Medical Error

PLAB II-UKMLA CAPSULES

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Medical Error
 1. Missed Renal Biopsy

 2. Missed Fracture In A Child

 3. Missed MI

 4. Normal X-ray Mixed Up With A Pneumonia X-ray (Wrongly Diagnosed With Chest Infection)

 5. Missed Blood Sample (Unlabeled) – Your Mistake

 6. Missed Foreign Body In A Child – Your Mistake

 7. Antibiotic Was About Be Given To Allergic Child – Near Miss

 8. Missed Fracture In An Old Lady – Talking To Son

 9.Missed Piece of glass in child’s arm

Medical Error Approach
 GRIPS
 So I understand that you have had...done, is that right? Well Am here/calling today to update you but before
that I would like just to have a quick recap on what happened last time/in the first place
 Last Visit Questions: What did the doctors say? Have they done any tests? Any Treatment?
 Specific questions: related to the station ?
 MMA: Regarding your General Health: Any medical conditions ? Any Medications ? Any allergies ?
 Social: I can see that you have been through a lot recently, so is there anyone around to support you?
 ICE: DO you have any idea what might....(only if applicable), Do you have any concerns or questions for me at
the moment ?
 +/- Examination
 Narrative approach: So I understand that you have came here x days ago and you have done .... but when we
.... we discovered that ....am really sorry to tell you that....and this is totally our fault. This is actually considered
as a Medical Error. PAUSE
 EVE Protocol: I understand how angry/upset you are at the moment. Any one in your place would feel the
same. Once again am really sorry for what have happened.
 So what you are going to do for me now?
 What are you going to do so that wont happen again in the future?
Medical Error Approach – Cont’d
 Medical Part: Well first of all we will have to make sure that you weren't affected by what have happened....so
we are going to do for you ......
 Ethical Part: And to make sure that this wont happen again in the future:
 1- We are going to make an urgent meeting to discuss why this have happened and what have caused it to
happen in the first place.
 2- In addition to that we are going to fill an incident form to make sure that all of our colleagues would learn
from this incident in order to prevent it in the future.
 3- Moreover, we are going to review the guidelines and protocols governing such conditions and if they needed
any changes we will make sure that these changes are done.
 Doctor, I would like to make a formal complain ?
 Well that's totally your right and for that I would like to refer you to the department responsible for official
complains and is called PALS which is Patient Advice & Liaison Service where they are going to receive your
formal complain and the will act on it as a matter of urgency and they will investigate in to it and come back to
you as soon as possible in a very open and honest way.
 Once again am really sorry for what have happened
 Is there any thing else that I could do for you today?
Medical Error – Lost Renal Biopsy
Medical Error – Lost Renal Biopsy
 GRIPS
 So I understand that you have had a renal biopsy done last week, is that right? Well Am here today to update
you but before that I would like just to have a quick recap on what happened in the first place?
 Last Visit Questions: What did the doctors say? Have they done any other tests? Any Treatment given?
 Specific questions: Could you tell me how was it last time when the biopsy was taken? Was it painful? Any
complications?
 MMA: Regarding your General Health: Any medical conditions ? Any Medications ? Any allergies ?
 Social: I can see that you have been through a lot recently, so is there anyone around to support you?
 ICE: Do you have any concerns or questions for me at the moment ?
 +/- Examination
 Narrative approach: So I understand that we have taken the renal biopsy from you last week, and after that it
was sent to the lab. We have waited for the result to come but when we didn’t hear from the lab, we called
them and they informed us that they didn’t receive the sample in the first place. We have searched everywhere
in the hospital and we couldn’t find it. I am really sorry, this is totally our fault and this is considered as a
Medical Error. PAUSE.
 EVE Protocol: I understand how angry/upset you are at the moment. Any one in your place would feel the
same. Once again am really sorry for what have happened.
 So what you are going to do for me now?
 What are you going to do so that wont happen again in the future?
Medical Error - Lost Renal Biopsy – Cont’d
 Medical Part: Well first of all, I know how painful it was last time when the sample was taken, but am afraid it is
very important to take another sample in order to decide what type of kidney disease you are having & start
