Introducing CMPA

CMPA:
Patient safety
 Objectives

❖ After completing this domain you will be able to:

I. Describe the fundamental elements of safe patient care.

II. Explain a just culture of patient safety.
III. Explain why advocating for improvements in system processes supports safe care.
IV. Identify the role of the healthcare provider in providing safe patient care.
V. Describe the elements of negligence (professional civil liability in Québec).
❖ Harm to a patient may result from:
1. worsening of a medical condition (disease, disorder, or injury)
2. healthcare delivery
A. the inherent risk of an investigation or treatment
B. system failure
C. issues in the performance of an individual provider
3. a combination of both of the above

❖ Changes in a patient's condition most often reflect the progression of the underlying disease.

❖ This guide describes 3 terminology conventions commonly used in Canada:

• "Adverse event" terminology
• "Patient safety incident" terminology
• Terminology used in Québec
 "Adverse event" terminology
❖ Harm
An outcome that negatively affects the patient's health or quality of life. It may result from the underlying medical condition or
an adverse event, or a combination of these factors.

❖ Underlying medical condition/disease

Most unexpected poor clinical outcomes result from the natural progression of the underlying disease despite the best of
care.

❖ Adverse event
Unintended harm resulting from the care or services provided to the patient.

❖ Inherent risks of investigations or treatments

Most adverse events are due to certain recognized complications or side effects, which are independent of who is providing
the care.

❖ System failures
Events may arise secondary to the lack, malfunction or failure of policies, operational processes, or supporting infrastructure
for the provision of healthcare.

❖ Individual provider performance

❖ Potential problems include:

I. lack of skills, knowledge, or experience with a clinical condition or treatment;
II. departures from or violations of sound policy; or
III. poor performance related to a provider's underlying health condition.
 "Patient safety incident" terminology
❖ Medical condition
Most unexpected poor clinical outcomes result from the advancement of a medical condition (i.e. the disease
process).

❖ Harmful incident from healthcare delivery

Harm results from the care or services provided to the patient.

❖ Recognized risks inherent to investigations and treatments

Most investigations and treatments have inherent risks. Certain complications, adverse reactions or side-effects
may occur and are independent of who is providing the care.

❖ Harmful patient safety incident

A patient safety incident that resulted in harm to the patient.

❖ No-harm incident
A patient safety incident that reached a patient but no discernable harm resulted.

❖ Near miss
A patient safety incident that did not reach the patient and therefore no harm results. These have also been
called "close calls" or "good catches.“

❖ Reportable circumstance
A situation in which there was significant potential for harm, but no patient safety incident occurred. (Specific
patient not involved)
 "Patient safety incident" terminology

❖ Patient safety incident: An event or circumstance which could, or did, result in unnecessary harm to a patient.
There are four types:
1) harmful incident
2) no-harm incident
3) near miss
4) reportable circumstance
❖ A patient safety incident can be classified
as more than one type
 Terminology used in Québec

❖ Harm: An outcome that negatively affects the patient's health and quality of life.

❖ Underlying medical condition: Most unexpected poor clinical outcomes result from the advancement of a
medical condition despite the best of care.

❖ Accident: In Québec law, "an action or situation where a risk event occurs which has or could have
consequences for the state of health ore welfare of the user, a personnel member, or professional involved or a
third person." (Act respecting Health services and Social Services)
❖ A just culture of safety — what is it?

• "Safer patients — every patient, every time."

• recognizes adverse events (accidents in Québec) can occur
• takes steps to avoid or reduce risks
• deals effectively with harm when it occurs
• is a supportive learning environment that implements improvements leading to safer patient care
• facilitates fairness for both patients and healthcare providers
 Approaches to patient safety
❖ There a number of different approaches for identifying patient safety risks.

✔ Reporting - Adverse event (accident in Québec) and near miss (close call) reporting systems are common but result in
under-reporting. Traditionally these reports have captured patient identification issues, falls, and medication problems.

✔ Using trigger tools - A retrospective audit in which certain occurrences (e.g. readmission to hospital, abnormal
laboratory values, or the use of certain medications) identify possible underlying adverse events (accidents in Québec).

✔ Executive walk rounds - Senior management (e.g. a hospital's CEO, financial officers, leaders in nursing and
medicine) regularly visit patient care units to learn from providers about existing risks to patient safety.These generally
capture problems in equipment, electronic medical records (EMRs), and the work environment, and sometimes
problems in the care of individual patients.

✔ Discussions during morbidity and mortality rounds - Traditionally focused on the care provided by individual
providers, increasingly these also look at how to improve systems of care.

✔ Learning from autopsies - Can identify differences in pre-mortem and post-mortem diagnoses.

✔ Follow-up systems for discharged patients - Can identify patients who are not improving as expected.

✔ Learning from patient complaints - Can identify communication problems and other care issues.

✔ Learning from legal claims - Can identify both provider and system issues. Many deal with allegations of delays in
diagnosis, including inadequate communication with patients and failures in team communication.

✔ Other approaches exist - Can you think of some?

❖ What is "systems thinking"
• an organized approach for improving care
• focusing on the system, rather than on the individual, prevents more adverse events (accidents in Québec)
• individuals have responsibility in the system

❖ Failures of the system may occur because of such factors as:

• inadequate resources
• unexpected technical or equipment failures
• lack of communication across teams
 Systems thinking and patient harm

❖ The foundation for safe patient care is based on multiple components, including:

1. funding
2. organizational just culture of safety
3. leadership
4. adequate clinical resources
5. proper design of equipment and technology
6. clear roles and responsibilities
7. training and orientation
8. good communication
9. maintenance of equipment
10. sound policies
11. provider well being and alertness
12. few distractions
13. teamwork
14. effective handovers
15. patient health literacy

❑ A house of cards is made by stacking playing cards on top of each

other. Sometimes just the removal of one card results in the collapse
of the entire structure, but usually several need to be removed for this
to happen.

❑ Patient safety: Similarly in patient safety, it is usually the failure of

several components of care that results in harm to a patient.
The Swiss Cheese model
 The Swiss Cheese model

❑ The defensive barriers or safeguards for patients may be perceived as being like slices of Swiss cheese. Usually
the slices are protective but are not perfect and vulnerabilities exist. Each slice may have many holes, each
representing weaknesses or possible failure points; these are continually opening, closing, or changing location.

❑ A single mishap or failure is unlikely to result in an adverse event. Adverse events in healthcare usually occur
because of failures in successive "slices" of protection. The holes or failures line up to allow harm to occur.

❑ Safety is improved by minimizing holes to reduce the likelihood that similar types of adverse events will occur in
the future. This means not only strengthening the system of knowledge and skills of providers, but also the
system and processes of care in the workplace.

❑ Although not a part of the traditional Swiss cheese illustration, patients can be effective in managing risk to
themselves if they have appropriate information.

❑ Every unexpected incident, no matter how unpleasant or how minor (including a "near miss" or "close call") should
be regarded as an opportunity to learn and to improve.
 Case: A 48-year-old woman complaining of hearing loss

• Background
A 48-year-old woman presents to her family physician complaining of bilateral hearing loss. On examination, the
physician finds cerumen blocking the external canals of both ears.
The physician recommends ear syringing and proceeds with the procedure. While pressure is applied, the syringe
suddenly breaks apart, causing a rupture of the tympanic membrane.
The physician refers the patient to an otolaryngologist who follows the patient.
The tympanic membrane perforation eventually heals with conservative treatment and there is no permanent
hearing loss.

• Lessons learned
Problems such as this can occur with any equipment that physicians use in their practice. For example, examination
tables may collapse due to poor repairs or from being too old.
Patients have been injured by faulty electrocautery equipment.
Failures in equipment, such as refrigerators for vaccines or sterilizers for surgical equipment, can also cause problems.
❖ What is accountability ?
• To be accountable is to be professionally responsible or answerable.
• Every healthcare professional or trainee is accountable to:
I. patients
II. hospital or facility
III. university or school
IV. provincial/territorial professional regulatory body

• Every healthcare professional should:

i. maintain knowledge and skills
ii. be professional
iii. comply with sound policies
iv. stay healthy — and practice only if healthy to do so
 Case: A physician falls asleep

• Background
A staff physician is belligerent and verbally abusive to students and colleagues. The physician sometimes falls
asleep when taking histories from patients.
A concerned colleague complains to the hospital. The Chief of the department conducts an accountability review and
the allegations are confirmed.

• Think about it
How would you handle this situation?

• Outcome
The physician is referred for a medical assessment. The diagnosis is narcolepsy.
A treatment plan is approved, and after several months the physician's health condition is satisfactory and he
returns to work.
❖ Improving safety

❑ Risk management
✔ activities to identify, analyse and educate, and to structure processes to reduce the likelihood of adverse events
(accidents in Québec)
✔ on an individual or institutional level
✔ proactive or reactive in nature

❑ Continuous quality improvement (CQI)

✔ Many use this term to describe a philosophy for improvement [REF] :
✔ gaps in quality are usually due to the effect of the system on the individual rather than due to the individuals themselves
✔ a team approach to improvement is important
✔ blame is avoided

❑ High reliability organizations

✔ Many Canadian hospitals are seeking to adopt the high reliability approaches used in the airline, military, nuclear and
other industries.
✔ A high reliability organization is one that anticipates serious "accidents", despite the high risk and complexity of their
activities and environment.
❖ Laws, regulations and policies
• Hospitals are regulated by provincial/territorial laws and regulations (e.g.Hospital Act).

• Physicians are governed by provincial/territorial laws (e.g. Medical Act, Hospital Act); College by-laws and
regulations; and hospital by-laws and regulations.

• Physicians are self-regulated through their provincial medical regulatory authority (College). The Colleges provide
policies and guidelines for practice.

• Other regulated healthcare professionals have similar regulatory structures.

• Physicians are also bound by the policies and rules of the hospital, facility, or organization where they work.

• Students and trainees are accountable to their educational institution, as well as to any facility in which they may
work on an educational rotation.
❖ The Canadian legal system

❑ Generally speaking, citizens are governed by:

I. the law created by statute, either federally, provincially, or territorially, including the Civil Code in Québec
II. common law (except in Québec)

❑ Legal actions in Canada generally fall into one of two categories:

i. criminal
ii. civil

❑ Criminal legal actions

• Purpose: To secure a conviction and punishment for a crime

⮚ In a criminal action, the accused:

• will be found guilty if the charge is proven beyond a reasonable doubt
• often has a right to trial by jury
• if found guilty may be fined, imprisoned, or both

❑ Civil legal actions

• Purpose: To resolve disputes between two or more parties.
• Uses the litigation process.
• Often includes mediation.
 Negligence in common law
⮚ Civil legal actions in all provinces, except Québec, are generally decided based on common law.
• "lack of proper care and attention"
• most common allegation in medical lawsuits

❖ Most medical-legal actions are based on a claim of negligence (professional civil liability in Québec). The plaintiff
(the patient or the patient's representative) must prove, on the balance of probabilities, the following elements for
the claim to be successful:
1) The physician owed a duty of care to the patient. The courts say a duty of care exists when a physician has
knowledge of a patient and knows, or ought to know, that the advice given will be relied upon.
2) There was a breach of the standard of care (termed "fault" in Québec). In determining a breach of the
standard of care to a patient, the courts consider the care and skill that might reasonably have been applied in
similar circumstances by a colleague — a normal, prudent practitioner of similar training and experience. The
courts do not expect perfection.
3) The patient must have suffered harm or injury.
4) Causal connection. The patient must establish that the physician's conduct caused or contributed to the harm
or injury sustained.
 Professional civil liability in Québec
❖ Most medical-legal actions in Québec are based on a claim of civil liability. In Québec, the plaintiff must prove the
3 basic elements of civil liability for a claim to be successful:

1) Fault. This concept is at the heart of civil liability. Every person has a duty to abide by certain rules or standards
of conduct, and if a person does not, they have committed a fault. The plaintiff must demonstrate the physician
committed a fault, that is, did not act as a reasonably prudent physician of similar training and experience would
have under the circumstances.
2) Damages. The plaintiff must have suffered a prejudice (bodily, moral, or material) as a result of the fault
committed.
3) Causation. The plaintiff must establish the physician's fault caused the damages.
 "Defensive medicine" and good care

❖ Defensive medicine:
I. is excessive investigation
II. yields low probability of abnormal result
III. often stems from fear of litigation
IV. is neither necessary nor good medicine

❖ Physicians best defend themselves with good care and by showing that their care was that of a reasonable
physician in similar circumstances. They should be able to demonstrate that they:
✔ took an adequate history
✔ did an adequate exam
✔ had adequate knowledge
• clinical
• policies of authoritative medical organizations
• policies and procedures of the facility
✔ applied their knowledge appropriately
✔ made a reasonable diagnosis/differential diagnosis
✔ treated appropriately given the available resources
✔ The clinical notes and records should provide evidence of the care provided.
1-That is correct
The incident (prescribing another first-generation cephalosporin for a patient with life-threatening allergy to
cephalexin (also a first-generation cephalosporin)) was caught in time and did not reach (touch or enter) the patient.
Patients should be provided information and be encouraged to become knowledgeable about their clinical
conditions. Patients can be active members of the healthcare team.

2-That is incorrect
This term refers to events or incidents that reached (touched or entered) the patient but did not result in harm.

3-That is incorrect
This is not a recognized term but the concept is valid. Patients should be encouraged to voice concerns.

4-That is incorrect
A potential-for-harm event reached or entered the patient.

5-That is incorrect
Possible loss of trust is not a formal patient safety term. However, patients who believe their concerns are not taken
seriously may lose trust in their providers, hospital, or healthcare institution. If concerns have not been explored and
addressed appropriately, subsequent problems in care may increase the risk of a complaint or legal action. Patients
who are made welcome and thanked for raising questions and concerns are more likely to be allies than
adversaries.
1- That is incorrect
Physicians' fiduciary duty means they must act in good faith and with loyalty toward the patient and never place their personal
interests ahead of those of their patients.
Claims of a breach of fiduciary duty most often occur when it is alleged the physician has abused the trust within the doctor-
patient relationship by having an inappropriate sexual relationship or committing sexual misconduct.

