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Beltran-Aroca et al. BMC Medical Ethics (2016) 17:52DOI 10.1186/s12910-016-0136-y
RESEARCH ARTICLE Open Access
Confidentiality breaches in clinical practice:
what happens in hospitals?
Cristina M. Beltran-Aroca1*, Eloy Girela-Lopez1, Eliseo Collazo-Chao1, Manuel Montero-Pérez-Barquero2
and Maria C. Muñoz-Villanueva3
Abstract
Background: Respect for confidentiality is important to safeguard the well-being of patients and ensure the
confidence of society in the doctor-patient relationship. The aim of our study is to examine real situations in which
there has been a breach of confidentiality, by means of direct observation in clinical practice.
Methods: By means of direct observation, our study examines real situations in which there has been a breach of
confidentiality in a tertiary hospital. To observe and collect data on these situations, we recruited students enrolled
in the Medical Degree Program at the University of Cordoba. The observers recorded their entries on standardized
templates during clinical internships in different departments: Internal Medicine; Gynecology and Obstetrics;
Pediatrics; Emergency Medicine; General and Digestive Surgery; Maxillofacial Surgery; Plastic Surgery; Orthopedics
and Traumatology; Digestive; Dermatology; Rheumatology; Mental Health; Nephrology; Pneumology; Neurology;
and Ophthalmology.
Results: Following 7138 days and 33157 h of observation, we found an estimated Frequency Index of one breach
per 62.5 h. As regards the typology of the observed breaches, the most frequent (54,6 %) were related to the
consultation and/or disclosure of clinical and/or personal data to medical personnel not involved in the patient’s
clinical care, as well as people external to the hospital. As regards their severity, severe breaches were the most
frequent, accounting for 46.7 % of all incidents. Most of the reported incidents were observed in public areas
(37.9 %), such as corridors, elevators, the cafeteria, stairs, and locker rooms.
Conclusions: In addition to aspects related to hospital organization or infrastructure, we have shown that all
healthcare personnel are involved in confidentiality breaches, especially physicians. While most are committed
unintentionally, a non-negligible number are severe, repeated breaches (9.5 %), thus suggesting a certain
carelessness, perhaps through ignorance about certain behaviors that can jeopardize patient confidentiality.
Keywords: Confidentiality/privacy, Professional ethics, Professional-patient relationship
Background From the ethical point of view, respect for the principles
Medical professionals are obligated to protect the confi- of beneficence, non-maleficence and also autonomy is
dentiality of their patients. The duty to ensure discretion recognized as a major justification for maintaining pa-
and confidentiality in the medical profession is morally tient confidentiality, based upon a fundamental consider-
justified based on the rights arising from relationships, ation for persons [3]. Altisent [4] defines it as “the moral
and medical practice involves trust relationships with right to assist people in maintaining the privacy of what
both patients and society. This duty of confidentiality they entrust to others, who correlatively acquire the ob-
provides a fundamental basis for the existence of some ligation to guard secrecy”.
level of trust in the doctor-patient relationship [1, 2]. Respect for confidentiality is important to safeguard
the well-being of patients and ensure the confidence of
society in the doctor-patient relationship. Health infor-
* Correspondence: cristinabeltran@uco.es
1
Section of Legal and Forensic Medicine, Faculty of Medicine and Nursing,
mation is not only based on objective observations, diag-
University of Córdoba, Avenida Menéndez Pidal s/n, 14004 Córdoba, Spain noses, and test results, but also subjective impressions
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
, Beltran-Aroca et al. BMC Medical Ethics (2016) 17:52 Page 2 of 12
about the patient, their lifestyle, habits, and recreational Additionally, our study adheres to STROBE guidelines
activities. The improper disclosure of such highly sensi- (Additional file 1) for reporting observational research. 2
tive information could harm patients’ reputation or re-
sult in lost opportunities, financial commitments, and Selection of participants and sample collection
even personal humiliation [5]. This obligation is strin- To observe and collect data on situations in which confi-
gent but not unlimited. In fact, there are two general ex- dentiality was breached, we recruited 5th-year and 6th-
ceptions where it is necessary to question whether or year students enrolled in the Medical Degree Program at
not to maintain confidentiality: when the safety of others the University of Cordoba at the beginning of the aca-
or public health is threatened [6, 7]. demic years 2010–2011, 2011–2012, 2012–2013, and
Medicine today is practiced by healthcare teams 2013–2014. All participants were adults, and signed a
formed not only by physicians, residents, and nursing consent form with a confidentiality agreement, especially
staff, but also nursing assistants, orderlies, administrative in order to avoid awareness of the study and conse-
personnel, and even students. Patients should be aware quently the bias of changing the behavior of the ob-
of the large number of people in hospitals who need to served subjects. A total of 99 observers (75 women and
access their medical records to provide the best possible 24 men) participated in the study, two of which aban-
health care [8], which consists in obtaining an accurate doned the project.
