1. DISCLOSURE WITH ADVERSE OUTCOMES AAOS Ethics Committee Kyle J. Jeray, MD 1

2. Objectives Define a medical error Identify disclosure obligations to patient and family Identify responsible parties relating to disclosure What is the purpose of an apology and why do they sometimes fail? 2

3. 40,000 Americans die every year because of medical errors. How do we define an error? 4

4. Errors  Acts  Omissions  May or may not result in harm/undesired outcomes 5

5. Case 1 A 56 year-old undergoes a lumbar spinal fusion and during the case a pedicle screw is placed into the vertebral foramen. Stockbyte/Thinkstock It is recognized and changed during the case. Postoperatively the patient has a foot drop. 5

6. What is the responsibility of the attending surgeon? What is the responsibility of the resident physician? 6

7. Do you apologize? What constitutes a successful apology? Why do apologies fail? 7

8. What are the ethical issues? What are the practical issues? Altered lifestyle? Bracing? Future surgery? Etc. 8

9. Who is responsible for increased cost? What are the medicolegal issues? 9

10. Case 1 - Altered What if the resident was left to close the wound and a sponge is left in the patient that is recognized on a post-op film Stockbyte/Thinkstock in the office at 2 weeks? 10

11. Is there a change in responsibility? 11

12. Case 2 During a routine decompression for a herniated disc, the surgeon inadvertently tears the dura. Medioimages/Photodisc/Thinkstock It is a small tear easily repaired and does not change the post op course. 12

13. Is this error different? Does the surgeon have a responsibility to disclose? 13

14. Case 3 Your office nurse calls you about a post-op wound that looks infected, and you ask him to begin antibiotics. The nurse writes a iStockphoto/Thinkstock prescription for a sulfonamide antibiotic. The patient gets it filled and did not recognize that he is allergic to the medicine as he has a documented sulfa allergy. He ends up in the ER, is treated, released, and changed to an appropriate antibiotic. 14

15. What is the responsibility of:  The physician?  The medical system (i.e. pharmacist)?  The nurse?  The patient? 15

16. Summary  The decision to admit or acknowledge an error should be based on ethical guidelines.  Disclosure is often difficult, but failure to do so can damage credibility and compromise integrity destroying the physician- patient relationship. 16

17.  By learning from and admitting errors, the quality of medical care is enhanced for all. 17

18. References American Academy of Orthopaedic Surgeons: Code of Ethics and Professionalism for Orthopaedic Surgeons, I.A., I.F., II.A., II.B. Adopted October 1988, revised 2011. http://www.aaos.org/about/papers/ethics/code.asp American Academy of Orthopaedic Surgeons: Standards of Professionalism on Providing Musculoskeletal Services to Patients, Mandatory Standard 4. Adopted April 18, 2005, amended April 24, 2008. http://www3.aaos.org/member/profcomp/provmuscserv.pdf American Academy of Orthopaedic Surgeons: Communicating Adverse Events or Poor Outcomes, Information Statement 1028. Adopted 2004, revised 2011. http://www.aaos.org/about/papers/advistmt/1028.asp 18

19. American Academy of Orthopaedic Surgeons: Wrong-Site Surgery, Information Statement 1015. Adopted 1997, revised 2008. http://www.aaos.org/about/papers/advistmt/1015.asp Kohn L, Corrigan J, Donaldson M, (eds). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000. Gallagher T, Studdert D, Levinson W: Disclosing harmful medical errors to patients. N Engl J Med 2007;356:2713-2719. Blendon R, DesRoches C, Brodie M, et al: Views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:1933-1940. 19

20. Lo B: Resolving Ethical Dilemmas, A Guide for Clinicians. Philadelphia: Lippincott Williams & Wilkins, PA; ed 4; 2009. Gallagher T, Garbutt J, Waterman A, et al: Choosing your words carefully: How physicians would disclose harmful errors to patients. Arch Intern Med 2006;166:1585-1593. Lazare A: Apology in medical practice: An emerging clinical skill. JAMA 2006; 296:1401-1404. Zimmerman R: Doctors’ new tool to fight lawsuits: saying “I’m sorry.” Wall Street Journal. May 18, 2004:A1. 20

21. Gertner R: The art of apologizing takes hold in the legal world. St Louis Daily Record. December 22, 2005. Lazare A: On Apology. New York, NY, Oxford University Press, 2004. Ring D, Herndon J, Meyer G: Case 34-2010: A 65— year-old woman with an incorrect operation on the left hand. N Engl J Med, November 11, 2010. Council on Ethical and Judicial Affairs: Code of Medical Ethics, Opinions 8.12, 8.121,9.032. Chicago, IL, American Medical Association, ed 2010 – 2011. 21