2-That is incorrect

3-That is correct
In this case there was a claim of negligence based on the failure to meet the standard of care, including the failure to discuss
the complication with the patient.

4-That is incorrect
These claims are brought when it is alleged that the physician has breached an expressed or implied term of the agreement
that arises out of the doctor-patient relationship, usually an allegation that the physician failed to achieve the result
"guaranteed." This occurs most often in the context of cosmetic surgery.
A claim for breach of contract may also be advanced when it is alleged the physician, or someone for whom the physician is
responsible in law, has disclosed confidential information about the patient without proper authorization and in the absence of
being required to report the information by law.

5-That is incorrect
The Supreme Court of Canada has restricted such claims to those non-emergency situations where the physician has carried
out surgery or treatment on the plaintiff without consent, or has gone well beyond or departed from the procedure for which
consent was given. Assault and battery may also be committed where fraud or misrepresentation is used to obtain consent.
These claims are typically restricted to errors where the wrong operation is performed on the patient or the operation is
performed on the wrong patient.
1-That is incorrect
The law does not demand perfection. Medicine is not an exact science. Untoward results may occur even when the
highest degrees of skill and care have been applied.

2-That is incorrect
The weight given to published information depends on the testimony of peer experts as to its credibility, validity,
applicability, and degree of acceptance at the time of the care in question.

3-That is incorrect
The weight given to a clinical practice guideline depends on the testimony of peer experts as to its credibility, validity,
applicability, and degree of acceptance at the time of the care in question.

4-That is incorrect
The law recognizes that all treatment afforded a patient cannot have a successful outcome. Rather, a plaintiff (patient)
must establish on a balance of probabilities that an alleged breach of duty caused or contributed to the harm
sustained.

5-That is correct
The expert witness advises the court in what constitutes the care and skill that could reasonably be expected of a
healthcare provider with similar training and working in similar circumstances.
The expert does not act as an advocate for any party. The expert should ask whether the result could have happened
to others even when being reasonably careful. In formulating an opinion, it is a luxury to be able to review all the facts
in retrospect. Allowances must be made for hindsight bias.
CMPA :
Teams
 Objectives

❖ After completing this domain you will be able to:

I. Describe how teams can improve patient care.

II. Identify the principles of effective teams.
III. Explain the roles of the leader and members of a team.
IV. List what should be considered before delegating care to a trainee or another
healthcare provider.
V. List the responsibilities of a trainee when accepting a delegated task or decision.
VI. Explain how Canadian courts have viewed the accountability of individual providers
working in teams.
VII. Describe some of the lessons learned from medical-legal cases involving teams.
❖ Composition of healthcare teams
• The composition of a team is driven by the needs of the patient.

• A healthcare team comprises a patient and at least two healthcare professionals.

• The patient is not just a recipient of services but an integral part of the team with the right to be involved in
decisions about care.

❖ Scopes of practice
• Scope of practice is the range of healthcare tasks, decisions or activities of a qualified, licensed healthcare
professional (e.g. doctor, nurse practitioner, nurse, pharmacist) allowed by law and the provincial/territorial
licensing authority governing that profession.

• Healthcare professionals should understand the scopes of practice of those with whom they work.
❖ Roles and responsibilities
• When each member understands their own role and the roles of the other team members, they can share
responsibility and authority appropriately.
• Each individual's role is defined by that person's training and competency.
• Trainees may be part of the team and are expected to contribute to care at a level appropriate to their level of
training.

❖ Physicians on teams
❑ Several physicians may be on a team to provide treatment and follow up, and fulfill roles such as:
✔ most responsible physician
✔ consultant
✔ temporary replacement (e.g. night, weekend, locum)
✔ learner (student or resident)

❑ Each physician needs to know:

✔ the scopes of practice of team members
✔ their own role and responsibility
✔ the responsibility and expectations of the other physicians and team members
✔ possible interactions among their own treatments and those of others
❖ What makes an effective and safe team?
• Good teams understand their goals and objectives.

• Teamwork allows the team to improve its performance, optimize clinical outcomes, and reduce risk for patients.
 Characteristics of successful teams
❖ The workplace culture supports teamwork

❑ Team members focus on what is right for a patient and accept appropriate accountability.

❑ Team members do not prejudge the reasons for adverse events (accidents in Québec) or blame others; they treat
each other fairly, support each other, and view the team's performance and successes as group
accomplishments.

❑ In a culture that supports teamwork:

✔ team members have clear accountability and authority
✔ all strive for thorough care, attention to detail, and patient safety
✔ all members of the team are listened to
✔ the diversity of skills and knowledge is appreciated
✔ teams are resourced adequately
✔ tasks are distributed appropriately

❖ Roles and responsibilities are understood

❑ Good teams:
✔ define and understand the roles and responsibilities of individual members of the team
✔ understand how decision-making occurs
✔ distribute tasks appropriately
✔ understand what knowledge and skills need to be developed
✔ provide new team members with a proper orientation
✔ maintain appropriate supervision
 Characteristics of successful teams

❖ Good teams have good leaders

❑ It is important that teams have leaders so that decisions are made in a timely way and care is
coordinated. A team leader should welcome, encourage and acknowledge input from all of the
team members, including the patient. The leader is responsible for setting a collaborative tone and
encouraging every member of the team to speak up and contribute to quality care.

❑ The most responsible physician will not only be a member of the team but is often appropriately
the overall leader.

❑ Other healthcare professionals may become the leader for specific decisions because of their
knowledge and expertise in dealing with the patient's specific needs.

❑ Good team leaders:

✔ serve as role models for teamwork, provide motivation, and foster cohesion within the team
✔ structure and regulate team processes
✔ consult and listen
✔ ensure the team's goals are met
✔ prepare for the unexpected
✔ are aware of current situations (exhibit "situational awareness")
✔ learn from their experiences
 Characteristics of successful teams
❖ Good team members know their limitations

❑ Team members should consider their level of competence and comfort, and ask themselves whether their
personal skill set and training is adequate for a particular clinical situation.
❑ The physician has an obligation to refer the patient or to obtain consultation
I. when unable to diagnose the patient's condition,
II. when the patient is not responding to treatment or
III. when the required treatment is beyond the competence or experience of the physician.“
❑ However, because the clinical condition of a patient may evolve rapidly and unexpectedly, or if there are unusual
or life threatening circumstances or a lack of immediately required resources, team members may be required to
provide patient care that is beyond their usual clinical skills.

❖ Good teams communicate

❑ Effective team communication can make the difference between an adverse event and a good clinical outcome
for the patient.
❑ Communication within teams is challenging and can fail for many reasons:
✔ when team members do not actively listen to each other, the patient, and family
✔ when team members or providers have different communication styles or do not share a common vocabulary and
misunderstand each other
✔ when there is uncertainty or confusion about the roles and responsibilities of team members
✔ when hierarchies or behaviours interfere with conveying important information about the patient's medical
condition and status, or issues in care
 Characteristics of successful teams
❖ Avoiding communication pitfalls

❑ Poor communication can be resolved by holding briefings, using structured communication approaches, and
getting suitable training.
❑ Differences in terminology used between healthcare providers and across specialties are not uncommon and may
lead to confusion.
❑ Even more important are the frequent assumptions that a consultant will understand what is wanted, without an
explicit question or explanation of the clinical concerns.

❖ Good teams learn from adverse events and near misses

❖ Good teams train together

❑ Many teams benefit from training together:

✔ attending workshops and lectures
✔ real-time mentoring
✔ practising communication skills
✔ doing clinical drills and using simulators
❖ Delegating tasks

❑ Before accepting a delegated task, ask yourself:

✔ Do I have the knowledge and technical skill to do it?
✔ Has the patient consented to my doing it?
✔ Do I understand the expectations of the supervisor?
✔ Do I know what might go wrong?
✔ Do I know what to do if problems arise?
✔ Have I communicated any concerns to the supervisor?
If the answer to any of these questions is "no," the task should not be accepted.

❑ As a staff physician or resident, ask yourself the following questions before delegating a task or decision:
✔ Is this task or decision within your own competence?
✔ Have you considered the level of training of the student or resident?
✔ Does the task or decision need to be delegated or is the healthcare professional acting within his or her scope of
practice and does not require supervision?
✔ Is the individual accepting the delegation capable and competent to perform the task?
✔ Have you made your expectations clear?
✔ Are the indications and contraindications understood?
✔ Is there a plan to deal with unexpected events?
If the answer to any of these questions is "no," the task or decision should not be delegated.
 Case: Limited knowledge

• Background
A patient has a central venous pressure (CVP) line post-operatively. The attending surgeon asks a senior resident
to see the patient and remove the line.
A medical student in clinical clerkship goes along, and when the resident is delayed outside the room, the student
decides to help the patient move from a chair to the bed.

• Outcome
The CVP line is in the way so the clerk disconnects it.
The patient suffers an air embolism and severe stroke. Subsequently she and her family launch a lawsuit naming all
of the healthcare providers involved, including the student.

• Lessons learned
Peer experts determined:
• It was appropriate for the surgeon to delegate the removal of the central line to a senior resident.
• The resident did not delegate this care and so was not responsible for the harm done.
• The student chose to perform the act but did not have the knowledge or skill to do it safely.
• The student was therefore responsible for the harm to the patient.
 Supervision

• The person delegating a task may have a responsibility for supervising the delegate, especially in a training
situation. While it is important for trainees to gain independence, patient safety is equally important.

• Supervisors should consider all the factors related to delegation, including the delegated person's training level
and experience and what is the appropriate level of monitoring for this individual.
❖ Potential medical-legal risks for teams
❑ While teams deliver care, individual team members are responsible, accountable, and therefore potentially liable
for their role in instances of patients suffering harm.
❑ Individual team members must have and maintain adequate liability protection.
❑ If teams are unable to answer the following questions they may pose significant clinical risk for patients and
increased medical-legal risk for individual providers:
✔ What are the anticipated health outcomes for the patient?
✔ Is the patient an integral member of the team?
✔ How will the team manage expectations of patients and respond to their concerns?
✔ Are the roles and responsibilities of individual team members clearly defined, based on their scopes of practice
and on each person's knowledge, skill, and ability?
✔ Do all team members know their respective roles and the roles of the other team members?
✔ How will decisions be made? Who is responsible — and accountable — for care delivery decisions?
✔ Is a quality assurance mechanism being used to monitor the functioning of the team and health outcomes?
✔ Is a policy and procedural framework in place to define and support the team?
✔ Does the team have sufficient resources to achieve the desired health outcomes?
✔ Who will coordinate care, manage the team, and ensure efficient and effective communication among team
members and across teams?
 Case: An obstetrical team
• Background
A 36-year-old mother is admitted in active labour. The attending obstetrician ruptures her membranes, assesses the fetal heart
tracing as normal, and asks to be notified when the patient is ready to deliver.
The case room is very busy and the head nurse assigns a young, recently graduated nurse to monitor the patient — despite the
junior nurse's pleas that she is uncomfortable monitoring fetal heart tracings.
Immediately on arriving at the patient's bedside, the junior nurse notes the fetal heart tracing shows marked decelerations. As she
has been taught, the junior nurse turns the patient on her side and administers oxygen, however, the tracing continues to show
marked decelerations.
Two hours later the head nurse remembers to check up on the junior nurse and her patient. The supervisor immediately requests
a scalp electrode to better assess the fetal heart rate. The obstetrical resident applies the scalp electrode, diagnoses severe fetal
distress and arranges for an immediate C-section.
The crash section occurs within 20 minutes, however the child is born with a severe anoxic brain injury.
• Outcome
The child and family launch a lawsuit naming everyone on the obstetrical team, alleging that the failure to react to the abnormal
tracing lead to the delay in delivering their child and ultimately caused the brain damage.
The hospital alleges the physicians should have verified that the nurses were monitoring the fetus.
• Think about it
Should the physicians have been supervising the nurses?
Did the nursing supervisor appropriately delegate to the junior nurse?
Did the nursing supervisor adequately supervise the junior nurse?
• Lessons learned
The judge concluded the following:
✔ Each member of the obstetrical team had a defined role. It is essential that each person's role be carried out within a
standard of care and training appropriate to that role.
✔ Nurses are professionals who possess special skills and knowledge and have a duty to use their skills in making appropriate
assessments of patients and to communicate those assessments accurately to physicians.
✔ Limited resources preclude the ability of every provider to double-check the work of other providers.
✔ An obstetrician in a hospital setting is entitled to rely on staff nurses to monitor and assess a woman in labour and the fetus.
✔ The head nurse on an obstetrical team has the obligation to supervise other nurses on the team and to ensure that they are
competent to assess patients and to cope with the workload placed on them.
✔ The head nurse was made aware of the junior nurse's lack of experience.
✔ The head nurse failed to perform her assigning and supervisory duties in accordance with an appropriate standard of
nursing care.
 Case: New equipment for a team

• Background
An interventional radiologist has considerable experience with the balloon angioplasty technique, but is using a new
catheter for the first time to treat a patient's subclavian steal syndrome.
The new catheter is advanced in the patient's artery, however, the balloon does not readily inflate. Manipulation is
unsuccessful and the physician specifically asks the nurse if she has removed the balloon sheath. She says she has,
but the sheath has fallen on the floor, out of sight.
The patient returns to the hospital months later, with neck pain and headache. Investigations reveal the balloon sheath
lodged in the artery and it is surgically removed. The patient experiences post-operative complications and is left with a
significant scar.
• Think about it
What are some of the risks associated with working with unfamiliar equipment or in unfamiliar environments?
What are some of the barriers to effective team function?
• Lessons learned
There are a number of risks and barriers associated with this case.
I. Lack of orientation in the use of the new equipment.
In this case, the radiologist and nurse did not familiarize themselves with the new catheter.
II. Inadequate information sharing, faulty assumptions, defensiveness.
In this case, the nurse did not indicate she could not find the sheath as she assumed it had fallen under a drape
or onto the floor.
III. Complacency, failure to monitor each other's performance, lack of situational awareness.
In this case, the radiologist accepted assurances the sheath had been removed even though it could not be
found.
 Case: Psychiatric team caring for a suicidal patient

