What Is a Physician’s Obligation to Disclose ‘Near-Miss’ and ‘No-Harm’ Events to Patients?

Our Responsibility

Our professional duties to patients with respect to near misses and no-harm events are fundamentally values-based. The unique patient–physician relationship at its best is based on honesty, trust, forthrightness, compassion, and understanding. Underpinning these values is the need for meaningful communication between the patient and physician that leads to an appropriate shared medical decision-making process. Patients deserve to know all facets of information regarding their health status, which, in turn, informs their choice of placing their trust in their physician. Any health issue, decision, or risk purposefully withheld from patients could potentially undermine trust or shift the balance of the shared decision-making process toward paternalism. It’s far better to disclose near misses and no-harm events directly to patients as soon as possible, as it’s likely patients may learn of such events from other sources, eroding trust.

Ethical obligations also compel us to disclose based on the four principles of medical ethics. Autonomy requires that patients be informed of all aspects of their health, including real or potential risks, to make self-determined decisions. Failure to disclose near misses and no-harm events may deprive the patient of information that could be important and may jeopardize future informed consents.

The dyad of beneficence and nonmaleficence begs for balance in the sense that disclosure provides for the patient’s welfare and recognizes the need to prevent future occurrences that could lead to harm. Social justice requires that all patients are treated fairly and equally. Legal requirements aren’t codified for disclosure of near misses and no-harm events, but they may soon follow, given the advent of new disclosure and apology standards for adverse outcomes.

Physicians have an additional fiduciary obligation to society in that distrust of physicians’ failure to act can become an indictment of the medical profession in general. Near miss and no-harm events shouldn’t be ignored. Quality improvement in medical care implies accepting responsibility for an event that occurs outside the boundaries of good care, cultivating an awareness of the potential effects an event might have had on a patient, and gaining an understanding of why that event should be analyzed for future safety management. Disclosure to the patient, and perhaps the family, including what, how, why, and the steps to be taken to prevent similar occurrences, will have a positive effect on the confidence a patient places in a physician.

Regarding the case scenario, computer and electronic health record crashes aren’t rare, and the circumstances require disclosure to the patient. Bringing Mrs. Smith back to an examination room or your office, preferably with an office staff member in attendance, for the purpose of disclosing the circumstances of concern and apologizing for putting her at risk is fundamental to recognizing her autonomy and your obligation to disclose. If she has not previously been advised to do so by her primary care physician, you could recommend that she purchase a medical ID bracelet indicating the prolonged QT interval syndrome. The responsible otolaryngologist would also discuss instituting new processes for preventing another potential medication error in the same and similar circumstances.