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Difficulty: MediumMedical Errors and Malpractice

A 58-year-old woman is currently receiving treatment in the medical intensive care unit for severe sepsis secondary to pneumonia. She is mechanically ventilated and continuously sedated with propofol. On hospital day 4, the patient develops a new-onset tachyarrhythmia. The cross-covering night physician hastily reviews the electronic health record and orders an intravenous amiodarone bolus. However, the physician fails to notice that the patient is already receiving a continuous infusion of fluconazole, a medication known to prolong the QT interval. Shortly after the amiodarone is administered, the patient develops torsades de pointes requiring emergent electrical defibrillation. The patient is successfully stabilized, but her intensive care unit stay is significantly prolonged. The attending physician is made aware of the event the following morning. The patient's husband is present at the bedside.

Which of the following is the most appropriate next step in the management of this medical error?

  1. Promptly inform the husband about the medication error, explain its clinical consequences, and offer a sincere apology on behalf of the care team.Answer
  2. B
    Delay discussing the event with the husband until a failure mode and effects analysis (FMEA) is completed to retrospectively determine the exact cause of the error.
  3. C
    Wait until the patient regains legal competence to disclose the error, as sensitive medical information must only be shared directly with the patient.
  4. D
    File a mandatory report with the state medical board regarding the cross-covering physician's prescribing practices.
  5. E
    Explain to the husband that the event occurred due to an incomplete shift handoff from the day team that omitted the patient's active medication list.

Answer

The attending physician should promptly disclose the medical error to the patient's husband, explain the clinical consequences, and offer a sincere apology.
Medical ethics and professional guidelines mandate the full, honest, and immediate disclosure of any medical error that causes harm to a patient. When a patient lacks clinical decision-making capacity (e.g., due to sedation and intubation), this disclosure must be made to their designated surrogate decision-maker or next of kin. The discussion should include a clear explanation of what occurred, the potential clinical consequences, the steps taken to mitigate harm, and a sincere apology. Physicians must take professional responsibility during these conversations rather than inappropriately shifting blame to other staff members or waiting for administrative investigations to conclude.

Step-by-Step Solution

1
Identify the event as a medical error that reached the patient and caused harm (torsades de pointes requiring defibrillation and prolonged ICU stay).
Determine that ethical guidelines mandate disclosure of the error.
All medical errors resulting in patient harm must be fully disclosed to maintain trust and adhere to professional ethical standards.
2
Assess the patient's current ability to receive this information.
Recognize that the patient is sedated and lacks clinical decision-making capacity.
Disclosure must be directed to the appropriate individual. If the patient lacks capacity, the surrogate decision-maker (the husband) must be informed.
3
Determine the appropriate timeline and content for the disclosure conversation.
Conclude that the disclosure should happen promptly and include an apology, without blaming other staff or delaying for administrative reviews.
Immediate, honest communication prevents the appearance of a cover-up and fulfills the physician's fiduciary duty to the patient and their family.

Key Concept

Disclosure of Medical Errors and Harms
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Topics

Medical Errors and Malpractice

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