Epilogue: Issues and Repercussions Directly Related to Institutional and Individual Responses during the Patient’s Hospitalization
Immediately following the surgery there was concern on the part of the son and husband as to what had happened to lead to the surgical outcome. They sought without success a primary individual to provide this information. This continued into the ICU admission and contributed to the significant tension between the husband and son regarding decisions about her care. Two siblings were also asking questions about what happened. Further, the entire family was concerned about the apparent lack of coordination among her care-givers and the relative lack of communication about her condition. They came to this conclusion based upon conflicting opinions offered by the various specialty teams and no true sense of “who was in charge” and inadequate explanations about events.
In fact, the family’s level of concern had reached a level that they felt required action. As the city’s mayor, the son reached out to the local newspaper and asked for some investigative reporting. Within a few days the newspaper headlined the patient’s story and raised issues including care access, medical errors, and general quality of care at the military facilities. The newspaper appeared to have access to a significant amount of clinical information and has also highlighted previous adverse events at these military facilities. The son also contacted a prominent malpractice attorney in town who requested that all medical records be made available. Additionally, the patient’s husband contacted the local Congressman’s district office with concerns about his wife’s care. These outside inquiries created enough visibility to cause inquiries from the local base commander and from DHA and the Service Surgeons General.
Although upon her transfer to the ward, the level of communication with the medical team improved, both the husband and son still could not get answers to specific questions regarding the overall ICU course since those attending physicians and consultants were no longer available to them. Moreover, the family’s concerns about multiple care-related issues, including the recently diagnosed UTI and medication error, remained unanswered. They remained concerned about the length of her hospital stay, her hospital course and long-term prognosis.
QUESTIONS: Adverse Event Information Disclosure - Family
1) What is your ethical/legal/institutional obligation with regard to disclosure to the family members?
a. What are applicable HIPAA requirements?
2) How does the initiation of formal quality of care reviews impact further disclosure of information about this case?
a. What is the legal basis for disclosure limitations?
3) What are some of the factors that you should consider before providing disclosure to the patient or family members?
4) When should the initial disclosure be made?
5) Who should make the disclosure?
6) What information if any should be considered for inclusion in an initial disclosure?
7) Is disclosure the same as an apology?
Questions: Release of Information following the initiation of a Quality Assurance Investigation
1) What are the applicable statutes, rules, and DoD Instructions that deal with the handling of investigation related data?
2) What are the applicable HIPAA issues for all patient data release with regard to the issues of disclosure raised by this case?
3) Specifically: Through what process and at what level of detail may quality assurance information (10 USC 11002) and/or HIPAA defined PHI be disclosed to:
a. Family members
b. Service Commands, including the OTSG
c. Base and Installation commanders
d. Other components of the Department of Defense (e.g. ASHA, DHA, The Under Secretary of Defense for Personnel and Readiness)
e. Congressional inquiry