• Background
An 18-year-old student is depressed and has suicidal ideation. He is admitted to a psychiatric facility for treatment
following an examination by the psychiatrist.
The physician prescribes an anti-depressant medication and orders close observation which means the young man
will be seen every 30 minutes. A team comprising a psychologist, nurses, a social worker, and the psychiatrist will be
caring for the patient.
As is often the case, it is extremely busy on the psychiatric ward. The hospital policy states that an "intake conference,"
intended to orient all of the team members to a patient, should occur for each admitted patient, but this does not
happen.
The patient's room is at the end of the corridor, away from the nursing station, so it is difficult for nurses to observe his
behaviour.
The patient refuses to take the oral anti-depressant and generally does not communicate with the team members.
While any member of the team could increase the level of observation to "constant," and although they are all
concerned, none of the team members does so.
The patient's aunt alerts the duty nurse that the patient has told her how he could commit suicide while in the hospital.
She neither records this information in the medical record, nor alerts other members of the team.
• Outcome
The next day the teenage patient crashes through the glass window of his hospital room, runs across the parking lot
and is hit by a car.
He is left paraplegic and requires continuous care.
• Think about it
What are some of the barriers to the effective functioning of the team that might have played a role?
 Case: Psychiatric team caring for a suicidal patient
(continued)

• Legal action
The family launches a lawsuit, naming each member of the team.
The allegations include:
1- incorrect diagnosis
2- failure of the team to hold an intake conference
3- failure to increase the level of observation
4- inadequate strength of the window glass in the facility
• Legal outcome
The psychiatrist was found negligent for having misdiagnosed the severity of the patient's psychiatric
condition.
Each member of the team was found negligent for failing to increase the level of observation of the patient.
Each member of the team was held accountable in the failure to hold the intake conference.
The judge was also critical about the lack of documentation in the medical record.
• Lessons learned
This case highlights several issues in healthcare:
1. workload and resource issues: lack of beds close to the nursing station, distractions among the team
2. lack of documentation
3. lack of communication of critical information between team members
4. lack of coordination of care across the team: each team member had the ability to increase the level of
observation of the patient, but no one did
5. inadequate hospital policy: while the policy stipulated an "intake conference" should occur, it did not specify
who was to arrange the conference, and this lack of clarity resulted in no one arranging the meeting
 Case: "This isn't a surgical problem"

• Background
A patient with a past history of Crohn's disease develops abdominal pain. Specialists in medicine, gastroenterology
and surgery assess him. CT scanning is initially reported to be inconclusive. The resident in surgery declares that
"this isn't a surgical problem."
The patient continues to deteriorate, but the first-year resident cannot convince the surgical service to reassess him.
The internist does not respond to the resident's pleas, and also has great difficulty getting the attention of the surgical
service.
• Outcome
Only when the resident becomes more forceful and demanding that a surgeon attend, does the surgeon arrive and it
becomes clear that this is indeed a surgical problem.
The patient subsequently has a stormy post-operative course but survives.
• Lessons learned
The assertiveness by the resident and the internist that the patient needs urgent intervention is an example of
appropriate advocacy on behalf of the patient that should be respected and trigger a suitable response.
1-That is incorrect
This was not the issue in this case. However, if there are resource constraints, healthcare providers are expected to do
the best they can for patients and to act reasonably in such circumstances.

2-That is incorrect
Although clinical situations exist that warrant ordering constant observation of specific psychiatric patients, it would not
be appropriate or possible to constantly observe every patient.

3-That is correct
Collaborative practice has many benefits for patients, but also reinforces the need for a team to communicate concerns
with each other. The method of communication should match the perceived urgency and seriousness of the clinical
situation.
It is important to take advantage of all the information available. For example, the nursing notes in the medical record
can be a valuable resource.

4-That is incorrect
Research shows suicide is difficult to predict. However, better communication by the healthcare team and the use of
suicide risk assessment tools might have made a difference in this case.

5-That is incorrect
There is a better answer. An existing policy and procedure was in place and was not the issue in this case. However
sometimes policies and procedures may require review and improvement.
1-That is incorrect
A resident will generally be held to a standard of care appropriate to the level of training received, experience, and the situation.
The courts have stated that a medical trainee must not fail to understand one's own inexperience, lack of knowledge, and lack
of skill. Residents who seek guidance and advice in a timely way can reduce medical-legal risk and liability.
The courts have also recognized the attending physician may be indirectly liable for failing to take reasonable steps to ensure
that the resident was properly supervised. In the event of litigation, the supervising physician will be held to a standard of care
that could reasonably be expected of a normal prudent physician in the circumstances.

2-That is incorrect
Given that surgery was significantly delayed in this case, the extent of the infarcted bowel was likely greater. Early intervention
by the senior resident or staff surgeon would likely have been helpful in this case.

3-That is incorrect
Residents may be named in legal actions. In some legal actions, plaintiffs (patients) have stated they did not understand who
was treating them and the roles of each member of the team. When patients feel as if no one is in charge of their care, they
may become frustrated.

4-That is incorrect
Departments usually have policies that outline the expectations for supervision by attending staff physicians. The timing of
assessment by a staff physician will depend on the perceived urgency of the clinical condition.
Some departments or individual staff physicians may establish a set of triggers to help residents know when to contact the
attending physician about clinical matters.

5-That is correct
Despite several years of training, residents may not yet have gained sufficient knowledge or experience to fully address the
clinical needs of some patients. Consequently they depend on more advanced residents and staff physicians for guidance and
advice.
Staff physicians or senior residents that delay assisting a resident when contacted, or avoid direct assessment as required, run
the risk that if the clinical condition worsens or becomes critical, the patient and family may perceive that there was insufficient
supervision and the quality of care provided was poor. A court may agree.
1-That is correct
If important information is not shared poor outcomes may result. It appears in this case that the nurses were reluctant
to voice concerns about the changes in FHR with more senior members, especially after being rebuked by the
resident. This probably delayed the recognition of the fetal distress in this case. A provider is expected to act in the
best interests of the patient.

2-That is incorrect
The nurse continued to observe the patient, noting the progress and her concerns in the medical record. In this case,
these concerns were not relayed to the resident after he rebuked the nurse. This may have been a factor leading to the
poor outcome.

3-That is incorrect
Although non-specific, certain FHR rates and patterns are considered predictive of intrapartum fetal hypoxia. However,
the ongoing abnormalities were not shared among team members so these could be appropriately addressed.

4-That is incorrect
The C-section was delayed due to a failure in communication. Once the team identified the requirement for C-section,
this was arranged and accomplished quickly.

5-That is incorrect
Uterine rupture is rare and often catastrophic.
 CMPA :
Communication
 Objectives

❖ After completing this domain you will be able to:

• Describe patient-centred communications.

• Explain the importance of privacy and confidentiality.
• List the components of informed discharge.
• Identify the characteristics of effective team communication.
• Discuss the importance of handovers and barriers to effective handovers.
• Explain 3 characteristics of an ideal consultation report.
• State 3 ways in which documentation promotes safe care and reduces medical-legal
risk.
❖ Barriers to understanding

❑ Health literacy
• Patients seek medical care because they have concerns. Anxieties and fears may affect the way patients think and
express themselves. Health literacy and the ability to understand healthcare information will vary from patient to
patient and may be less than expected, potentially leading them to misinterpret information.

❑ Non-verbal clues
• Communication is more than just what is said. A patient's hesitancy, tone of voice, facial gestures, and body
language can all be indicators of potential misunderstanding. A physician in tune with these clues will try to clarify
the meaning. Of course, it is important to avoid using a tone or gestures that might offend the patient.

❑ Gender
• Physicians need to be aware of the potential discomfort male patients may experience with female physicians
and vice versa. Carefully explain to the patient the reasons for potentially sensitive questions or physical
examinations.

❑ Cultural and language barriers

• In Canada, patients and physicians come from many different cultures. It is possible to unintentionally offend by
missing clues or misunderstanding a cultural viewpoint.
• A patient may seem to be fluent in the doctor's language, but if it is the patient's second or third language there may
be gaps in understanding. In such circumstances, it may be appropriate to use a trusted interpreter. Physicians
should however be wary about using friends or family members, whose interpretation may be influenced by their
own views of the discussion. For instance, a family member might be embarrassed to translate your questions about
sexual activity, and the patient might be reluctant to reveal the truth.
 Case: Miscommunication with a mother

❖ Background
A two-year-old child is brought to his family physician with a fever, cough, and tachypnea. After a careful history
and a thorough physical examination, the physician orders a chest X-ray which confirms pneumonia. The physician,
who is very rushed, prescribes an antibiotic and succinctly informs the mother to follow up in 2 to 3 days .
The mother believes the physician was not listening to her concerns and does not have confidence in his
recommendations. She takes her child to see another physician the same day. The second physician
independently arrives at the same diagnosis and prescribes the same antibiotic.
The child's mother complains to the medical regulatory authority (College) that the first doctor did not listen to her
concerns and, as a result, she was forced to see a second physician.
❖ Outcome
The College reviewed the medical record created by the first physician and concluded the examination and treatment
were appropriate.
The College reminded the physician that his failure to communicate effectively with the child's mother left her
feeling unsure of the diagnosis and unaware of the rationale for his recommended treatment.
 Case: Impatience with a new patient

❖ Background
A 33-year-old male with a long history of drug abuse attends an appointment with a new physician. He indicates he
is taking Methadone prescribed by another physician. The patient speaks despairingly about previous physicians he
had consulted and indicates he wishes to stop all his medications immediately.
The physician advises him not to do this due to potential life-threatening withdrawal symptoms. She recommends that
the patient follow up with his previous doctor to determine a plan to discontinue the Methadone.
The patient complains to the College that the physician was rushed, impatient, and lacked appropriate knowledge
about addiction and treatment options.
❖ Outcome
The physician admitted she was impatient with the patient but also stated she had tried to develop a working
relationship to no avail.
The College dismissed the complaint but reminded the physician of the importance of patience when
communicating with patients.
Case: Cancer patient declines to sign consent form for
surgery

❖ Background
An overall healthy man with a history of hemorrhoids presents to his family doctor due to streaks of blood in the
stool. An investigation reveals bowel carcinoma. The patient is referred to a surgeon. Following a consent
discussion for partial bowel resection, the patient refuses to sign the consent form.
❖ Think about it
What should you do if a patient declines to sign a consent form?
❖ Suggestions
There may be several issues to deal with:
I. Concerns: Despite the explanations of the risks and benefits of the proposed treatment, does the patient
have unanswered questions about the surgery? Further explanations may help.
II. Signing a form: The refusal to sign may be related to apprehension about signing a legal form. An
explanation about the reason for the form may alleviate the patient's concerns.
III. Barriers: If a language barrier exists, a family member may be asked to translate (with the patient's
permission), or a translation service may be used. Consider whether additional supports for those with visual,
hearing, or other impairments are required.
IV. Culture: Try to be sensitive to the cultural background of your patient. Because communication styles vary
across cultures, consider seeking advice from those knowledgeable in a particular culture.
Any discussions with the patient and the patient's decision should be documented in the medical record.
 Overcoming barriers

❖ Common complaints to medical regulatory authorities (Colleges)

The doctor... , didn't listen , was rude , ignored my concerns , discriminated against me

❖ Etiquette-based medicine simply means bringing politeness into the patient interview. Even before asking about
the patient's condition or feelings, remember to:
• Knock on the door and announce yourself prior to entering an examination room.
• Introduce yourself and state your level of training.
• Sit down to face the patient.
• Explain your role in the patient's care.

❖ Politeness also means paying attention:

• Listen actively
• summarize or paraphrase the patient's statements
• try to make eye contact.
• Don't check your mobile device for email.
• Write any notes unobtrusively.
• If you refer to the medical record, explain what you are checking.

❖ Good etiquette means;

• Not offending by word or action.
• Don't roll your eyes, sigh audibly, or laugh when patients have unusual or unscientific beliefs.
• Always let the patient know your intentions, whether asking personal questions or touching patients during a
physical examination.
 Uncomfortable situations
❖ When the news is bad
Not all medical news is good news. Bad news needs to be delivered with compassion and empathy. Physicians can
make it easier by using the SPIKES format:
I. Setting — private and calm
II. Perception — what does the patient think?
III. Invitation — how much does the patient want to hear?
IV. Knowledge — after explaining, what does the patient understand?
V. Empathy — acknowledge every emotion that arises
VI. Strategy — set out the next steps

❖ When there's disagreement

Patients may sometimes have expectations that can't be met. They may be disappointed or angry, and may become
aggressive and threatening.

❖ Physicians have a professional responsibility to stay above the fray:

i. Keep calm.
ii. Explain the facts and situation rationally.
iii. Offer possible solutions.
iv. Do not try to intimidate the patient or allow yourself to be intimidated.
v. Consider asking your supervisor or a colleague to help defuse the situation.
vi. If there is no way to resolve the issue, end the interview politely.
vii. Record the facts objectively and without emotional language.
 Case: A demanding and concerned mother

❖ Background
A woman attends the emergency department with her 18-month-old child, who has a cough. She states at the
outset that she wants a prescription for antibiotics.
The exam reveals a healthy-looking child with an occasional cough, no fever, and an otherwise completely negative
exam. The doctor explains this to the mother, and says that antibiotics are not indicated.
The mother becomes angry and insists that her child needs the antibiotics. Other modalities for treatment are
suggested, but finally the mother says she will sue the doctor and have his medical license revoked. She refuses
further examination or assessment by a colleague and storms out. The doctor writes a note in the medical record.
❖ Outcome
The College notifies the doctor of a complaint. The College reviews the medical record and the response from the
doctor. It concludes the doctor has given medically sound advice and has treated the patient and the mother politely.
The complaint is considered groundless and is dismissed.
❖ Confidentiality is:

✔ a cornerstone of medical ethics

✔ fostered by Canadian law
✔ important to patient safety

❖ Confidentiality encourages the patient to provide the doctor with all relevant information. This helps the physician
to determine the diagnosis and treatment, and reduces the possibility of harm for the patient.
 Circle of care

❖ The "circle of care" is the group of healthcare providers treating a patient who need information to provide that
care.

