To tell the truth: the ethical and legal implications of disclosure of medical error.

In early 2004, Carol Smith and David Jones (as we will call them) were seriously ill patients in Intensive Care Units at the Foothills Medical Centre in Calgary. On March 4, 2004, Carol, who was 83, died suddenly and unexpectedly. Just prior to her death, Carol was alert, oriented and did not seem to be in imminent danger. In these circumstances, it might have been easy to dismiss Carol’s death as a result of complications from her serious underlying condition. However, an astute ICU physician investigated further and ultimately it was discovered that her death was the result of receiving potassium chloride instead of sodium chloride in her dialysate solution.