diagnosis, providing the appropriate treatment, as well To ensure the anonymity of the participants in the
as receiving the necessary training to do so. It is for this study, each of the observers was assigned a numerical
reason that hospital personnel are required to protect code. In order to standardize the collection of data, the
patient confidentiality. Breaches of confidentiality in observers were trained by the researchers through inter-
clinical practice due to carelessness, indiscretion, or views and in training sessions with groups of up to three
sometimes even maliciously, jeopardize a duty inherent students. A checklist was used during the training ses-
in the doctor-patient relationship [9]. Careless behavior, sions to inform the observers about different types of
such as speaking about patients in public spaces like ele- confidentiality breaches. Specifically, the checklist con-
vators [10] and cafeterias, during telephone conversa- tained several items describing situations in which the
tions, or even when accessing electronic data, can result most common confidentiality breaches may occur. How-
in breaches of patient confidentiality [7]. ever, the observers were also instructed to record any
By means of direct observation, our study examines other type of incident that was not specifically reflected
real situations in which there has been a breach of confi- on the checklist. Incidents that the researchers did not
dentiality. To achieve our aim, we first estimate the fre- consider to be examples of unethical conduct (i.e.,
quency of the phenomenon, that is, we quantify the breaches of confidentiality) were excluded from the
number of times that patient confidentiality is breached study.
in the different medical departments of a hospital. We The observers recorded their entries on standardized
then classify the situations recorded by the observers ac- templates during clinical internships in the following de-
cording to two characteristics: type and severity. Thirdly, partments and units: Internal Medicine; Gynecology and
we establish a relationship between the data recorded Obstetrics; Pediatrics and specialties; Adult Emergency
during the observations: the specific medical department Medicine; General and Digestive Surgery: Hepatobiliary
and area where the observations were made, and the Surgery, Colorectal Surgery, Breast Surgery, Endocrine
type of professional involved. The identification and and Upper Gastrointestinal Surgery, and Oncological
characterization of such situations could be of use to Surgery; Maxillofacial Surgery; Plastic Surgery; Orthopedics
health professionals and hospital management with a and Traumatology; Digestive; Dermatology; Rheumatology;
view to implementing the necessary measures to prevent Mental Health; Nephrology; Pneumology; Neurology; and
such incidents. Ophthalmology.
In addition to describing each breach of confidential-
Method ity, the observers recorded the total number of days and
Experimental design hours corresponding to each period, the area/s where
We conducted an observational, cross-sectional epidemio- the breach occurred, the day and time of the incident,
logical study on situations defined as breaches of confi- the type of health professional responsible for the
dentiality in clinical practice. The study was carried out in breach, as well as the gender and age range of the per-
a 1197-bed university tertiary hospital with an average of son involved. It seems important to underline that ob-
39,912 admissions and 748,245 patient visits per year.1 servers were interested in collecting the type of
Research was conducted in compliance with the professional, as well as another anonymous sociodemo-
Helsinki Declaration and approved by the Ethics Com- graphic data; therefore, the identity of the observed sub-
mittee of Clinical Research of the reference hospital. jects remained unknown for the researchers.
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