A 62-Year-Old Woman with Skin Cancer Who Experienced Wrong-Site Surgery

Review of Medical Error

This article explores the issues surrounding medical error, including how well physicians and other health professionals communicate with their patients after an error has occurred. The author describes the case of a 62-year old woman (Ms. W), who experienced two separate medical errors within a 10-year period; one from complications following an injection and the other from a wrong-site surgery to remove a cancerous lesion. The author examines the perspective of the patient and of the physician. Widespread consensus now exists that the patient should receive prompt full disclosure of the error and a sincere apology. Ms. W’s expressed needs after the second error reflected three key elements:

  1. share information with the patient;
  2. provide emotional support, including an apology; and
  3. schedule follow-up with the patient.

The relationship between disclosure and litigation is acknowledged and some research studies have revealed that more disclosure leads to less litigation. In conclusion, the author suggests that measuring the quality of disclosure processes may help in understanding best practices after a medical error has occurred.