Medical Error

Scenario

Your role: You are the doctor in a general internal medicine ward

Problem: Discussion regarding medical error of administering Penicillin to a patient with a documented penicillin allergy.

Patient: Mr. John Doe, a 60-year-old man

Mr. John Doe, a long-term patient of yours with chronic obstructive pulmonary disease (COPD), was admitted to the hospital for pneumonia. As part of his management, he was started on amoxicillin-clavulanate (a penicillin-based antibiotic) by a junior doctor unaware of Mr. Doe's penicillin allergy.

Unfortunately, this oversight was not caught during the medication review and Mr. Doe was administered the medication, leading to an anaphylactic reaction. Immediate actions were taken, his condition was stabilised and he is now recovering.

The medical error was subsequently identified during a review of his medication chart and electronic patient record, where his penicillin allergy was clearly mentioned.

Your task is to discuss this medical error with Mr. Doe, providing an open and transparent account of what occurred, why it happened, how it was addressed, and what steps will be taken to prevent this from happening in the future.

DO NOT EXAMINE THE PATIENT DO NOT TAKE A HISTORY.

Any notes you make must be handed to the examiners at the end of the station.

Conducting the Station: A Step-by-Step Guide

Introduction:

Introduce yourself and your role.

Confirm you are speaking with the correct patient, Mr. John Doe.

Establish rapport and patient understanding:

Ask about his current condition and how he is feeling after the recent incident.

Assess his current understanding of what happened.

Explanation of the incident:

Provide a clear and straightforward explanation of the medical error that occurred.

Explain how penicillin was mistakenly given despite his known allergy.

Describe the immediate response that was taken to treat his anaphylactic reaction and stabilise his condition.

Apology:

Offer a sincere and unreserved apology for the mistake.

Explanation of Cause and Steps for Prevention:

Discuss how the error occurred due to a lapse in reviewing the electronic patient record.

Outline the steps the healthcare team will take to avoid similar errors in the future. This might include improved staff training, double-checking allergies before medication administration, and enhancing the electronic patient record system to highlight allergies more prominently.

Inform him about the penicillin allergy wrist band that he will be given as an additional safety measure.

Incident Report and Patient's Right to Complain:

Mention that an incident report has been made regarding the error and it will be thoroughly investigated to ensure such mistakes are not repeated.

If Mr. Doe expresses anger or the wish to lodge a complaint, acknowledge his right to do so. Provide information about the Patient Advice and Liaison Service (PALS) which he can contact for further advice or to raise his concerns.

Addressing Patient Concerns:

Ask Mr. Doe if he has any questions or concerns.

Answer his questions clearly and honestly.

Address his concerns empathetically, recognising the anxiety this incident may have caused.

Reassurance:

Assure him that his safety and care are the healthcare team's top priority.

Emphasize that such incidents are taken very seriously and that everyone is committed to learning from this error to improve patient safety.

Closure:

Summarize the key points discussed.

Ask him if there is anything else he wants to discuss or any other questions he has.

Thank him for his understanding and patience.