the proper treatment for it. So how does that sound to you? Well, this time we will try to make it much easier &
quicker, & for the pain we are going to give you a numbing agent & will use the finest needle possible.
 Ethical Part: And to make sure that this wont happen again in the future:
 1- We are going to make an urgent meeting to discuss why this have happened and what have caused it to
happen in the first place.
 2- In addition to that we are going to fill an incident form to make sure that all of our colleagues would learn
from this incident in order to prevent it in the future. So how does that sound to you?
 3- Moreover, we are going to review the guidelines and protocols governing such conditions and if they needed
any changes we will make sure that these changes are done.
 Doctor, I would like to make a formal complain ?
 Well that's totally your right and for that I would like to refer you to the department responsible for official
complains and is called PALS which is Patient Advice & Liaison Service where they are going to receive your
formal complain and the will act on it as a matter of urgency and they will investigate in to it and come back to
you as soon as possible in a very open and honest way.
 Once again am really sorry for what have happened
 Is there any thing else that I could do for you today?
Medical Error – Missed Foreign body
 GRIPS
 So, I understand that you brought your sone today after a suspected ingestion of a button battery and I have
seen him and ordered an x-ray for him. Well, Am calling today because I have further updates on his condition
but before that I would like just to have a quick recap on what happened in the first place?
 Last Visit Questions: Has he been seen by other doctors other than me? Have they done any other tests? Any
Treatment given?
 Specific questions: General questions: So How is he generally doing now? Is she playful & Active? Is she eating
well? Did you feed her? Any vomiting? Has she been able to pass stool since you left the hospital? Is she breathing
well? Any drooling of saliva? So, Has anyone other than me seen her x-ray today?
 MMA: Regarding Her General Health: Any medical conditions ? Any Medications ? Any allergies ?
 Social: I can see that you have been through a lot recently, so is there anyone around to support you?
 ICE: Do you have any concerns or questions for me at the moment ?
 Narrative approach: So, You brought Anna to the hospital this morning & I have seen her & an X-ray was done
for her in the emergency department which I reported as normal & therefore she was discharged. Unfortunately,
when the radiologist took a look at the X- ray he found that it wasn’t normal and that there is foreign body in the
food pipe that looks like a button. I am really sorry to tell you that, but this is totally my fault, and this is considered
as a Medical Error. PAUSE.
 EVE Protocol: I understand how angry/upset you are at the moment. Any one in your place would feel the
same. Once again am really sorry for what have happened.
 So, what you are going to do for her now? What are you going to do so that won’t happen again in the future?
Medical Error - Missed Foreign body – Cont’d
 Medical Part: Well first of all, I Know that you might be shocked to hear that, and am really sorry but it is very
important that you bring her immediately to the hospital to assess her again and to do another X-ray to check
where the button battery might be in order to make sure that there isn’t any complications and treat her
accordingly. So how does that sound to you?
 Ethical Part: And to make sure that this won't happen again in the future:
 1- The department is going to make an urgent meeting to discuss the matter, and they will decide what should
be done to avoid such mistakes in the future & am ready for any consequences.
 2- In addition to that I am going to fill an incident form to make sure that all of our colleagues would learn from
this incident in order to prevent it in the future. So how does that sound to you?
 3- Moreover, we are going to review the guidelines and protocols governing such conditions and if they needed
any changes, we will make sure that these changes are done.
 Doctor, I would like to make a formal complain ?
 Well, that's totally your right and for that I would like to refer you to the department responsible for official
complains and is called PALS which is Patient Advice & Liaison Service where they are going to receive your
formal complain and they will act on it as a matter of urgency, and they will investigate into it and come back to
you as soon as possible in a very open and honest way.
 Once again am really sorry for what have happened
 Is there any thing else that I could do for you today?