Clinical Review & Education
JAMA Professionalism
Disclosure of Medical Error
Wendy Levinson, MD; Jensen Yeung, MD; Shiphra Ginsburg, MD
Case Summary
Dr Yeung, a dermatologist, had just completed skin biopsy proce-
dures on 2 patients and when he went to get an instrument tray
for a third procedure, he realized that none of the instruments he
used had been sterilized. He
spoke to the clinic staff and
Audio at jama.com
looked at the sterilization test
strips for all the trays and con-
Editorial page 720 firmed that none of the trays
were sterile.
Related article page 698 Dr Yeung realizes that the
risk of infection from the un-
sterilized equipment is very
CME Quiz at
jamanetworkcme.com low, but blood-borne infections
such as hepatitis and HIV could
be transmitted. His dilemma is whether to tell the patients about
the error and, if so, what to say.
What Would You Do Next?
1. Do nothing; the risk for infection is low and telling the patients
about the potential problems will cause undue anxiety.
2. Tell the patients there was an “adverse event” and offer a state-
ment of regret.
3. Report it to the department that does root cause analysis of er-
rors so future errors might be prevented.
4. Tell the patients the details of the mistake and apologize. Tell the
patients that the hospital will investigate how it happened and
that you will inform them of the outcome.
Consider the Options
Medical errors that potentially harm patients create great anxiety
for clinicians and patients.1 Often when errors occur, the involved
clinicians will not have experienced the circumstances in which the
error occurred and may not know how to address the problem. Pro-
fessionalism in this context provides a framework to assist clini-
cians when negotiating the unknown so that they and their pa-
tients have the best possible outcomes (Audio 1:09).
1. While it is true that the risk of having complications related to the
use of unsterile instruments for these procedures is low, clini-
cians have an obligation to inform their patients about all as-
pects of their medical care, even when mistakes are made. Aside
from disclosure being the ethical approach, the exposure to sig-
nificant medical liability is much greater if a patient finds out that
an error occurred and he/she was not told about it.
2. Not telling the patients what happened might be Dr Yeung’s first
instinct because of a concern for medical liability. He may want
to withhold any incriminating information to minimize his liabil-
ity exposure. Dr Yeung may be anxious and personally vulner-
able because he was ultimately responsible for the care deliv-
ered, even though the error was beyond his control. He could tell
764 JAMA August 16, 2016 Volume 316, Number 7 (Reprinted)
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Bottom Line
1. When errors occur, the patient should be told about the error
and an apology provided. Information about errors should
never be withheld from patients.
2. All personnel involved should participate in the review of the
error and in solving any systems problems that contributed to
the occurrence of the error.
3. Contact the institution’s quality assurance department, risk
management group, and/or malpractice carrier to inform them
of the error.
the patients an adverse event occurred related to instruments
used for the procedures not being autoclaved. He also might say,
“I am so sorry this happened to you” while reassuring the pa-
tients that the risk of infection is low and offer to see them again
to ensure that no infection develops. This will allow him more time
to pursue further testing if necessary.
Although this approach offers an explanation of what hap-
pened to the patients and provides an expression of regret, it falls
short of an apology. The wording used (“adverse event”) may not
be understood by the patients, and more direct language such
as “an error occurred” is preferable because it is easy to under-
stand and clearly indicates that something went wrong. By not
providing enough information about the consequences of the
error, the patients cannot make informed decisions about what
to do next—eg, be tested for HIV even though the risk is low. By
not sharing relevant patient information, the professionalism prin-
ciple of patient autonomy is violated (Audio 5:03).
3. Dr Yeung may think that the most important outcome of this
event is to prevent it occurring to other patients. Reporting it to
the quality improvement department, which regularly con-
ducts root cause analyses of errors, would be a reasonable ap-
proach. A root cause analysis for this case would involve a de-
tailed review of all the people and processes involved in handling
of the equipment. The review would investigate how the biopsy
trays are handled from the time of their last use, including the
cleaning, autoclaving, and restocking. This would likely identify
steps in the process that are susceptible to errors and allow
changes to be implemented and staff to be appropriately trained.
Although this should be done, it is not the only action to be pur-
sued in response to this incident because the patients need to
be informed of what happened and appropriately counseled re-
garding risks of subsequent infection related to their exposure
to blood-borne diseases (Audio 8:35).
4. Dr Yeung could offer a full disclosure that would include an apol-
ogy, explanation of what he knows about how the error oc-
curred, discussion of the consequences for the patients, and ex-
planation of the plan to learn from the event to prevent future
similar mistakes. This conversation includes recommended best
jama.com
 JAMA Professionalism Clinical Review & Education

