey, E., & Anderson, S. (2009). A Better Approach to Medical Malpractice Claims? The University of Michigan Experience. Journal of Health and Life Sciences Law, 2(2), 125-59.

3. Vincent, C., Young, M., & Phillips, A. (1994). Why Do People Sue Doctors? A Study of Patients and Relatives Taking Legal Action. Lancet, 343(8913), 1609-13. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7911925

4. Kearns, L. (2014). Apology Laws and the Doctor-Patient Relationship. Voices in Bioethics: Columbia University. Retrieved January 16, 2016 from http://voicesinbioethics.org/2014/03/26/apology-laws-andthe-doctor-patient-relationship/