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Student's Guide

Case summary

A 9-month-old boy, Andre, comes to the clinic with his mother for his well-child visit. His mother specifically wants to address his immunization status and make sure he is up-to-date. She hands you his state immunization record. You see that he hasn’t received his third Haemophilus influenzae type b (Hib) or inactivated poliovirus (IPV) immunization yet. Since his mother is in a hurry to get to her own doctor’s appointment, you help expedite Andre’s catch-up shots by asking your medical assistant (MA) to give them as you leave the patient’s room. Ten minutes later, as you begin to write a note in Andre’s chart, you notice a note written three months earlier, when Andre saw one of your partners. The note states that Andre received Hib#3 and IPV#3 as part of that visit. It occurs to you that the immunization card was probably not completed after Andre’s last visit. You run out to see if you can stop the MA from administering the shots, but meet her coming out of Andre’s room just having given them.

  • Does the accidental administration of an extra dose of a recommended vaccine qualify as a medical error? How would you define medical error?
  • Can a physician make a mistake with it being considered negligence?
  • Do you feel an obligation to disclose the situation to the mother? In general, do health-care providers have an obligation to disclose errors?
  • Would your feeling about disclosing this situation to the mother change if you had just caught the MA before she went in the room to give the shots, i.e., if it had been a near miss?
  • If you decide to disclose this situation to the mother, how will you go about it?
  • What are your concerns about having this conversation with the patient’s mother?

Learning objectives

  1. Be able to formulate a definition for medical error, recognize the variability in this process, and understand that the definition is not dependent on harm to the patient.
  2. Understand the moral and ethical obligations surrounding disclosure.
  3. Understand patient expectations with respect to disclosure of medical errors.
  4. Be able to identify important components of an appropriate conversation with a patient or patient’s family regarding the disclosure of a medical error.

Suggested reading for students

American College of Emergency Physicians. Policy statement: disclosure of medical errors. Ann Emerg Med. 2004;43(3):432.

Bok, S. Lying: Moral Choice in Public and Private Life. New York: Random House (Vintage Books); 1978.

Bok, S. Secrets: On the Ethics of Concealment and Revelation. New York: Random House (Vintage Books); 1983.

Boverman, M. Truth-telling in medicine. JAMA. 1982;248(11):1307.

Crigger NJ. Always having to say you’re sorry: an ethical response to making mistakes in professional practice. Nurs Ethics. 2004;11(6):568-576.

Crook ED, Stellini M, Levine D, Wiese W, Douglas S. Medical errors and the trainee: ethical concerns. Am J Med Sci. 2004;327(1):33-37.

Gallagher TH, Levinson W. Disclosing harmful medical errors to patients: a time for professional action. Arch Intern Med. 2005;165:1819-1824.

Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.

Gawande A. The bell curve. The New Yorker. 2004 (Dec 6): 82-91.

Gawande A. When doctors make mistakes. The New Yorker. 1999 (Feb 1): 40-55.

Groopman J. What’s the trouble?: how doctors think. The New Yorker. 2007 (Jan 29); 47: 36-41.

Hebert et al. Disclosure of medical error. CMAJ. 2001;164(4):509-513.

Hevia A, Hobgood C. Medical error during residency: to tell or not to tell. Ann Emerg Med. 2003;42(4):565-570.

Hilfiker D. Facing our mistakes. NEJM. 1984;310:118-122.

Hobgood et al. Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Pediatrics. 2005;116(6):1276-1286.

Institute of Medicine. To Err is Human. Washington, DC: National Academy Press, 2000.

Leape L. Error in medicine. JAMA. 1994;272:1851-1857.

Matlow A, Stevens P, Harrison C, Laxer RM. Disclosure of medical errors. Pediatr Clin N Am. 2006;53:1091-1104.

Runciman WB, Merry AF, Tito F. Error, blame, and the law in health care—an antipodean perspective. Ann Intern Med. 2003;138:974-979.

Sheldon M. Truth-telling in medicine. JAMA. 1982;247:651-654.

Wu A. Medical error: the second victim. BMJ. 2000;320:725-6.

This student’s guide was developed by Douglas J. Opel, MD, senior fellow, Clinical Bioethics, and Douglas S. Diekema, MD, MPH, director of education, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital.

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