❖ Consent to share information with providers in the circle of care is generally implied. A patient who accepts a
referral to another healthcare provider implies consent for sharing relevant information. This includes sharing with
physicians and other healthcare providers who are caring for the patient, but does not include others such as
family, friends, police, and so on.

❖ Express consent is required to share information with others outside the circle of care.

❖ Only the province of Québec has an "age of consent," set at 14 years of age.
 Case: Sharing health information with family

• Background
A father is scheduled to see you immediately following his 15-year-old daughter's appointment. At her visit, the
daughter requests a prescription for the birth control pill (BCP).
After taking her sexual history, counseling her about sexual health issues and explaining the risks associated with the
BCP, you write out the prescription. During the father's visit, he asks you whether his daughter is sexually
active.
• Think about it
What would you tell him?
• Outcome
The father is not within the circle of care in this case. If a patient is able to provide informed consent for treatment,
the patient should also authorize the release of her confidential health information.
An adolescent's expressed wish should be respected.
 Mandatory reporting
❖ In Canada, provincial, territorial and federal statutory requirements mandate that physicians must report
specific patients to the appropriate agencies.

❖ In some instances if the physician fails to report confidential information to a public authority and thereby fulfil the
statutory obligation, the physician may be prosecuted, fined, or face imprisonment.

❖ Some examples of mandatory reporting situations include:

I. a child in need of protection (to prevent physical, sexual, or emotional harm, or abandonment)
II. concerns about a patient's fitness to drive (e.g. cars, airplanes, trains, boats — requirements vary by province or
territory)
III. patients with certain communicable diseases
IV. If a physician has reason to believe a child is in need of protection, the physician is responsible for seeing that the
appropriate authority is informed in a timely manner.
V. The child should not be put at risk by any delay or delegation of the act of reporting.

❖ Every Canadian province and territory has enacted legislation requiring physicians to report children who may be
in need of protection, including instances of suspected child abuse, to the child welfare authorities or the
equivalent agency in the province or territory. The duty to report is mandatory even though the information
reported may otherwise be confidential.
 Case: Mandatory reporting of suspected child abuse

• Background
A father brings in his four-year-old child because the child is not weight bearing following a "fall from a swing."
X-rays of both lower extremities reveal a new fracture and other healing fractures. The father denies the child has
ever been injured.
• Think about it
In addition to providing clinical care for the fracture, what is your best next step?
• Outcome
Report your suspicion that the child may be in need of protection to the child protection authorities. The purpose is
protection, not accusation. The authorities will investigate further.
 Sharing information

❖ Consent for release:

I. Implied consent
Much of a health professional's work is done on the basis of consent which is implied either by the words or the
behaviour of the patient or by the circumstances under which treatment is given.

II. Express consent

Express consent may be in oral or written form.
When there is doubt, it is preferable that the consent be expressed.

✔ A patient might ask for a note excusing her from work. Handing the note to the patient allows her to control its
distribution. Alternatively, providing the note directly to the patient's employer can be done on the basis of implied
consent.

✔ Express consent, usually in writing, should be obtained for most personal health information sent directly from the
doctor to a third party (insurance company, an employer, etc.). If the information is sensitive, or the patient may
not be aware of the contents, the doctor may wish to confirm that the patient understands what information will be
divulged.
 Sharing information

❖ Public Safety

Arising from the decision by the Supreme Court of Canada in the landmark case Smith v. Jones, physicians are
permitted to disclose confidential information to the relevant authorities in the interest of public safety if all of
the following conditions are present:
I. There is a clear risk to an identifiable person or group of persons.
II. The risk is one of serious bodily harm or death.
III. The danger is imminent.
Physicians are encouraged to seek specific advice and legal counsel in individual situations concerning the
appropriateness and scope of disclosure of information relevant to public safety.
 Case: Threat of harm

• Background
A patient tells you he was fired unfairly. As he talks to you, he becomes more and more agitated, finally declaring "I'm
going to make my boss wish he'd never seen me."
You ask the patient to elaborate and he tells you he's going to make a car bomb and set it off at the workplace
during working hours. He convinces you he knows how to make a bomb and bolts from the office.
• Think about it
What would you do next?
• Suggestions
This would appear to be an imminent, credible risk of serious bodily harm to a recognized group of individuals.
Canadian law permits you to take steps to warn the potential victims (e.g. the plant manager) or the police. Only
the facts relevant to the warning should be divulged. You should seek legal advice on how to proceed if you believe
time permits.
 Breaches
❖ Most breaches of confidentiality are unintentional
– unguarded conversations
– misdirected documents

❖ Some breaches are deliberate

– unauthorized access

❖ A healthcare provider who is unclear about whether she should access patient information should ask herself
two questions:
1. "Do I need this information to provide care to this patient?"
2. "Do I have the patient's consent, implied or expressed, to access this information?"
If the answer to either question is not certain, it would be prudent to obtain express consent first.

❖ Possible consequences of breaches:

I. for the patient:
– embarrassment, social stigma, loss of job, increased stress, and in some cases worsening mental illness
II. for the physician:
– complaints to hospital, College, privacy commissioner
– legal action
III. for students:
– complaint to your medical school
– legal action
 Case: Treating multiple members in a family

• Background
A young woman is applying for insurance. She asks her family physician to complete the attending physician's
statement, as requested by the insurance company.
In the statement, the physician includes the family history of diabetes, as he knows the patient's mother
suffered from the condition.
The insurance company writes back asking for more information, specifically for the diabetic family member's
relationship to the applicant.
• Think about it
Would providing the information about this patient's mother breach the mother's confidentiality?
• Outcome
If the patient had not revealed the family history of diabetes but the physician was aware of the mother's diabetes only
because the mother was also his patient, he cannot reveal the information to the insurance company without the
mother's consent.
In this case, the family physician was free to release the information to the insurance company because the daughter
had informed him about her mother's condition and he had placed the information in the daughter's file.
• Lessons learned
A significant advantage in family medicine is that the physician is often aware of the medical histories and social
circumstances of each member of a family. However, when releasing an individual patient's health information — with
the consent of the patient — to a third party, the family physician can reveal only information obtained directly
from that patient.
 eCommunication

❖ What does eCommunication mean to you?

More than you might think: apps , big data , telemedicine , email , EMR/EHR , online forums , patient portals , social
media , Texting

❖ Communicating with patients electronically

✔ Many patients want it

✔ Can improve efficiency of care: scheduling, reminders
✔ May save time and unnecessary visits
✔ Can foster patient engagement

❖ Communicating with colleagues electronically

✔ Many colleagues want it

✔ Perceived to be a more efficient means of communication : compared to paging or telephone calls
✔ Sharing forum for medical education
✔ Facilitates remote consultations
 Case: A misdirected email

• Background
A 55-year-old woman with cough and dyspnea sees her family physician before travelling for business to a remote
part of Canada. The physician orders chest X-rays, and it is agreed that the results will be communicated to the
patient by email.
• Clinical events
The X-rays reveal a moderately-sized pneumothorax of the right lung and suggest the possibility of an underlying
neoplasm. The radiologist dictates an urgent report, which is flagged in the family physician's electronic medical
record. The family physician sends an email describing the X-ray findings and advising the patient to go to the
emergency department.
• Outcome
The email is mistakenly sent to the patient's ex-husband, who sees the message only the following day. He then
informs the patient of her diagnosis and the need for urgent follow-up. Fortunately, the patient is seen prior to her
planned trip and does not experience any harm as a result of the delay.
• Think about it
What are the risks of communicating with patients via email?
Is it appropriate to deliver bad news or a serious diagnosis by email?
• Lessons learned
Establish and document a plan with patients regarding electronic communication. Clarify expectations and
discuss the risks of using emails or text messages with patients, taking into consideration whether the means of
communication to be used is secure. Even if the patient's consent is obtained, the physician is still obligated to
protect the patient's privacy. Physicians should ensure that their office staff are trained on privacy requirements, and
that contact information for patients, including email addresses, is confirmed on a regular basis.
Finally, keep in mind that sensitive or urgent information may be more appropriately communicated in person
or by telephone.
 Case: Think before sharing clinical photos

• Background
A 32-year-old recreational hockey player is diagnosed with a comminuted tibial fracture. He is assessed by a
medical student doing a rotation in the emergency department. She sends a photo of the initial X-ray via text
messaging to her fellow classmates for its teaching value. She fails to notice that the patient's demographic
information is visible on the photo.
• Follow-up
The patient is seen again one week later in the orthopaedics clinic by a different medical student. He incidentally
mentions to the patient that he had already seen his impressive X-ray by text message the previous week.
• Outcome
The patient is very upset that his medical information was shared without his consent and files a complaint against
the first medical student to her school.
The medical student is required to write an essay about the importance of patient privacy and a reprimand is
officially documented in her academic record.
• Think about it
How might sharing a photo of a patient's X-ray, rash, or other clinical findings constitute a breach of confidentiality?
What strategies could the medical student have used to prevent this complaint?
• Lessons learned
Prior to sharing, consider whether the recipient of the shared information is in the circle of care. When sharing
identifiable information outside the circle of care or for purposes other than providing care, it is generally necessary to
obtain patient consent. Not doing so could result in a privacy breach with serious consequences.
When sharing using social media, be mindful that even de-identified medical stories or photos might be identifiable by
others through metadata. If you have any doubts, consider obtaining express consent from the patient.
 eCommunication
❖ eCommunication checklist
i. Is the communication within the circle of care?
ii. Is explicit (written) consent of the patient required?
iii. Is the information secure (encrypted)?
iv. Is your device password-protected?
v. What are the relevant regulatory standards?
vi. Is only essential information being shared?
vii. Is person-to-person communication more appropriate?

❖ Privacy considerations
• Physicians who communicate via email, text, social media, or web portals need to be mindful they are governed
by the same legal and professional standards as would apply in other professional settings (e.g. a hospital
setting, family practice, or clinic).
• Relevant regulatory standards include federal, provincial or territorial privacy legislation, or guidelines published
by medical regulatory authorities (Colleges).

❖ Encryption: protecting information

• Physicians have an obligation to protect the confidentiality of their patients' personal health information and to
comply with privacy requirements.
• Privacy regulators agree that the use of appropriate encryption software to protect electronic messages is a
reasonable safeguard under the circumstances.
• Various enterprise solutions (e.g. patient portals) can provide encryption, and an increasing number of encryption
applications are available for use on personal devices such as smartphones.
 eCommunication
❖ Obtaining patient consent
⮚ Physicians considering using unsecured or unencrypted email or text messaging should do so only for information
that does not include identifiable personal health information (e.g. scheduling, reminders). When doing so with
patients, patients should agree to:
i. how these messages will be used
ii. the type of information that will be sent
iii. how the emails or texts will be processed
iv. the risks of using email or text messages
⮚ The discussion and patient's agreement should be documented in the medical record. Nevertheless, obtaining the
patient's consent or using disclaimers in emails does not obviate a physician's legal and professional obligations
to reasonably protect patient health information. Physicians should similarly ensure their office staff are trained on
privacy requirements and have signed confidentiality agreements.

❖ When talking might be a better option

• Finally, there are times when face-to-face (or at least person-to-person) communication may simply be more
appropriate. Examples include conveying sensitive test results to patients or transferring patients requiring more
complex care to a colleague, where interpreting nonverbal cues or giving feedback may be essential to the
interaction.
❖ Why and when do we need consent?
❑ Patient autonomy — the right to make one's own health decisions
❑ "Treatment" is more than surgery

The principle of patient autonomy applies to all treatment, whether medical, surgical, or investigative.
Discussion with the patient and consent from the patient are needed for situations such as:
• physical examinations (entails touching)
• taking blood
• injecting vaccines or other drugs
• exposing the patient to radiation as a part of investigation
• medications including interactions with other drugs
The doctor's role is to give good advice — it is the patient's right to accept or reject that advice.

❖ Legal principles

• Legal actions are usually based on claims of negligence (professional civil liability in Québec).
• Allegations often include assertions that the consent discussion was inadequate.
 Why and when do we need consent?

❖ Reasonable patient standard

• Walk in the shoes of your patient.

The adequacy of consent explanations is judged by the "reasonable patient" standard, that is, what a
reasonable patient in the particular patient's position would have expected to hear before consenting.

❖ Express and implied consent

• Most patient care is based on implied consent.

• Express consent can be verbal or written.

Consent is often implied either by the words or the behavior of the patient, for example by volunteering a
history, answering questions, or submitting without objection to physical examination.
When the reason for examination may be misunderstood, as with rectal, vaginal, or breast examinations, it
may be prudent to state the intention in advance.
When treatment may cause more than a little pain or carry significant risk, the patient should be asked to
express their consent.
A note in the patient's record may be adequate to document consent, but in some circumstances it may be
wise to obtain written consent.
 Three key elements of consent

❖ For consent to be considered valid:

1) it must be voluntary
2) the patient must have the mental capacity to consent
3) the patient must be properly informed

1. Voluntary consent
I. Patients must be free to consent to or refuse treatment.
II. Consent should be obtained without duress or coercion.
 Case: A patient brought by the police

• Background
The police bring a man from the airport customs to an emergency department and request that you do the
appropriate examinations to determine if the man is trafficking in cocaine. The police suspect he has swallowed the
drugs in condoms. Your patient does not give consent for the examinations.
• Think about it
As the emergency physician, what is the best next step?
• Suggestions
In this case, the physician should explain the grave risks if a condom containing cocaine ruptures internally. The
patient might then consent to examination.
In these types of circumstances, physicians should be more careful than usual to assure themselves the patient is in
full agreement with what has been suggested, that there has been no coercion (for example, by exaggerating
the risks of consenting or of refusing) and that no one else has imposed their will on the patient.
 Case: A 55-year-old man scheduled for colonoscopy

• Background
A gastroenterologist meets a patient for the first time immediately before a screening colonoscopy. He describes
the list of potential risks for colonoscopy and requests the patient sign the consent form before proceeding.
• Think about it
Is the patient consenting voluntarily?
• Suggestions
Ideally the patient would be provided information about the nature and risks of an investigation as early as possible in
the process. While timing is important when engaging in a consent discussion — especially for an elective procedure
— the practical realities of providing care to all patients in an efficient way may make this difficult.
In this case, the patient has already made the decision to undergo the procedure and has completed the
required preparation. Despite this, the patient is entitled to engage in a full discussion and should not be made to feel
obliged to continue with the investigation.
 Three key elements of consent

2. Capacity to consent
A patient is considered to have the capacity to consent if he or she understands the:
i. nature of the proposed investigation or treatment
ii. anticipated effect of the proposed treatment and alternatives
iii. consequences of refusing treatment

❑ Patient understanding
• Take reasonable steps to be satisfied the patient comprehends the consent discussion.

