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Opinion 8.121 - Ethical Responsibility to Study and Prevent Error and Harm

In the context of health care, an error is an unintended act or omission, or a flawed system or plan, that harms or has the potential to harm a patient. Patient safety can be enhanced by studying the circumstances surrounding health care errors. This can best be achieved through a legally protected review process, which is essential for reducing health care errors and preventing patient harm.

(1) Because they are uniquely positioned to have a comprehensive view of the care patients receive, physicians must strive to ensure patient safety and should play a central role in identifying, reducing, and preventing health care errors. This responsibility exists even in the absence of a patient-physician relationship.

(2) Physicians should participate in the development of reporting mechanisms that emphasize education and systems change, thereby providing a substantive opportunity for all members of the health care team to learn. Specifically, physicians should work with other relevant health care professionals to:

(a) Establish and participate fully in an effective, confidential, and protected error-reporting mechanism

(b) Develop means for objective review and analysis of reports regarding errors, and to conduct appropriate investigations into the causes of harm to a patient

(c) Ensure that the investigation of causes of harm, and the review and study of error reports result in preventive measures that are conveyed to all relevant individuals

(d) Identify and promptly report impaired and/or incompetent colleagues so that rehabilitation, retraining or disciplinary action can occur in order to prevent harm to patients

(3) Physicians must offer professional and compassionate concern toward patients who have been harmed, regardless of whether the harm was caused by a health care error. An expression of concern need not be an admission of responsibility. When patient harm has been caused by an error, physicians should offer a general explanation regarding the nature of the error and the measures being taken to prevent similar occurrences in the future. Such communication is fundamental to the trust that underlies the patient-physician relationship, and may help reduce the risk of liability.

(4) Physicians have a responsibility to provide for continuity of care to patients who may have been harmed during the course of their health care. If, because of the harm suffered under the care of a physician, a patient loses trust in that physician, the obligation may best be fulfilled by facilitating the transfer of the patient to the care of another physician.

(5) Physicians should seek changes to the current legal system to ensure that all errors in health care can be safely and securely reported and studied as a learning experience for all participants in the health care system, without threat of discoverability, legal liability, or punitive action. (I, II, III, IV, VIII)

Issued December 2003 based on the report "Ethical Responsibility to Study and Prevent Error and Harm in the Provision of Health Care," adopted June 2003.