Blog | Monday, March 30, 2009

When test results go missing, an internist searches for answers

Ethics columnist Paul S. Mueller, FACP, discusses a case study that would bring chills to any primary care provider: what happens when an internist orders test results, and then never sees the results?

From an actual case file, Dr. Mueller discusses a 61-year-old asymptomatic man seeing his internist of 10 years for a check-up. When reviewing the medical record, the internist sees PSA test results of 11.8 ng/mL. Surprised by this finding, the internist digs further. A year ago, the PSA was 8.2 ng/mL and three years ago it was normal. The patient was never told; the internist is certain she never saw it. She wonders what to do next.

Click on "More" below for advice on how to handle the disclosure of previously missed test results.

Clinicians experience negative emotions when they realize they have committed an error, Dr. Mueller writes. Nevertheless, they are ethically obligated to disclose errors to patients.

First, clinicians should act in the best interests of patients. Explain the nature of the error and its implications and continue to provide professional and compassionate care.

Second, respect for patient autonomy requires that clinicians disclose errors to patients to allow for informed decision making.

Finally, justice requires that patients be given what is due to them, such as information about their medical condition and, if injured, appropriate compensation.

In this case, the internist met with her patient and his wife to tell them that the prior PSA test result was mishandled. The patient was upset, angry and felt helpless, which internist acknowledged. However, the patient later stated that he appreciated the internist's honesty. Together, they developed a follow-up plan.

Dr. Mueller suggests these steps when disclosing medical errors
-Speak in private with the patient, his or her loved ones, and essential members of the health care team present. Avoid interruptions (such as pagers) and allow time for questions.
-Discern the patient's perception of the problem before disclosing the error. For example, you might ask, "Do you recall the results of your PSA from a year ago?" Such questions allow for correction of misinformation.
-Speak clearly and check for comprehension (such as, "Is there anything I can clarify?"). The patient should understand what happened and the consequences of the error.
-Avoid attributing blame (such as, "The laboratory must have forgotten to call me about the result"). Patients desire a sincere apology and want to know how the clinician and organization will act to prevent future errors.
-Acknowledge the patient's emotional response to the disclosure by using empathic statements, such as, "I can see that you are upset by this news."
-Formulate a plan for further assessment, treatment, and follow-up and how you will work to prevent future errors.
-Document all discussions related to the error and its disclosure.

Dr. Mueller contributes to Ethical Dilemmas, a regular column appearing in ACP Internist.