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Dr Yeung, a dermatologist, had just completed skin biopsy procedures on 2 patients and when he went to get an instrument tray for a third procedure, he realized that none of the instruments he used had been sterilized. He spoke to the clinic staff and looked at the sterilization test strips for all the trays and confirmed that none of the trays were sterile.
Dr Yeung realizes that the risk of infection from the unsterilized equipment is very low, but blood-borne infections such as hepatitis and HIV could be transmitted. His dilemma is whether to tell the patients about the error and, if so, what to say.
Levinson W, Yeung J, Ginsburg S. Disclosure of Medical Error. JAMA. 2016;316(7):764-765. doi:10.1001/jama.2016.9136