By engaging in dialogue with the patient, a physician will be reasonably confident that the patient appears to
understand the explanation of consent. One way to achieve such confidence is the teach-back technique: asking the
patient to re-phrase what they have just been told and inviting the patient to ask questions.

As appropriate, a physician may wish to encourage a patient to invite a family member or friend to attend the
discussion.

❑ Patients who refuse treatment

• A capable patient has a right to refuse to follow the advice given.
 Case: A patient with skin cancer

• Background
Mr. Jones, a successful tax accountant, has been diagnosed with an invasive melanoma. His dermatologist wishes to
excise the cancer as soon as possible. Despite being informed of the risks, Mr. Jones insists on delaying the
surgery by four months so he can continue to work during his busiest time of year.
• Think about it
What is the dermatologist's next step?
• Suggestions
Even when faced with an serious operable cancerous lesion and the strong likelihood of a good surgical outcome, a
mentally capable patient may instead choose a less effective treatment than what is recommended, despite a thorough
discussion of the risks and benefits of surgery. This is the patient's right.
Mr. Jones should be told about the consequences of leaving the condition untreated. Although there should be no
coercion (i.e., unduly frightening patients who refuse treatment), the courts now recognize there is an obligation to
inform patients about the potential consequences of refusing treatment.
The dermatologist may wish to advise the patient to discuss with his family about the decision to delay the
surgery. If the patient persists in wanting to delay the surgery, consultation with a colleague for a second opinion
may be helpful.
 Three key elements of consent

❖ Minors

❑ Except in the province of Québec, the criterion for capacity to consent is maturity, not chronological age.
❑ A child must be able to appreciate the nature and consequences of their decision.
❑ Report to child protection authorities if a parent/guardian refuses medically necessary treatment.
❑ In Québec, the parent/guardian must consent if the child is under the age of 14.

✔ A young person is considered capable of consenting or refusing treatment (i.e. a mature minor) if the physical,
mental, and emotional development of the person will allow for a full appreciation of the nature and
consequences of the decision.

✔ Only Québec has established a fixed age of 14 years, below which the parent or guardian or the court must
consent to the proposed treatment.

✔ Generally, a capable minor would need to consent to the involvement of parents in healthcare decisions.
Depending on the nature of the medical condition and the complexity of any proposed treatment, it is often
prudent to stress the importance of involving the parents, and to obtain permission to do so.
 Case: A request from a youth
• Background
A 14-year-old girl comes to see you to ask for a prescription for birth control pills. You find her to be very mature
and sensibly wanting protection.
• Think about it
Can this youth consent to treatment or must her parents be involved?
• Outcome
Yes, this youth can consent to treatment. If, in the physician's judgment, the patient is a mature minor the physician
cannot inform the parents without the patient's consent.
 Case: A conflict with the parents of a child

• Background
Ann, who is eight years old, presents with polydipsia, polyuria, polyphagia, and weight loss over the past two months.
You diagnose Type 1 diabetes based on her blood glucose.
Ann requires insulin therapy; however her parents refuse, believing she can be managed with diet and a new
herbal remedy they have read about. What should you do?
• Think about it
What should you do?
• Suggestion
A parent or guardian is required to act in the best interests of the child. If medically necessary treatment is refused, the
doctor is obliged to report the matter to the child protection authorities
 Three key elements of consent

❖ Life threatening situations

If life or limb are in danger and the patient is unable to consent and the substitute decision maker is not
immediately available, a doctor has a duty to:
A. Do what is immediately necessary.
B. Respect any known previous wishes of the patient.
C. Obtain consent as soon as reasonably possible.
 Case: Life-threatening injury requiring immediate
treatment

• Background
While on vacation, a young woman who is hiking in the woods is attacked by a bear. She is brought to the emergency
department unconscious with extensive blood loss. No substitute decision maker is available.
• Think about it
Can you treat her to save her life without her consent?
• Lesson learned
Yes. In an emergency when the patient or substitute decision maker cannot consent the physician may proceed
if there is demonstrable severe suffering or an imminent threat to the life or health of the patient.
 Three key elements of consent

3. Properly informing the patient

Canadian legal judgments dealing with informed consent suggest the following interpretations:

⮚ When possible inform the patient of the diagnosis. If some uncertainty exists about the diagnosis mention this
uncertainty, the reason for it, and what other possibilities are being considered.
⮚ Explain the proposed investigations or treatments.
⮚ Indicate the chances of success.
⮚ Inform the patient about available alternative treatments and their risks. There is no obligation to discuss what might be
clearly regarded as unconventional therapy, but patients should know there are other accepted alternatives and why the
recommended therapy has been chosen.
⮚ Inform the patient about the consequences of leaving the medical condition untreated.

The courts have been quite clear that physicians are expected to answer patients' questions as honestly and completely as they
can.

❖ Material and special risks

• Material risks include risks that occur frequently as well as those that are very serious, such as death or permanent
disability.
• A patient's special circumstances might require discussion of potential but normally uncommon risks of the investigation
or treatment, when typically these might not be seen as material.
• The courts have been clear that the consent discussion extends to what the physician knows or should know a particular
patient would deem relevant to making a decision about whether or not to undergo treatment.
 Case: A patient with an inflammatory bowel disease

• Background
Joan is a 57-year-old post-menopausal woman with a known diagnosis of osteoporosis.
• Think about it
Before prescribing a course of steroids as treatment for Crohn's disease, what material and special risks might you
wish to discuss with Joan?
• Suggestions
You will want to discuss the possible common, but generally non- serious, side effects associated with corticosteroid
therapy. As well, you will want to discuss the more serious, but fortunately less common potential side effects, such as
the possibility of avascular necrosis of bone.
Given Joan already has osteoporosis, you will also want to discuss the special risks of bone loss. Be sure to answer
any questions Joan asks.
 Case: A violinist with hand symptoms

• Background
A plastic surgeon is discussing a carpal tunnel release in a 59-year-old violinist.
• Think about it
What risks should be included in the consent discussion?
• Suggestion
The surgeon will want to discuss the material risks of the procedure, as well as the special risks to a violinist.
 Medical students and consent
• Consent may be delegated to medical students.
• The delegate requires sufficient knowledge and experience to provide adequate explanations to the patient.

✔ The physician who performs the treatment or investigation is ultimately responsible for obtaining
consent. She or he may delegate the duty, but should be confident the delegate has the knowledge and
experience to provide adequate explanations to the patient and to answer the patient's questions.

✔ Although a student may know about the investigation, procedure, or medication to be prescribed, the student
should also know the special risks for the specific patient based on their medical condition.

✔ As a medical student, if you are uncertain what should be included in the consent discussion or the patient asks
you a question that you cannot answer, alert your supervisor and arrange for someone else to obtain
consent.
 Documenting consent

❖ It is important to make notes in the patient's medical record about the consent discussion. The note might
contain the following:
i. major risks discussed
ii. minor but important risks mentioned
iii. any questions the patient asked
iv. answers given
v. the patient's apparent understanding (especially if it is a young person, or one whose mental capacity or
competency might be questioned)
vi. any handout materials provided to the patient
Print material, videos, or other handouts support the consent discussion but do not replace it.

❖ What is the purpose of a consent form?

• A consent form itself is not the consent.

• The dialogue with the patient is the key element of the consent process.
• Follow hospital requirements, if applicable, for completing a consent form.

In many Canadian jurisdictions it is now a legal requirement that a consent form be completed before any surgical
procedure is undertaken in a hospital.

In witnessing a signature, the witness simply confirms the identity of the patient who signed the document. The
witness's role has no other legal significance.
 Other situations
❖ Assault and battery

• Touching (or treating) without consent is battery.

• Battery includes treatment beyond or deviating significantly from that for which consent was given.
Only when additional or alternative treatment is immediately necessary and vital to the health and life of the patient,
not merely as a matter of convenience, should a physician proceed without express consent.

❖ Patients with mental illness

Individuals with mental illnesses, including those admitted to a psychiatric facility, are capable of controlling and
directing their medical care if they understand:
• what is proposed and why
• the risks and alternatives
• the potential consequences of their decision

❖ Patients who are "incapable" — Substitute decision makers

If your patient is not capable of consenting:

• Follow the procedure for obtaining consent that is governed by legislation in your jurisdiction.
 Other situations
All jurisdictions have legislation (e.g. Mental Health Act or its equivalent), governing procedures for obtaining consent
when a patient lacks capacity.

Many jurisdictions also have legislation regarding advance directives for patients and the appointment
of substitute decision makers (SDM) for patients who may be unable to communicate their wishes.
• An SDM can only give valid consent after receiving all the information that the patient would need before making
a decision.
• Sometimes it may be necessary to act when no SDM has been appointed. Physicians have often proceeded on
the basis of the family's approval in such cases, but medical or legal consultation may be wise if:
• There is disagreement among family members.
• The proposed treatment carries significant risks.
• There are questions or doubts about what is in the patient's "best interest."
• There is dispute over whether or not a proposed treatment is "therapeutic."
 Case: A serious condition is discovered

Background
Ms. Smith presents to a plastic surgeon for an augmentation mammoplasty. While operating, Dr. Adam finds a
suspicious mass in the patient's left breast.
Frozen section biopsies confirm her impression of a malignancy. Dr. Adam performs a lumpectomy to save the patient
from having an additional anaesthetic.
Outcome
The patient is upset to discover she has had a lumpectomy without her consent even though the final pathology
confirmed a malignancy.
Lesson learned
Dr. Adam was proceeding in the medical best interests of her patient and the lumpectomy was clearly medically
indicated. However, the courts have repeatedly affirmed that good intentions of a physician cannot be substituted for
the will of the patient.
❖ What patients need to know
• Symptoms and signs alerting them to seek further medical care.
• Advice tailored to their specific clinical situation.
• They are welcome (made to feel comfortable) to return for re-evaluation.

One Canadian court judgment stated that patient information should include not only instructions regarding appropriate
care, necessary medication, frequency and nature of follow-up visits, but also instruction on the predictable
complications and any symptoms or signs alerting to danger.

Just as when obtaining informed consent, it is important to describe the symptoms and signs of even rare
complications if the potential harm is serious. If the patient has any questions during the discussion, the questions
should be answered.

The discussion with the patient should be documented in the medical record.

❖ Patient care handouts

• Handouts support the informed discharge discussion but do not replace the personal interaction.
 What patients need to know

❖ Families and companions

• Consider the safety of the "incapable patient" and provide appropriate advice to those who will be with the patient.

Patients may be discharged from an emergency department or a day-surgical facility while still not fully capable due to
alcohol or drugs taken prior to arrival, or medications such as anesthetics or sedatives that were provided while
under medical care.
In these circumstances the patient should generally be accompanied by a relative or friend who is willing and
able to help. With the patient's consent, that individual should be part of the discharge discussion.
 Follow-up

❖ Follow-up instructions

• Inform the patient about who is the most responsible health professional for follow-up care.

When a patient is discharged from a physician's care, the patient should be made aware of any need for follow-up,
who will be providing the follow-up, and how the arrangements will be made (i.e. appointments, etc.).

❖ Who else needs to know?

• Alert those health professionals who are responsible for follow-up care of the patient.

If the patient has been given responsibility for making a follow-up appointment with another physician or healthcare
provider, that healthcare provider should have been notified so that appropriate follow-up can be arranged.

If follow-up is perceived to be urgent, it is often helpful to contact the subsequent provider to verbally explain the
clinical situation. Document your efforts in the medical record.
 Case: Trouble in follow-up of an INR

• Context
A 54-year-old male patient begins a course of anticoagulants prescribed by a consulting cardiologist. She instructs the
patient to see his family physician to manage the International Normalized Ratio (INR).
• Outcome
The patient calls the family physician for an appointment. The receptionist, who is not aware of the importance of the
follow-up, arranges an appointment in three weeks. Unfortunately the patient dies from massive cerebral bleeding prior
to being seen.
• Think about it
How might this patient's outcome have been prevented?
• Lessons learned
To facilitate continuity of care, the health professional responsible for following the patient after discharge should
receive information about any outstanding investigations or any required follow-up testing.
The discharge information should be sufficient to enable ongoing care. In particular, the information should indicate the
provider most responsible for following the patient and for arranging recommended investigations.
 Leaving against medical advice (AMA)

• Patients who leave against medical advice are a risk to themselves and represent a potential medical-legal
risk.
• In these situations, physicians should try to educate patients on what symptoms and signs should prompt them
to seek further medical attention.

❖ Documentation of leaving against medical advice

• In the medical record document the discharge instructions provided.

• A signed AMA form is acknowledgement that a discussion with the patient of the risks of discharge has occurred.

The recommendations for care, the mental capacity assessment, the patient's reasons for refusing investigation or
treatment, and the follow-up and discharge instructions should be documented in the medical record.

A signed AMA form is potentially useful if issues about the assessment and informed discharge arise later. In these
circumstances some physicians ask nursing staff to witness that an assessment and discussion have occurred.

