Reading an interesting newspaper article about breast cancer in her local newspaper, Elsa Ross is shocked to see her name and hospital code on an x-ray used to illustrate mammography.

After visiting his nephew at Hope Hospital, George Carter opts for a quick lunch in the cafeteria. At the next table two residents are discussing a patient admitted the previous evening. After summarizing the patient's cardiac tests, one resident says, "We barely got his girlfriend out the back door when his wife came in the front. She thought he was in Michigan on business." Earlier that morning George had heard that his supervisor was rushed to Hope the night before with chest pain.

Both of these incidents, based on actual occurrences, illustrate a breach of patient confidentiality. Most serious breaches are not committed by malicious personnel, but by decent people acting carelessly.

What is confidential information? A legal definition refers to "information the patient finds harmful, shameful, or embarrassing." Of course, it is impossible to know the mind of each patient. We should consider the entire medical record to be confidential. This includes not only medical information, but psychosocial reports, marital history, and other data.

What does confidentiality entail? Keeping information within proper bounds. In other words, when there is a legitimate need to know some or all of the medical record, it should be accessible. Overly rigid criteria may impede patient care. In an emergency, for example, electronic records provide immediate access to important information such as medical history, primary physician, and next of kin.

However, errors occur by confusing legitimate need to know with ability to access records. The fact that a clerk, technician, nurse, or physician can access a patient database, for instance, does not justify browsing the records of family, friends, or VIP patients. Unless one is directly involved in the care of a particular patient, it is unethical to read or release patient records or information to unauthorized third parties without permission or as required by law.

While the motivation for reproducing Ms. Ross's mammogram in the newspaper was a worthy one, it was wrong for the hospital to release her x-rays without consent. Additionally, the newspaper should have removed identifiers from the image. Personnel at teaching hospitals should be particularly vigilant about protecting patients' confidentiality by changing the facts of case reports and masking names on test results, films, and other hard copy.

Location, tone, and manner also pertain to protecting confidentiality. In the case Mr. Carter overheard, both residents may be directly involved in the patient's care. Nevertheless, it is inappropriate to discuss patient information (medical or personal) in public spaces such as elevators and cafeterias. Also, the fact that a patient's name is not used does not insure confidentiality.

A moment's carelessness can seriously damage the trust patients place in health care professionals and institutions. Remembering the requirement "legitimate need to know" and attentiveness to place and manner of conversations are important habits to cultivate in daily practice.