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You accidentally reveal patient's sister received STI treatment

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

You are in the middle of a consultation with a patient and, on looking at her records, ask her whether she finished her treatment for a sexually transmitted disease. She denies ever needing or receiving this, but according to the latest letter this is definitely the case. On further questioning, it transpires the letter is wrongly filed and it refers to her sister. It dawns on the patient in front of you that you are discussing her sister. What should you do?

Dr Julian Randall

'There is no escaping the fact you are culpable for the error'

What a clanger. Confucius, he say, when immersed in brown and smelly stuff up to molars, do not open mouth to sing about it.

Once said, the spoken word cannot be unsaid. So shut up and think. Is there anything that can be said by way of damage limitation, rather than exacerbation?

You should apologise and explain that it was a case of mistaken identity, but say nothing to give away any further confidences.

Next, as the Americans would say, you need to 'kick butt' for this. You must get the practice staff together, explain that it is potentially a very damaging disaster, both for the patient and the practice, and that there is no excuse: it was caused by sheer sloppiness and you do not expect any repetition. Consider whether any practice procedures, including your own, were at fault and need changing to reduce the risk.

If the worst happens, and the patient makes a complaint, then there is no escaping the fact you are culpable for the error. You had a duty of care to protect confidentiality, and two chances to perform that duty were lost – first by whoever filed the correspondence, second by yourself in failing to check what you were reading. Expect to make a grovelling apology at the very least.

At worst, we live in the Age of the Treasured Grievance. These days righteous indignation, even at trivial offences, confers status. Inform your defence organisation, so that if the complaint is taken further they can ensure that penalties are kept proportionate and libellous publicity contested.

But regardless of outcome, make sure it doesn't happen again. Quality control and the actions of your staff are your responsibility. Always be checking for errors, and apply as much foresight as you can muster, to prevent blunders before they cause damage.

Dr Zoe Rogers

'I would admit to both patients there had been a breach of confidentiality'

I would deal with this by trying to stick to the principals of honesty and openness.

Firstly I would apologise and admit to the patient in front of me that there has been a breach of confidentiality. I would ask her not to divulge the information to anyone else. I would ask her if I can tell the patient with the STI – as it is her sister, hopefully she would agree – and if I may contact the patient first before she speaks to her.

Next I would contact the patient with the STI. Although calling would obviously be quicker, there is the danger that she will ask me on the phone what is going on, and I think it would be better face to face.

When she comes to see me I would admit what has happened, and apologise. I would explain how it has happened and that I am going to investigate and take appropriate action to try to prevent it happening again. I would be prepared for her to be angry and I would give her as much time as she needs.

Having now been open and honest with the parties involved, I would speak to the receptionists. If however the filing was done electronically there will be an audit trail. Whoever was responsible, this situation can be used as a learning tool for all the reception team. If we can identify the receptionist involved, the reception manager, with the partners' support, can be asked to explore whether any retraining is required.

We do need to remember all human beings make mistakes.

Dr Declan Fox

'I would phone my medical defence union and be guided by them'

I'm sure there was a good reason for this awful error. My impression from working in paperless practices is that fewer items get misfiled, probably because paperless practices have specific protocols for checking documents before filing them. But with the volume of workload in modern practices, it is impossible to guarantee perfection.

I cannot confirm or deny to her that her conclusions – that this report refers to her sister – are correct. Trying to do either one of those will most likely lead to more trouble.

What I have to say is that I am terribly sorry, I have made a terrible mistake, I shall take action today to sort this out – but right now, we need to get on with why you came to see me today. If I can do all that without having a panic attack, I am doing pretty well.

The problems start afterwards. Is there any way I can minimise the upset to her sister? Or am I expecting the worst? Perhaps STIs are not a big deal in this family; perhaps the sisters have a close relationship. On the other hand, one or both may turn out to be vicious, vindictive and spoiling for a fight.

My inclination is to come clean here, phone up the sister, apologise profusely and promise to review procedures. But might I risk accepting responsibility for something that is not my fault? Might some of my words result in legal action against me?

I shall be careful here. Before I call the sister, I shall call my medical defence body and be guided by them.

What does this teach us?

Learning checklist

Confidentiality in primary care

• Patients expect their medical records to be treated confidentially and this allows them to share very personal details with health professionals.

• They are often quite surprised by how many people do have access to their details, especially reception staff, medical students and hospital staff in the event of secondary referral.

• The NHS computer project claims to be building in confidentiality safeguards. How safe can this be made?Effects of a breach of confidentiality

• This depends upon the nature of the information disclosed, what the third party does with it and how the patient feels about what has been disclosed.

• For either patient, it could cause emotional and social upset and also damage their trust in the GP. It might also affect their relationship with each other. Even if either patient changes doctors as a result of the incident, they may never access care in the same way.

• Both the GP and the surgery may find their reputation affected by the incident, and vulnerable groups such as teenagers may be suspicious about consulting with personal problems.

• Such incidents can dent the image of primary care in the wider community.

Ensuring confidentiality in practice

• Good staff induction and continuing training is the best way of doing this.

• A culture of caring about information and not gossiping is important.

• Reception desks are high-risk places – background music, queues away from the front desk and a side window away from the waiting area might help.

• Using name and date of birth when booking appointments and when the patient arrives is good practice to ensure the correct record is accessed.

• Computers should be password-protected and logged off when you are not using them. Try to have a screen without personal information on it when the patient enters the room. This gives you chance to check you have the right patient. Positioning of the screen to share information but maintain confidentiality is not always possible.

Investigating what went wrong

• Significant event analysis is the method of choice for investigating an incident such as this. The aim is to blame the system rather than an individual and learn from it. Although misfiling will occasionally occur, recognising the consequences and reviewing the system should ensure it is minimised. If a pattern suggests one member of staff is responsible, it may raise issues that require addressing.

Talking to the patient affected

• Respect for the patient's autonomy means that they are entitled to know what has happened. Can you justify not telling them on the grounds that it will do them more harm than good?

• Actually telling them what has happened is very similar to dealing with a complaint. Respond as soon as possible then arrange a further meeting when you have had a chance to investigate what happened. Expect to have to listen, explore the patient's feelings, explain how you think the mistake occurred, and explain how you think you may be able to prevent it happening again. If the patient feels that you understand and empathise with her, she is more likely to accept your apology.

Dr Richard Stokell is a GP and trainer in Birkenhead, Merseyside

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