practices in disclosing medical errors. However, since the risk of
infection is low, it does potentially increase the patients’ worry—
which may end up being unnecessary—and possibly make them
angry at the physician and the hospital. Although informing the
patients about the error is important, only the facts as they are
known at the time of the incident should be shared with the pa-
tients without any speculation (Audio 9:43). If the speculation
proves incorrect, then the patients may become angry, believ-
ing they were misled. It is better to plan on having several con-
versations with the patients, letting them know the facts as they
are revealed and to let the patients know how any processes will
change to ensure that future patients will not be exposed to the
same error (Audio 14:00).
Discussion
Dr Yeung is upset and anxious about the error. Medical mistakes are
a cause of distress for health care professionals, a class of individu-
als who are dedicated to providing high-quality care.2,3 But mis-
takes do happen, and clinicians must possess the knowledge and
skills to handle them for the patients exposed to the error and to pre-
vent harm to future patients. In addition to knowing how to man-
age these situations when they arise in their own practices, clini-
cians must also have the skills required to support colleagues who
find themselves in similar situations and reach out to them for help.
Guidelines exist for how to disclose medical errors. These uni-
formly recommend having a frank conversation with the patient,
using plain language, and providing the details regarding the error.4-6
Any future necessary medical care should be discussed; in this case,
testing for hepatitis and HIV might be needed. A straightforward and
honest apology, such as “I am sorry that we made this mistake in your
care,” can be helpful. Patients want, and expect, clinicians to apolo-
gize. Patients also want to know that the health care system will learn
from the mistake and prevent it from happening again.4-6 When er-
rors occur, all personnel involved in the care pathway, such as nurses,
other clinicians, technicians, and hospital administrators, should be
involved in reviewing the event to identify its cause and mecha-
nisms for prevention.
Health care systems must develop a safety culture. An essen-
tial element of this is a culture that fosters open reporting of errors,
assists clinicians in disclosing errors, and provides emotional sup-
port to stressed personnel involved with the error. Hospitals are
required to analyze all errors. The National Quality Forum’s “Safe
Practice” program assesses institutions’ policies and procedures for
error disclosure.7 Programs like this can help guide institutions in
their efforts to improve professionalism among their staff and
develop a more effective culture of safety. Professionalism is a set
of core values and behaviors that physicians, health care teams,
hospitals, and other institutions can use to help solve problems
when they arise.8
Resolution
After Dr Yeung recognized the error, he contacted his supervisors
and the infectious disease service and developed a plan for what to
tell the patients. Using plain language, Dr Yeung explained to the pa-
tients what happened and why, apologized to the patients, and in-
formed them that the error was being investigated. He also ex-
plained the very low risk for complications related to the use of
nonsterile instruments and obtained the appropriate blood tests to
screen for infection. He followed up with them for the purposes of
infection monitoring and to let them know that the cause of the er-
ror was identified (personnel stocking the clinic not being familiar
with how the clinic worked) and remedied.

ARTICLE INFORMATION
Author Affiliations: St Michael’s Hospital,
University of Toronto, Toronto, Ontario, Canada
(Levinson); Department of Dermatology, Women's
College Hospital and Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (Yeung);
Department of Medicine, University of Toronto, and
Wilson Centre for Research in Education, Toronto,
Ontario, Canada (Ginsburg).
Corresponding Author: Wendy Levinson, MD,
Department of Medicine, St Michael’s Hospital,
University of Toronto, 30 Bond St, LKSKI 339,
Toronto, ON, M5B 1W8 Canada (wendy.levinson
@utoronto.ca).
Section Editor: Edward H. Livingston, MD, Deputy
Editor, JAMA.
Conflict of Interest Disclosures: The authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Related Audio and CME: Listen to Dr Yeung and
several experts on the disclosure of medical errors
discuss this case and how professionalism factors
into helping negotiate a problem like disclosing
medical errors to patients. After listening to the
audio, take the related CME quiz at
jamanetworkcme.com.
REFERENCES
1. 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.
2. Institute of Medicine. To Err Is Human: Building a
Safer Health System. Washington, DC: National
Academy Press; 2000.
3. Wu AW. Medical error: the second victim.
The doctor who makes the mistake needs help too.
BMJ. 2000;320(7237):726-727.
4. Canadian Patient Safety Institute. Disclosure
Guidelines: Being Open With Patients and Families.
http://www.patientsafetyinstitute.ca/en
/toolsResources/disclosure/pages/default.aspx.
November 2011. Accessed September 1, 2015.
5. Massachusetts Coalition for the Prevention of
Medical Errors. When Things Go Wrong: Responding
to Adverse Events. http://www.macoalition.org
/documents/respondingToAdverseEvents.pdf.
2006. Accessed September 1, 2015.
6. Gallagher TH, Mello MM, Levinson W, et al.
Talking with patients about other clinicians’ errors.
N Engl J Med. 2013;369(18):1752-1757.
7. National Quality Forum. Safe Practices for Better
Healthcare – 2010 Update. https://www
.qualityforum.org/News_And_Resources/Press_Kits
/Safe_Practices_for_Better_Healthcare.aspx. April
2010. Accessed September 1, 2015.
8. Levinson W, Ginsburg S, Hafferty FW, Lucey CR.
A practical approach to “professionalism.”
In: Understanding Medical Professionalism.
New York, NY: McGraw-Hill Education; 2014.

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