Ethics and Patient Safety

Match each clinical scenario regarding informed consent and refusal of care with the most appropriate legal or ethical course of action.

A 16-year-old boy comes to the adolescent medicine clinic unaccompanied. He requests screening for sexually transmitted infections (STIs) because his recent sexual partner tested positive for *Chlamydia trachomatis*. The patient specifically asks that his parents not be informed of this visit or the testing. He lives at home with his parents and is financially dependent on them. During the physical examination, the physician notes severe, excoriated atopic dermatitis on the patient's antecubital and popliteal fossae. The patient states, 'The itching is driving me crazy and keeping me awake at night. My parents think prescription creams are dangerous, so they refuse to take me to a doctor for it. Since I am already here, can you please prescribe a strong steroid cream for me?' Which of the following is the most appropriate next step in management?

An intern is working on an internal medicine ward under the supervision of a senior resident. They are managing a 78-year-old man who is unresponsive following a severe ischemic stroke. The patient has a legally appointed healthcare proxy, his daughter, who is currently flying in from another state. The patient also has a complicated urinary tract infection; urine culture and sensitivity results just returned, indicating that the pathogen is susceptible only to a specific narrow-spectrum antibiotic.

The senior resident, who appears exhausted at the end of a 24-hour shift, tells the intern: "Just keep him on the broad-spectrum antibiotics, it is easier than changing the orders. Also, his wife is at the bedside right now—just have her sign the consent for the feeding tube so we can get the procedure scheduled." The resident then steps into the busy main hallway and loudly complains, "These families always take forever to make end-of-life decisions; they are wasting our resources."

The intern recognizes that the resident's instructions and conduct are inappropriate. Which of the following is the most appropriate next step for the intern?

An unresponsive patient is admitted to the intensive care unit following a severe anoxic brain injury. The clinical team determines that the patient completely lacks decision-making capacity. A review of the electronic health record reveals no advance directive, and the patient has never formally designated a durable power of attorney for healthcare. Several individuals who know the patient have arrived at the hospital, each wishing to direct the goals of care. According to the standard legal hierarchy for surrogate decision-makers in most US jurisdictions, arrange the following individuals in the correct order of priority from highest (first in line to make decisions) to lowest (last in line).

A resident physician is covering the surgical intensive care unit when a 45-year-old competent male patient experiences a severe hypotensive episode with a blood pressure of 70/40 mm Hg. Upon reviewing the electronic medical record, the resident discovers that the day-shift attending physician inadvertently prescribed a massive overdose of a continuous antihypertensive medication infusion due to a user interface error. When the resident contacts the attending, the attending states, "Just give him intravenous fluids, stop the drip, and do not document the medication error in the chart. I do not want to get sued." The resident immediately stops the infusion and stabilizes the patient with fluids. The patient's blood pressure improves to 110/70 mm Hg, and he is currently awake and alert. Which of the following is the most appropriate next step for the resident?

A third-year surgical resident is eating in the hospital cafeteria when approached by a surgical technician. The technician mentions that a prominent professional athlete was recently admitted to the orthopedic service for a complex joint repair. The technician, who is assigned to the general surgery service and has no role in the athlete's care, admits to reviewing the operative report in the electronic medical record (EMR) out of personal curiosity. The technician begins detailing the specific surgical hardware used. Which of the following is the most appropriate next step for the surgical resident?

Evaluate the following distinct workplace interactions and ethical dilemmas. Select the single most appropriate professional response or governing guideline for each situation.

Match each clinical scenario involving informed consent, refusal of care, or capacity to the specific ethical or legal principle that best classifies the situation.

For each patient presentation below, select the most appropriate legal or ethical guideline that dictates the physician's next action regarding informed consent or treatment.

Match each clinical scenario with the corresponding ethical or legal exception to the standard requirement for informed consent.

A hospital's patient safety committee is analyzing a series of diagnostic errors to improve clinical reasoning training for its medical staff. Match each described clinical scenario with the specific cognitive bias that most likely contributed to the diagnostic error.

For each of the following complex clinical encounters regarding end-of-life care and patient autonomy, identify the most appropriate governing ethical principle or legal framework that validates the physician's chosen course of action.

Healthcare administrators at an integrated health network are evaluating a comprehensive care pathway recently implemented to optimize inpatient flow and clinical safety. The quality improvement task force is monitoring several distinct data points to determine the success and systemic impact of these operational changes. Match each specific metric being tracked by the task force to its appropriate classification within quality improvement measurement frameworks.

A 45-year-old man is evaluated in the emergency department for a deep laceration on his right forearm. He is accompanied by police officers who report finding him intoxicated near the scene of an altercation. During the medical evaluation, the patient becomes highly agitated and repeatedly shouts, "As soon as I get out of here, I'm going to kill my neighbor, John Smith, at 123 Main Street! He's the one who cut me!" The patient is medically stabilized, his laceration is repaired, and he is subsequently placed on an involuntary psychiatric hold due to the credible homicidal threat. He explicitly demands that the physician tell absolutely no one about his statements or his medical treatment. Under standard medical ethics and federal privacy regulations, which of the following disclosures of this patient's protected health information are legally permissible or required without his authorization? (Select all that apply)

A 17-year-old high school student presents to an outpatient community clinic with a 3-day history of dysuria and a purulent urethral discharge. Nucleic acid amplification testing of the urine is positive for Neisseria gonorrhoeae. He is treated with appropriate antimicrobial therapy. During the encounter, the patient expresses significant anxiety about his parents discovering his sexual activity and explicitly requests that they not be informed of his visit. The physician assures him that his privacy will be maintained. The following afternoon, the patient's mother telephones the clinic. She states that she saw a pending clinic charge on her health insurance portal and insists on knowing the medical reason for her son's visit. Which of the following is the most appropriate action by the physician?

A 55-year-old man with a history of severe penicillin allergy is admitted to the medical ward for community-acquired pneumonia. During the admission medication reconciliation process, the admitting resident accurately documents the patient's anaphylactic allergy in the history and physical examination note. However, the resident forgets to enter this critical information into the electronic medical record's (EMR) dedicated allergy tab. The following morning, a cross-covering physician reviews the patient's diagnosis and prescribes intravenous ceftriaxone. Shortly after the first dose is administered, the patient develops a severe anaphylactic reaction requiring epinephrine and a brief transfer to the intensive care unit. The patient fully recovers. During a subsequent departmental review, the chief of medicine recommends placing the cross-covering physician on probationary leave for failing to thoroughly review the admission note prior to placing the medication order. Which of the following is the most appropriate recommendation by the patient safety committee regarding this adverse event?

Review the clinical situations below. Which ethical principle or legal decision-making standard most appropriately justifies the action taken in each situation?

Evaluate the following ethical dilemmas involving pediatric patients and pregnant individuals. Match each clinical situation with the most appropriate ethical or legal course of action.

Match each clinical scenario with the most appropriate legal or ethical action required by the physician regarding confidentiality and mandatory reporting.

A 28-year-old man undergoes surgery for acute appendicitis. During the preoperative surgical timeout, the circulating nurse observes that the written informed consent form specifies 'laparoscopic appendectomy,' whereas the electronic operating room schedule indicates 'open appendectomy.' The attending surgeon states that the written consent contains a clerical error and insists that an open approach was verbally agreed upon with the patient. Feeling intimidated by the surgeon's demeanor, the nurse does not escalate the discrepancy, and an open appendectomy is performed. Postoperatively, the patient is distressed by the large abdominal incision, stating he explicitly chose this hospital because he was promised a minimally invasive procedure.

Which of the following is the most appropriate action for the hospital's patient safety committee to take in response to this event?