HA400 Unit 9 Error Disclosure Seminar Reflection Example

Assigned the Risk Manager's Chair and Lost by the Second Round: A Seminar Reflection on a Mock Ethics Committee Weighing How Much to Tell a Family After a Composite Double Dose of Long-Acting Insulin

[Student Name]

Purdue University Global

HA400: Health Care Ethics, Law, and Governance

Unit 9 Seminar Reflection

[Instructor Name]

[Date]

The seminar exercise, the patient and the error are composite; the reflection shows the form of a seminar response and does not describe a real event or institution.

The Exercise

The seminar ran as a mock ethics committee. Roles were assigned a week ahead: the attending physician, the nurse who gave the dose, the patient's daughter, a patient advocate, the risk manager and the committee chair. The composite case: a 74-year-old woman admitted for pneumonia received her evening dose of long-acting insulin twice, once from the day nurse who stayed late and once from the night nurse, because the first dose was documented after the second was given. Her glucose fell to [48] at 0300, was treated and was monitored closely; she recovered with no lasting harm.

My Assigned Position, at Its Strongest

As the risk manager, I argued that the family should be told an adverse event had occurred, that the patient had been treated and was safe, and that the hospital was reviewing it. I argued that the cause, a documentation delay between two nurses, should stay inside the review until it was complete. My reasons were real: a cause stated too early may be wrong, the review is protected by state law and an incomplete explanation could harm the nurses involved. I was not arguing to hide the error; I was arguing to hide the part of it that explained how it happened, which turned out to be the part the family most needed.

How It Fell Apart

The first challenge came from the student playing the daughter. She said, "If you don't tell me how it happened, how do I know it won't happen tonight?" I answered that the review would prevent it. She asked what I would do before the review was finished. I had no answer. The second came from the patient advocate, who cited research showing that patients want to know what happened, why it happened, how the consequences will be handled and what will stop it recurring, and that they also expect to hear the words "we are sorry" (Gallagher et al., 2003). My position gave them only the first and the third. The third came from the chair, who asked whether my approach protected the hospital. I said it reduced legal risk. She pointed to a study of a disclosure program at one academic health system, where liability claims and costs fell after the hospital adopted full disclosure with an offer of compensation where appropriate (Kachalia et al., 2010).

What I Learned About My Role

I had assumed that a risk manager's job is to limit what the hospital says. The seminar showed me that limiting the explanation increases risk: it leaves the family with a fear that the hospital has not addressed, and fear is what turns a family toward a lawyer. The narrow disclosure protected nobody. It did not protect the patient, who needed to know the safeguards in place that night; it did not protect the nurses, whose actions would be guessed at; and it did not protect the hospital.

The Ethical Frame

Respect for autonomy means giving patients the information they need to make decisions and to trust their care, and veracity, or truthfulness, is closely linked to it (Beauchamp & Childress, 2019). A family that knows a double dose occurred because of a documentation delay can watch for it, ask about it and judge whether the hospital's fix makes sense.

What I Would Say Now

"Your mother received her evening insulin twice last night. The first dose was not recorded in time, and a second nurse gave it again. Her blood sugar dropped, we treated it quickly, and she is safe. We are sorry. Tonight, every insulin dose on the unit will be checked by a second nurse before it is given, and we are reviewing how doses are recorded. We will tell you what the review finds."

What Still Troubles Me

The nurses' feelings matter. A disclosure that names a documentation delay may feel like blame. The answer is to describe the system failure, not the person, and to support the nurses involved, but I do not think that removes the tension entirely.

What I Take Forward

The exercise also showed me how quickly a position can feel reasonable inside one role and indefensible from another. In a real hospital I would argue for disclosure of what is known, an apology, the immediate safeguard and a promise to share the review's findings. I would also ask whether the hospital has a communication and resolution program and how I could support it.

References

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA, 289(8), 1001-1007. https://doi.org/10.1001/jama.289.8.1001

Kachalia, A., Kaufman, S. R., Boothman, R., Anderson, S., Welch, K., Saint, S., & Rogers, M. A. M. (2010). Liability claims and costs before and after implementation of a medical error disclosure program. Annals of Internal Medicine, 153(4), 213-221. https://doi.org/10.7326/0003-4819-153-4-201008170-00002