If a patient refuses to take part in a discharge discussion or refuses to sign an AMA form this should also be
documented.
 Case: An older woman looking forward to seeing her
granddaughter
• Background
An 85-year-old woman with no significant medical history presents to the emergency department with a two-day
history of fever, cough, and shortness of breath. She is assessed by a medical trainee supervised by a staff physician.
The patient functions well and lives independently. On admission to the ED, her oxygen saturation on room air is a little
low. A chest X-ray shows a dense right lower lobe pneumonia. Based on the overall clinical assessment, it is
recommended that she be admitted to hospital.
She is upset by the "long wait" and adamantly refuses admission because of a much anticipated upcoming visit with
her only granddaughter. She appears fully cognizant of her disease and the risk of being discharged, but she remains
unyielding and asks to sign an "against medical advice" (AMA) form.
• Think about it
What would you do next in this situation?
• Lessons learned
A physician should make reasonable attempts to confirm that the patient understands the potential consequences
of refusing the recommended investigations or treatments. Consider the patient's mental competency. The patient
who appears to understand the nature of the disease and the consequences of accepting or refusing treatment is likely
capable.
This assessment is based on the overall clinical picture. In some situations, obtaining a consultation from another
physician may be helpful in determining the patient's mental competency.
Even if a mentally capable patient refuses treatment, the physician should explain why more observation, investigation,
treatment, and follow-up are recommended. This discussion may help alleviate the patient's concerns or fears.
It may also be helpful to ask if the patient has any other personal concerns, for example, responsibility for the care
of a spouse at home or a pet left unattended. There may be a way to resolve such issues. When possible and with the
patient's permission, it is generally useful to include family members in the discussion. Depending on the
apparent seriousness of the clinical condition and available resources, it may be helpful to ask another physician to
see the patient to reinforce the need for the recommended investigations or treatments.
The physician should advise the patient signing the AMA form of any necessary follow-up. Discharge instructions
should still be provided. The patient should be made to feel welcome to return and seek re-evaluation.
❖ Importance of teamwork
✔ Teamwork and shared care are critical for the delivery of quality healthcare. Shared care can mean treating a
patient with the cooperation of other physicians, or with other regulated or unregulated healthcare providers.

✔ Successful healthcare teams communicate well. Communication breakdowns and teamwork failures are common
reasons for adverse events (accidents in Québec).

✔ Inter-professional communication issues result in delays in diagnosis, mishaps in surgery, medication adverse
events, and failures in monitoring or follow-up of patients.

❖ Effective communication
• Good teams have a "shared mental model."
• Good teams communicate "often enough.
 Case: Fracture leads to paraplegia

• Background
An emergency physician identifies a compression fracture of the ninth thoracic vertebra (T9) on the X-ray of a middle-aged
patient who had fallen two weeks prior.
The patient has a known alcohol addiction, a history of ankylosing spondylitis, and cervical spine fracture. Despite the correct
diagnosis, the emergency physician fails to document his assessment or X-ray interpretation in the patient record prior
to admission.
The next day, the radiologist reports the mild loss of T9 vertebral body height, either acute or chronic, and recommends further
investigation. However, he fails to document the 2 mm shift or report the fracture as unstable. The family physician does not
see the X-ray and the report is not available for several days. He also fails to investigate the patient's back pain.
When the patient becomes confused and starts thrashing about the bed, the family physician prescribes chemical and physical
restraints for suspected alcohol withdrawal.
The following day, the nurse notes a fever, increased abdominal distension and urinary incontinence, which she documents in
the nurses' notes. However, she reports only the fever to the family physician, and the family physician does not read the
nurses' notes.
The next morning, signs of paraplegia are evident. A CT myelogram reveals a posterior process fracture of T9 with fragment
shift and large epidural hematoma resulting in cord compression. The patient undergoes spinal surgery, but he remains
paraplegic.
• Think about it
What information should have been shared between team members?
• Lessons learned
The emergency physician should have advised the family physician verbally or in writing of his interpretation of the X-ray of
the T9 compression fracture.
The radiologist should have noted the 2 mm vertebral shift and reported the T9 fracture as unstable.
The family physician should have read the nurses' notes.
The nurse should have documented the patient's neurological symptoms in the patient record, and communicated all of the
patient's symptoms to the family physician, not just the fever.
 Case: A developing infection

• Background
Following an uneventful lung removal and post-operative course, the thoracic surgeon writes an order that the
patient could be discharged the following morning. The patient's temperature spikes late that evening.
The on-call general surgery resident, who is covering for thoracic surgery, orders bloodwork and a chest X-ray. As
the white blood cell count (WBC) is elevated, he documents in the patient record that he suspects an infection, but he
does not inform the thoracic surgeon.
The next morning, the thoracic surgeon and team visit the patient. The nurse reports that the patient had a fever the
previous evening, but he now appears to be fine. She does not mention the elevated WBC and the order for a chest X-
ray. The thoracic surgeon also does not personally review the patient's chart. Unaware of the on-call resident's
concerns the previous evening, the patient is discharged as planned.
• Outcome
Five days later, the patient dies of a lung infection.
• Lessons learned
There were three communication breakdowns by different members of the healthcare team.
The on-call resident did not advise the thoracic surgeon that he suspected a post-operative infection based on the
patient's elevated WBC.
The nurse reported some — but not all — of the relevant information about the patient to the thoracic surgeon.
The thoracic surgeon did not read the patient's chart before discharging the patient.
Had any of these communication breakdowns been avoided, the lung infection would likely have been diagnosed and
treated.
 Effective communication

❖ Communication risk factors

The following circumstances increase the risk for miscommunication and the loss of important patient
information:

1. multitasking and frequent interruptions

2. noise and visual distractions
3. multiple providers
4. not knowing who is on the team
5. ambiguity about roles and responsibilities; dynamic leadership
6. changes in team personnel (e.g. during surgical operations)
7. lack of orientation of new members to the team
8. frequent handovers
9. hierarchies that inhibit speaking up
10. differences in terminology and cultures of health professions and subspecialties
11. different languages and societal cultures for both patients and providers
12. fatigue
13. assumptions that team members know how to work as a team and communicate
 Basics

✔ Be respectful.
✔ Be cooperative.
✔ Don't take your frustrations out on your team, including the patient.
✔ Avoid ambiguous explanations.
✔ Clarify each other's role and responsibilities.
✔ Develop your skill of active listening.

❖ Active listening

When a team member is giving information, others on the team may be distracted by other tasks. They may also be
anticipating what the person is going to say next and how they are going to respond.

Active listening involves focusing one's attention on the speaker. It includes suspending initial judgment and limiting
other internal mental activities. Repeating back or paraphrasing what was said helps to confirm understanding.

Maintaining eye contact and being mindful of body language are also important.
 Tools and techniques
• We can all communicate better.
• Structured approaches can improve the clarity of communication.

❖ Briefings

Teams in hospitals, clinics, or offices function better if everyone is on the "same page."
Briefings can set the tone for team interactions and help establish a shared mental model of what should
happen during patient care.
Briefings can be used to identify safety risks, concerns about specific patients, medications, equipment issues,
and backup plans.

Can you say "yes" to the following questions about your briefings?
• Is the information detailed and specific?
• Are the intended actions and possible problems understood?
• Have questions been welcomed and answered?
• Does everyone understand the plan?

❖ Debriefings

• Help enhance a culture of safety in an environment of respect, teamwork, and communication.

• Can help you identify what went well and what happened when things didn't go as planned? What might
be done better next time?
 Tools and techniques

❖ Closing the communication loop — Readbacks

• Use a readback for verbal instructions and orders.

When you order take-out food by phone, the person taking the order normally confirms your request by reading it back.
Similarly, readbacks in healthcare can also reduce miscommunication.

A readback is aimed at verifying that a message is correctly received and provides an opportunity to correct
misinformation. Many find it especially useful in crisis situations.

❖ Readbacks can be used to confirm such things as:

1. the patient's name
2. medication orders
3. critical test results
4. instructions and action items from supervisors

For similar-sounding medications, it may be worth spelling the name and stating what it is being used for.
Verbal orders must be entered in the medical record and be countersigned or approved.
 Case: A new-born with tachypnea

• Background
A newborn, who was delivered at term 24 hours prior, develops tachypnea. The treating family physician consults a
pediatrician by telephone.
The pediatrician recommends starting IV gentamicin and ampicillin while awaiting blood culture results. He
recommends the gentamicin be given in divided doses 12 hours apart (q12h) for a total daily dosage of 5 mg/kg/day.
However, the family physician misunderstands the pediatrician's instructions and prescribes the total daily
dose q12h.
• Outcome
The newborn receives three doses before the dose is corrected. There are no gentamicin-related ototoxic or
nephrotoxic complications.
• Think about it
How could the family physician have avoided misinterpreting the gentamicin dosage?
• Lessons learned
If the family physician had used a simple readback approach to verify the gentamicin instructions, the pediatrician
would have noticed the mistake.
 Tools and techniques

❖ SBAR — Situation, Background, Assessment, Recommendation

SBAR is an increasingly common format used to clarify communication, especially over the telephone. The
healthcare provider uses it to communicate concisely the patient's condition, including a recommendation about
what action is required and how urgently.
S - Situation
B - Background
A - Assessment
R - Recommendation

An SBAR dialogue might go as follows.

Nurse Phillips to Dr. Jones
"Dr. Jones, this is Nurse Philips on 5 East. Sorry to wake you. I'm calling about Briana Smith - she's a four-month-
old admitted to Dr. Murphy two days ago for fever and dehydration. She has Kawasaki's disease." (SITUATION)
"The child has been improving but now her temp is 39.8 rectal and she has vomited twice. She looks
unwell." (BACKGROUND)
"I am worried she is becoming more dehydrated. She's getting sicker." (ASSESSMENT)
"I need you to assess her." (RECOMMENDATION)
Dr. Jones to Nurse Phillips
"Ok, I'm on the way. I'll be there in 15 minutes."
 Tools and techniques

❖ Crew Resource Management (CRM) based communication

The aviation industry has long recognized that many airline crashes entail communication problems among members
of flight crews and with others such as air traffic controllers.
CRM addresses cultural issues and includes the principles of clear and "closed loop" communication, briefing
planned actions, dealing with hierarchy, and cross-checking of key actions. When problems occur there is an
expectation of safe reporting, fair analysis, and system improvement.

❖ Communication in the operating room — Surgical checklists

• Use a surgical safety checklist prior to an operation.

The World Health Organization and the Canadian Patient Safety Institute (CPSI), in collaboration with the University
Health Network at the University of Toronto, have promoted the use of the surgical safety checklist.

❖ Simulations

Simulations, such as mock clinical scenarios, are helpful to assess and strengthen how a team functions and
communicates while identifying gaps in skills.

Simulations can be simple or "high fidelity" (e.g. using sophisticated, realistic mannequins and materials with
technology that mimics human physiology).
 Situational awareness

• As a team member, speak up early.

• Welcome and facilitate input from all healthcare professionals.

Situational Awareness is a cognitive skill that includes:

1. being conscious of what is happening around you,
2. continuously checking perceptions with reality and the related flow of information
3. predicting the immediate and future impact of your own or the team's actions, including anticipating complications.

It is easy to lose situational awareness, so physicians should welcome and facilitate input from all healthcare
professionals.
Case: Elaine Bromiley – "Can't intubate, can't ventilate"

• Background
Elaine Bromiley was a 37-year-old healthy woman with chronic sinusitis, admitted to hospital for septoplasty.
After induction, the anaesthetist could not place a laryngeal mask. Based on the reasonable assumption that this resulted
from light anaesthesia, the anaesthetist administered an additional small dose of anaesthetic. The laryngeal mask could
still not be placed, and bag and mask ventilation remained inadequate. Further muscle relaxant was given but the larynx
could not be visualized, and endotracheal intubation failed. Nevertheless three highly experienced consultants persisted
in several more attempts to secure the airway by intubation for about 20 minutes. The pO2 was at or less than 40%
during much of this time.
At the outset the operating room nurses informed the consultants that surgical equipment was available. A surgical
airway was not attempted. It was decided the patient should be allowed to "wake up naturally" and she was transferred to
the recovery unit. Ms.
• Think about it
The many physicians and nurses involved in this case were all considered to be technically competent professionals.
Failure to intubate is a recognized inherent risk of anaesthesia. Guidelines for "can't intubate, can't ventilate" exist for this
recognized emergency in anaesthesia.
So what went wrong?
• Lessons learned
An investigation of Ms. Bromiley's care concluded the following:
⮚ Loss of situational awareness - The consultants, focusing on intubation, lost sight of the overall clinical condition
of the patient.
⮚ Leadership - An overall leader was required to facilitate communication and decision-making.
⮚ Cognition dispositions - The team, particularly the consultants, anchored on endotracheal intubation as a solution
in this stressful situation and did not consider the guideline protocol.
⮚ Failure to communicate assertively- Some of the nurses recognized the situation that was unfolding and made
surgical airway equipment available. The operating room culture and hierarchies interfered with the nurses' voicing
their warnings. They did not know how to speak up effectively.
 Speaking up
• All members of the team should have a voice.
• Team members should speak up respectfully if they have a concern about the safety of the patient.

Effective assertiveness is:

• respectful and polite (not aggressive) appropriately timed
• constructive and focused on achieving clarification and a solution

Supervisors should welcome polite questions and concerns from their trainees.
Trainees should recognize the clinical experience and wisdom of their supervisors.

Graded assertiveness is a communication approach adapted from the aerospace industry and the military to effectively
raise concerns with another team member when one believes the other team member's judgment or decision may be
incorrect.

