Commentary: doctors are obliged to be honest with their patients.

peter.singer? utoronto.ca "Let this be a lesson to all of us," said the senior consultant He was likely referring to three lessons: myocardial infarction must be considered in the differ ential diagnosis of abdominal pain; physicians must check the results of the tests they order; and mistakes should be handled in private. A lesson I draw, however, is that the senior consultant's actions may have unwittingly led to the deaths of many other patients. Everyone makes mistakes. Fortunately, we work in teams, organisations, and health systems that can be designed to ensure that mistakes are corrected before they cause adverse outcomes for patients. The mistake made in this patient's case was an accident waiting to happen. Electrocardiograms were recorded on rolled up strips that were easy to misplace. Someone put the diagnostic strip in a place where the doctor could eas ily miss it Processes that force abnormal electrocardio grams to be brought to the attention of the doctor were not used or were unavailable. How many other patients were harmed because of the lack of systematic safety processes for electrocardiography? Misplaced electrocardiograms are not the only mistake that can happen on a busy ward. How many other times did the senior consultant say in private, "Let this be a lesson to us all"? How many other patients died from the failure to identify and fix the processes that led to these mistakes? The senior consultant taught the junior doctor that the correct way to handle mistakes was "in private." How many house officers were trained under this sen ior consultant and also learnt this lesson? How many other patients died on wards that were subsequendy led by those trainees when they became senior consultants and dealt with mistakes in private? A narrow ethical analysis of this case would focus on the physician's obligation to disclose mistakes to the patient or the family (or the senior consultant's unacceptable attempt to cover up the mistake by falsi fying the medical record). There are good reasons for disclosing mistakes including maintaining the relation ship of trust between the patient and doctor and the possibility that disclosure may actually reduce the number of lawsuits filed. However, the ethical obligation to prevent mistakes is even stronger than either of these. The senior consultant's actions are based on an ethic of personal responsibility: the physician is individually responsible for the care of the patient Although a laudable value, personal responsibility is an inadequate ethic for medical practice because it isolates physicians from the teams, organisations, and systems in which they work. The Tavistock Group has proposed a draft statement of shared ethical principles for everybody who works in health care.1 One of these principles is that "all individuals and groups involved in health care, whether providing access or services, have the continu ing responsibility to help improve its quality." The idea that follows from this principle is that we should cherish each mistake as an opportunity for improvement This will require a change in medical culture from an ethic of personal responsibility to one that also values the safety of patients and the improve ment of quality. Senior consultants will need to lead this charge by what they say and do. The "lesson to all of us" is that we should learn to love mistakes because