Case Discussion for Medical Errors

00:01 Let's close this discussion on medical errors with a case discussion.

00:05 The case that I'm going to present to you is a 41-year-old female patient who undergoes an outpatient diagnostic radiologic procedure.

00:13 Despite the very clear documentation of the patient having a severe reaction to iodinated contrast material.

00:19 A member of the team was ill informed unaware and gave IV contrast to this patient.

00:26 Unfortunately, a very predictable outcome occurred, the patient developed an anaphylactic reaction and required intubation and hospitalization into the intensive care unit.

00:35 This is particularly difficult to explain to a patient when a particular allergy has been very clearly disclosed prior to the procedure.

00:42 The patient's sister is in the waiting room, and you must notify her of these very difficult events which have transpired.

00:49 How do you proceed? Well, here are some things you might be tempted to do.

00:53 Do you avoid speaking with the family to avoid an uncomfortable situation? Do we blame the member of the team who made the error thereby distancing ourselves from this error? Or do we minimize the concern saying something like, "Well, you know, these things, they happen." I would argue for you that all of the above are actually very inappropriate although understandable actions and not to be followed.

01:18 Specifically, the best course of action is to admit the error to be honest but remain compassionate and to offer to improve as a function of the situation.

01:28 The three principles there are honesty, compassion, and offering to improve.

01:34 It is important to notify the hospital's legal department will proactively reach out to the patient and family and implement risk management protocol.

01:44 This is important that you carry this out because the patient's admission and care in a case like this may be paid for the hospital in such a situation.

01:52 So to conclude, when we approach issues of medical error, the key issues to remain in mind are: 1. They were adequately informed and that we practice medicine well in order to minimize the risk of medical errors.

02:05 Secondly, if an error is made, and they will happen, that we approach them directly and honestly with the patient, but with a spirit of compassion and understanding.

02:15 And then finally, we offer to improve and we maintain adequate communication with all parties in the hospital to make sure these errors are avoided in the future.