❖ Two-challenge rule
A concern is stated at least two times to ensure it has been heard

❖ CUS : to voice one's increasing concern

C - "I'm concerned"
U - "I'm uncomfortable" or "This is unsafe"
S - "This is a safety issue" or "I am scared"

❖ Let's chat!
The MOREOB (Managing Obstetrical Risk Efficiently) program — teaches the use of CHAT, a communication tool for team
members when wanting to voice a concern in a birthing centre. CHAT stands for:
C - Context
H - History
A - Assessment
T - Tentative plan
 Case: A 16-year-old male with leukemia

• Background
During the last cycle of chemotherapy, the patient's oncologist is running behind schedule and asks a junior
resident to administer three chemotherapeutic agents to the patient. The pharmacy had sent all three preloaded
syringes in the same medication pouch.
The resident has had little orientation to the oncology service and asks the supervising oncologist to clarify his
instructions. Instead, he is chided for not knowing how to do this.
• Think about it
What is the best next step for this resident?
 Case: Questioning another clinician's assessment

• Background
A 27-year-old health economist and active rower presents in the emergency department complaining of sudden
headaches, weakness in his right arm and leg, slurred speech, nausea, vomiting, and mild aphasia.
A three-vessel arteriogram is ordered, and the staff interventional radiologist reads the films as normal. The radiology
resident (who has been on this rotation for only two weeks) also reviews them, and notes that the left carotid artery
looks narrower than the right. When the resident mentions her observation to the staff radiologist, he replies "that's
how the left carotid artery appears in young people." The resident feels that some further review is probably indicated,
but is not confident enough to pursue it further with a staff physician.
• Outcome
Several days later, the patient is readmitted after developing partial paralysis. A repeat arteriogram reveals a left
internal carotid artery dissection with emboli involving the middle cerebral and anterior cerebral arteries. Irreversible
brain damage has occurred.

• Think about it
How might the resident's concerns been asserted more effectively?
 Case: A question about dosage

• Background
As a resident you are speaking with the senior resident supervisor regarding an inpatient. The senior resident gives a
verbal order for warfarin which you believe is double the appropriate dose for this patient.
• Think about it
Using graded assertiveness, how might you discuss your concerns with the senior resident?
• Suggestions
Level 1: That's higher than the dose I was expecting.
Level 2: Perhaps we should check the dose?
Level 3: Is there a reason for the higher dose in this patient?
Level 4: Dr. Jones, the dose you ordered is too high for this patient.
Your choice of level would depend on the urgency of the situation and on the response to lower levels.
 Documentation

Documentation is communication. As such, the medical record should provide sufficient information for team members.
1. Use standard abbreviations.
2. Convey the degree of urgency of an order.
3. Keep your writing legible.

Sufficient information should appear in the medical record to enable all team members to understand the patient's
history, physical findings, diagnosis and rationale for the diagnosis, and the treatment and care plan.

Patient care orders and prescriptions should convey the appropriate degree of urgency. Orders can include triggers to
communicate. For example, a certain change in a patient's vital signs (e.g. a particular temperature) should trigger
notification of the physician.

Legibility is important. Illegible writing has resulted in many adverse events (accidents in Québec). Words may be
printed if necessary. Only standard abbreviations should be used.

❖ Reviewing notes from others

Nurses and other healthcare professionals are trained to document their observations. Physicians should take care to
review such documentation.
 The patient as team member

• Consider the patient as part of the team.

• Listen and respond to the concerns of the patient or family.

Patients can contribute to their own safe care and risk management, but they need to feel welcome and encouraged to
speak up, ask questions and voice concerns.

Some patients are embarrassed or fearful to ask simple questions, or speak up when they perceive a problem is
developing. Sometimes patients are deferential and assume that the healthcare providers, as experts, have the
situation under control.
 Case: The Josie King story

• Background
Josie King was an 18-month-old child who climbed into a hot bath and suffered extensive body burns. She was
admitted to a pediatric ICU at Johns Hopkins Children's Center in Baltimore. She stabilized and was transferred to an
intermediate-care floor. She died there after a sequence of miscommunications.
Her mother had repeatedly voiced concerns about her daughter's steady deterioration and was repeatedly reassured
by the residents and nurses that all was well. "In my case, no one was listening to me when I tried to tell the doctors
and nurses that Josie didn't look right to me."
• Outcome
Josie acquired a catheter infection, her fluid status was not recognized and managed, and she became dehydrated.
Narcotics that had been ordered stopped were still administered. She had a cardiac arrest and could not be
resuscitated. Subsequently the Josie King Patient Safety Program was launched at the Johns Hopkins Children's
Center.
❖ What is a handover?

A handover is the transfer of responsibility and accountability for some or all aspects of care for a patient or group of
patients, on a temporary or permanent basis. It entails appropriately transferring information to help deliver safe care.

❑ What information is included?

The information transferred depends on the clinical circumstances, and may include the:
• clinical condition
• status of investigations and treatments
• likely clinical course
• possible problems and consideration of strategies should problems arise
• responsibility for ongoing care
As appropriate, the handover process should include opportunities to discuss the meaning of the information, seek
clarification and ask questions.

❑ Handovers occur frequently

During even a short period of care, a patient can be treated by several different healthcare providers in multiple settings.
Whether in inpatient or outpatient settings, on any given day patients may encounter many staff shifts.
In the United States it is estimated that during a typical hospital inpatient stay, a patient's care will be handed over an
average of almost five times per day. Rates of handover in Canada are likely similar.
 What is a handover?
❑ Think about it

Reflect on your own experience and the number of times doctors, nurses, or others transfer responsibility for various
aspects of care to others in their own or other professions.
Common examples of handovers involving physicians include:
• at the end of a shift in an emergency department, intensive care unit (ICU), or ward
• to an on-call physician overnight or on a weekend
• to a colleague when going on vacation
• to a consultant
• to a specialist of another service at the same or a different facility
 Barriers to effective handovers
• Be aware of high-risk times in your workplace. Handovers at end-of-shift, end-of-day, end-of-week, and at the
time of any planned or unplanned absence are all high-risk times for a patient to "slip through the cracks."

❖ There are many barriers to effective handovers in the workplace.

1. The setting
Handovers often occur in busy workplaces. Frequent interruptions may lead to incomplete transfer of information and
decreased recall.
2. Time constraints
Multi-tasking, not scheduling, or not allotting sufficient time for handovers can impede the transfer of key information.
End-of-shift, end-of-day, and end-of-week periods may pose increased risk.
3. Communication styles
Communication styles can interfere with the effective transfer of information.
• When possible, face-to-face discussion allows for interactive questioning — a more effective communication style.
• Ambiguous language can lead to misinterpretation of information.
• Hierarchies in healthcare teams sometimes lead to reluctance to share information.
4. Missing information
Omitting critical information such as important background information, clinical updates or outstanding tasks may result
in adverse events or near misses.
5. Lack of standard communication tools
A standardized approach for handovers, including interactive questioning, helps to verify the information being
transferred.
5. Lack of training
Lack of formal training in handovers has been identified as a barrier to performing handovers effectively.
 Case: Handover failure

• Background
Mark is a 22-year-old who has a neck injury sustained in a snowboarding accident. Although he is neurologically intact,
Mark is diagnosed with a C6 fracture and a C6/C7 subluxation with 3.5 mm anterolisthesis.
• Operative course
The staff neurosurgeon performs a C6/C7 fusion, inserting pedicle screws to stabilize the spine.
He asks the resident to order a follow-up CT scan of the cervical spine on day 3 post-op.
• Post-operative
The CT scan is performed on day 3. The radiologist notes in her report that the pedicle screws are not positioned
correctly and appear to be transecting the vertebral arteries. There is no direct communication of these findings to the
neurosurgical team.
• Handover
The same day the neurosurgery resident transfers care of all his patients to the weekend on-call resident. He
mentions that Mark has had a CT scan of his cervical spine and could probably be discharged the following day. The on-
call resident assumes that his colleague has reviewed the CT scan. He discharges the patient the next day.
• Clinical outcome
Two days later Mark is rushed back to hospital after developing right-sided hemiparesis, diplopia, and ataxia. An
angiogram reveals that one of the screws had injured a vertebral artery, resulting in a stroke.
Mark is left paralyzed on the right side and can no longer walk independently.
• Think about it
How could the handover between the residents have been done differently?
How might communication between the staff neurosurgeon, the radiologist, the residents and the patient have been
better?
• Lessons learned
Effective communication between healthcare providers is essential during handovers.
Providing insufficient information, lack of interactive questioning, and lack of time can contribute to ineffective
handovers.
Roles and responsibilities should be clarified when handing over responsibility for a patient.
 Strategies for improving handovers

❖ Address the physical environment

Wherever possible choose a location that will limit the number of interruptions, noise and distractions during a
handover.

❖ Time constraints
Consider allowing a designated time for performing handovers and prioritizing your time on the patients who are most
sick. Some have found that using a standardized communication tool increases the amount of information transferred
without increasing the time to perform the handover [REF]. Others have used technology that automatically downloads
important patient data into a template to shorten the time spent on team rounds [REF].

❖ Communication skills
Improving communication skills through training can help providers use clear and unambiguous language during
handovers. Flattening existing hierarchies for communication may permit a junior member of a team to communicate
with the senior members more freely.

❖ Standardized communications
Consider using a standardized approach during handover communications that includes a face-to-face verbal
interaction whenever possible.
 Strategies for improving handovers
❖ A structured communication tool could include the following components:

The patient's history including:

1. background information
2. the current situation
A prospective view including:
1) the provider's assessment
2) what might happen next
3) what the patient and family have been told
If the diagnosis is not yet confirmed, this would also be important information to pass on.
A recommended plan might be proposed. This would contain:
1. a pending task list (action items)
2. contingency plans if a particular scenario was to occur
Interactive questioning that allows you to:
1) verify your understanding of the situation
2) assess the reasonableness of the recommendations being proposed
3) read back critical information
If the information is unclear, don't make assumptions — ask for further clarification.
Beware of labelling patients.
Comments made during handovers may inadvertently contribute to misdiagnosis or inappropriate treatment because of
the influence of cognitive biases and stereotyping.
 Case: Rushed handover

• Background
Melissa, a first-year medical resident doing a rotation in cardiology, is on call for the evening. Her senior resident wants to leave
for journal club and rushes through the handover on the phone. He tells her about Mr. C, a patient with chest pain who has had
blood work, including serial cardiac markers, and a chest x-ray. He tells her that Mr. C can probably be discharged if his work-
up is normal.
• Clinical events
Eight hours later, Melissa is reviewing Mr. C's bloodwork, which is normal. She is suddenly notified about an unstable patient
and quickly discharges Mr. C so that she can take care of the patient's hypotension. She assumes that her senior resident
had reviewed Mr. C's chest x-ray, which in fact shows a new right lung mass.
• Outcome
Unfortunately, there is no follow-up of the chest x-ray finding. Mr. C presents to his family doctor 2 years later with hemoptysis,
at which time he is diagnosed with an inoperable lung cancer. He is told that he could have been effectively treated if his
previous chest x-ray had been acted upon 2 years earlier.
• Think about it
What were some of the barriers in this case that contributed to an ineffective handover?
What strategies could Melissa and the senior resident have used during the handover to prevent this adverse outcome?
• Lessons learned
Handovers are high risk situations
Allow appropriate time for a safe and complete handover of care. Limit the number of interruptions and distractions.

Interactive questioning
Face-to-face exchanges allow for interactive questioning. Be aware of hierarchies that may impede effective communication.

Standardized content
The handover should include a retrospective and prospective view of the patient, along with a recommended plan and clear
responsibilities for pending tasks.
 Safer handovers through structured communications

❖ SBAR
Situation: problem, patient's symptoms, patient stability or level of concern
Background: history of presentation, background information
Assessment: assessment and differential diagnosis, where you think things are headed
Recommendation: recommendations and action plan, what you have done, what you would like the other person to do

❖ I-PASS
Illness severity: stable, "watcher", unstable
Patient summary: events leading to admission, hospital course, current condition, treatment plan
Action list: to-do list, timeline and who is responsible
Situation awareness and contingency planning: what's going on, plan for what might happen
Synthesis by receiver: closing the loop readback, further questions

❖ DRAW
Diagnosis
Recent changes
Anticipated changes
What to watch for in the next interval of care
 Safer handovers through structured
communications
❖ SIGNOUT
Sick or DNR: highlight the sick or unstable patients, identify code status
Identifying data: name, age, gender, diagnosis
General hospital course
New events of the day
Overall health status/clinical condition
Upcoming possibilities and plan
Tasks to complete

❖ Involving patients and family

During illness the patient and family can play a helpful role in ensuring continuity of care.
Some healthcare providers involve the patient (and with the patient's permission, the family) directly in the handover
process. This approach:
1. informs the patient there is a change to a new team or most responsible physician
2. allows for clarification of the history and correction of any misinformation
3. provides an opportunity to address any questions and concerns
 Case: Using SBAR
• Situation
"Mrs. White in room 231 is stable and has been admitted with a possible ectopic pregnancy."
• Background
"She is a 28-year-old gravida 1 who is 8 weeks pregnant. She presented at 2 p.m. with a 2-day history of vaginal
spotting and left-sided abdominal pain. She has gone through 2 pads today. Her vital signs are normal, and her
abdomen is soft with mild tenderness in the left lower quadrant. On pelvic exam, the os is closed, and the patient
has mild left adnexal tenderness with no mass. Her haemoglobin is 120 and her bHCG is 2032. She is Rh-
positive."
• Assessment
"She may have an ectopic pregnancy or a threatened abortion."
• Recommendation
"She will be having an ultrasound in 1 hour. You need to review the results with the radiologist and then call Dr.
Green. If the patient's pain increases or her BP drops below 100 you need to assess her and call Dr. Green right
away. You also need to be careful. Her sister is here but she doesn't want her sister to know that she is pregnant.
Resident: "Got it. I will review the ultrasound in 1 hour and call Dr. Green, unless the patient becomes unstable
while waiting. She doesn't want her sister to know she is pregnant."
Lessons learned
The use of this or other structured communication tools can help to organize and simplify intra- and inter-professional
discussion about patient care, and has the potential to improve the clarity of communications and patient safety.
Note also the effective use of readback — the receiving person repeats back important information during a handover,
which can improve everyone's understanding.
 Case: Failure to perform readback

• Background
John is a first-year paediatric resident who receives a handover from his colleague Jenna. She tells him about a young
child who has had several seizures treated with benzodiazepine. She advises him that if the child has another seizure,
he is to administer intravenous phenytoin at 15 mg/kg at a rate of 1 mg/kg/minute.
• Clinical outcome
John believes she has told him the dose is 50 mg/kg and orders this when the child has another seizure. The child
becomes phenytoin toxic after receiving more than 3 times the usual dose.
• Lessons learned
Readbacks can be helpful in preventing misunderstanding of information during handovers. A readback may be
especially useful for confirming:
1. to-do (action) items
2. medication orders and dosing
3. critical lab results
4. equipment settings
 Case: Involving the family

• Background
Mr. Greg undergoes the evacuation of a subdural hematoma. The family is present during the handover when the
team mentions that Mr. Greg would need a repeat CT scan the next day.
Unfortunately the requisition is misplaced and does not reach the diagnostic imaging department.
Two days later, the family realizes that the CT scan had not been performed, and brings this to the team's attention.
This prevents a further delay in the test being performed.
• Lessons learned
Keeping the patient or family informed of the planned investigations, treatment and follow-up plans is important for
good communication and may add an extra safety measure to limit the likelihood of some aspect of care being
overlooked.
Case: A 38-year-old man with gastrointestinal bleeding

• Background
A patient with a significant upper gastrointestinal bleed was admitted to a community hospital under the care of Dr.
A.
A peptic ulcer was suspected.
The patient's condition worsened and Dr. A transferred him to the tertiary care hospital, where Dr. B performed a
gastroscopy. Dr B made a preliminary diagnosis of a Dieulafoy-type lesion a rare condition involving bleeding from a
larger than usual artery in the gastric submucosa. The exact origin of the bleeding is often difficult to locate and treat.
Dr. B was off call for the weekend, and the care of the patient was transferred to Dr. C, a senior surgeon on-call.
However, Dr. B did not inform Dr. C of the diagnosis or the treatment plan. Dr B knew the patient needed to be
monitored closely and at the first sign of re-bleeding an immediate endoscopy needed to be performed to locate and
repair the Dieulafoy's lesion. There was no note of this written in the medical record.
Over the weekend, the patient again began vomiting blood, and his condition suddenly deteriorated. Unfortunately the
patient suffered a cardiac arrest while being re-investigated and could not be resuscitated.
The family commenced a legal action against many physicians, including the Doctors A, B, and C.
• Legal outcomes
Dr. C (on-call surgeon) was dismissed from the action prior to trial.
At the trial, the action against Dr. A was dismissed; however, the court found against Dr. B (receiving surgeon at the
tertiary centre).
The family was awarded compensation, paid by the CMPA on behalf of Dr. B.
Case: A 38-year-old man with gastrointestinal bleeding

In his decision the judge noted, given the diagnosis, the high risk to the patient and the nature of the treatment plan,
careful monitoring of the patient and appropriate intervention was likely to be required. It was therefore incumbent on
Dr. B to take all reasonable steps necessary to ensure the patient's history was communicated to Dr. C and the
treatment plan was followed.
If Dr. B had carefully explained to Dr. C in detail the history and precarious nature of the patient's condition and the
significant danger attendant upon re-bleed, it would be highly unlikely that Dr. C would not have alerted his staff to the
real nature of the patient's problem, the close monitoring that would be necessary and the urgent steps to be taken in
the event of further bleeding.
In his reasons, the judge stated that by these omissions, Dr. B had not met the reasonable standard of care of a
prudent physician. Moreover, he stated Dr. B owed the patient a duty to ensure he would be safe during Dr. B's
absence and failure to do so was not only an omission but also a failure to discharge a fundamental duty of care to his
patient.
• Lessons learned
This case highlights the importance of communication when handing over care to another physician. Consider the
following when handing over care:
Have you thoroughly explained your patient's condition (including any rare diagnosis) and anticipated treatment plan to
the physician to whom you are transferring care?
Are you satisfied the physician to whom you are transferring care has the required expertise to manage the patient's
condition?
 Documentation of handovers

Important information can be lost when multiple handovers occur. If you are assuming care of a patient, it may be
prudent to reconfirm the clinical history directly with the patient, and then to enter key elements of handover
information in a paper or electronic log to aid your memory.

A formal transfer of responsibility for care, for example, from one clinical service to another, should be recorded in the
patient's medical record.
❖ Before making a referral

Ask yourself:
1. What is the question I want answered?
2. Who has the specialized knowledge and skill to answer it?
3. How urgent is the clinical situation?
4. Do I need advice from the consultant or would a transfer of care to the consultant be more appropriate
in the specific circumstances?
5. Have all the appropriate steps been taken to this point?
6. Has the patient consented to the referral?
 Content of the referral request
Even in a hospital, where the medical record is generally readily available, it is important to make an explicit
request for a consultation. Identifying the reason for the referral saves time and provides safer care. If the
consultant is in a different location, this information becomes vital.

❖ State your expectations:

• What is your question? Do you want help with:
– diagnosis?
– management?
• (Sometimes a referral is made to get a second opinion.)
• What is the level of urgency?
• Do you know the date of the consultation and is it appropriate given the urgency?
• Should the consultant be contacted directly?
• Have you considered other options if you cannot obtain a timely consultation, such as referral to another
consultant or referral elsewhere?
• Have you had a discussion with the patient to obtain consent regarding the situation and the options?
• Have you alerted the patient to the symptoms and signs that should trigger seeking medical care while
awaiting the consultation? As the referring physician, you should continue to monitor the patient pending the
consultation. Request an earlier appointment as required and communicate to the consulting physician any
significant changes in your patient's clinical condition.
• Who will be the most responsible provider for follow up?
– you
– the consultant
– another health professional
 Case: Uninformative referral

• Background
A patient arrives at a dermatologist's office with a consultation letter. The dermatologist determines that the patient
has been treated with prescription creams and ointments (names unknown) and has had blood work (type and results,
unknown).
The patient is taking "tiny white pills" for the skin condition.
Examination reveals an erythematous ulcerated nodule on the patient's left calf. The patient also has a generalized
macular erythema which may be an allergic reaction to the medication, an id reaction to the infection, or it may be
unrelated.
• Outcome
The dermatologist's office needed to contact the family physician's office to determine the blood work results and the
nature of the previous prescriptions. Fortunately, this information was readily available.
• Think about it
How might the poor referral note have contributed to a poor outcome for the patient?
• Lessons learned
The consultant dermatologist uses the referral information to judge the urgency for the required appointment. This
request had insufficient information to be able to judge when to arrange the appointment.
Without information regarding previous investigations and treatments the consulting physician must arrange to speak
to the referring physician. Both physicians must interrupt their busy offices to transfer the information.
 Case: A 50-year-old male with headache

• Background
A school teacher, with a history of headaches and hypertension, presents with severe right-sided frontal headache.
His family physician performs a thorough physical examination and notes a "sluggish right pupil" and "possible right
ptosis." There are no physical findings.
The physician promptly refers the patient to a specialist with a note stating "headache - rule out pathology," but omits
information about the eye findings. The specialist, concerned about the possibility of an intracranial lesion, is unable to
reach the family physician by phone, however, he dictates and mails a consultation letter that same day. The patient is
told to see his doctor as soon as possible.
In the following days, the patient experiences more severe headache associated with vomiting. A leaking aneurysm of the
Circle of Willis is then identified. Following its clipping the patient dies due to diffuse cerebral vasospasm. A legal action
begins, naming all the physicians involved.
• Think about it
What might have improved the communication between the physicians?
• Outcome
The judge criticized a number of care issues in this case, including the failure of the family physician and specialist to
communicate effectively.
From the judgment: "Failing to include relevant clinical information in a referral amounts to negligence as a matter of law."
• Lessons learned
Share what you know:
relevant history and physical findings
results of relevant investigations
actions taken to date
treatments and effects
other consultations and conclusions
 Content of the consultant's report
❑ A consultant's report should be:

⮚ timely
• consistent with the urgency
• consider verbal notification of critical results
⮚ clear
• answer the question(s) posed
• state your conclusions and recommendations
• document the rationale for your management recommendations
• clarify who is responsible for investigations and further care
⮚ complete
• document the history and physical findings that you obtained
• include any additional relevant advice or recommendations (e.g. investigations, management,
recommendations to consult others)
 Case: Lack of follow-up after colonoscopy

• Background
A family physician refers a 52-year-old male to an endoscopist for investigation of an iron deficiency anemia and occult blood
in the stools. A colonoscopy is performed. Visualization is achieved only to the level of the mid-transverse colon and the
procedure is terminated due to patient discomfort. The patient is advised to follow up with the endoscopist, but no appointment is
given.
Three weeks later, the endoscopist dictates a note stating his intention to arrange a barium enema to ensure there is no bleeding
from the right side of the colon. The patient does not attend the follow-up as he had not received the appointment for the barium
enema and he believes the endoscopist wanted the test done prior to seeing him.
The endoscopist presumes the patient had opted to follow up with the family physician and makes no further enquiries.
During an unrelated visit with his family physician six weeks later, the patient mentions that no date had been set for a follow-up
with the consultant endoscopist. The doctor records the inadequacy of the colonoscopy and the recommendation for a barium
enema, but assumes ordering it would be the responsibility of the consultant.
Seven months after the colonoscopy, the patient returns to his doctor complaining of cramping abdominal pain, and is referred to
a general surgeon. A repeat colonoscopy reveals an obstructing and bleeding mass of the right colon; biopsy confirms
adenocarcinoma. The patient undergoes a right hemicolectomy for a locally invasive cancer. After a course of chemotherapy, the
patient develops a major depression requiring psychiatric care.
The patient starts a legal action alleging the seven-month delay in the diagnosis allowed the cancer to progress and metastasize
to the lymph nodes.
• Outcome
Experts were not supportive of the care given by either the family physician or the endoscopist:
Endoscopist expert: "...with the referral and subsequent follow-up to the incomplete colonoscopy, the onus of responsibility
specific to investigations, including the barium enema, was the primary and direct responsibility of the consultant."
Family physician expert: "...the family physician owed a duty of responsibility, given the time frame of the test not being done, to
ensure that this test had been requisitioned or to direct the patient to contact the consultant. Failure to pursue either option falls
below the standard of care."
Lacking expert support, a settlement was paid to the patient by the CMPA on behalf of both member physicians.
Imaging and laboratory consultations

❑ Diagnostic imaging and certain lab studies such as biopsies are an integral part of modern patient care.

❑ The same principles apply when requesting these studies as for other consultations:
1. Share what you know.
2. State your expectations.
3. Determine the level of urgency.
4. What do you hope to determine with this investigation or test?
5. Does the specialist have any recommendations for helping with your patient's diagnosis or management?
 Case: Hidden information
• Background
A patient suffering from headache is sent for a CT scan to rule out an intracranial lesion. The report's conclusion
specifically states there is no intracranial lesion.
Presence of a vague density in the right eye is mentioned in the body of the report.
The physician successfully treats the patient's migraine headaches. She later develops visual problems and the "vague
density" is found to be a retinoblastoma.
• Think about it
What might have prevented the delay in the diagnosis of the retinoblastoma?
• Lessons learned
To prevent a similar occurrence:
- The physician should read and act on the entire report.
- Potentially significant but incidental findings could be noted in the conclusions of the report.
- The physician should orally communicate critical results that require follow-up.
 Dealing with the consultation report
⮚ Read it!

⮚ If you don't understand the consultation report, have it clarified (by phone is best) and document your
understanding.

⮚ Satisfy yourself that follow-up plans and accountability for following up are clear.

⮚ Follow the recommendations, or document your reasons for deciding not to do so.
❖ Importance of medical records

❑ Medical records:
I. facilitate good care
II. allow a subsequent caregiver to understand the patient's condition and the basis for the current investigations
or treatments
III. provide a method of communicating with other team members
IV. satisfy legal and ethical obligations: medical regulatory authority (College), hospital, and legislative
requirements for clear and legible records
V. act as evidence: if your care is later questioned, it shows events as they happened

❖ Who is responsible?

❑ Everyone who provides care to a patient is responsible for documenting the care and recommendations that have
been provided.

❑ This can be delegated to an assigned recorder (for example, during an emergency resuscitation), but it is wise to
confirm the accuracy of the record as soon as reasonably possible.
 Case: Action not documented

• Background
A junior resident on a gynecology rotation assists at an abdominal hysterectomy. The staff surgeon points out the
anatomical landmarks and the steps being taken to define and protect the ureters.
Following the procedure the student is told to dictate the operative report. The resident dictates a standard operative
report using a template and does not mention the care taken to identify and protect the ureters.
• Think about it
How might this approach to record keeping compromise the patient and the physicians in the future?
• Outcome
The patient developed a post-op ureteral obstruction and later sued. When experts reviewed the operative report they
found no reference to the steps taken to protect the ureters and they inferred that no such steps had been taken.
Based on the documentation, surgical peer experts had difficulty supporting the surgeon.
• Lessons learned
Even if good care has been given, incomplete documentation can give the opposite impression.
Templates may help in record keeping but should not preclude a comprehensive note specific to the individual patient.
 What to document
❖ Clinical notes do not need to be exhaustive. To give an adequate picture of the clinical situation, the following information
may be necessary:
⮚ patient, source of the information, date and time
⮚ relevant history and physical findings
• positive findings
• important negative findings
⮚ conclusions
• working, differential, and final diagnosis
⮚ plan of action
• investigations, consultations, treatment, follow-up
• rationale for the plan
⮚ information given to patient (or substitute decision maker [SDM])
• verbal or written instructions
• questions asked and responses given
• apparent understanding, consent
• any disagreement or refusal of care
⮚ signature of writer and position (trainee level)

❖ Special notations

❑ Handover
When transferring care for the evening, the weekend, a vacation or any other reason, remember that the person
assuming responsibility doesn't have your depth of knowledge about the patient's condition.
 What to document
❑ Provide information about the following:
I. what you expect to happen
II. any pending investigations
III. any pending consultations or reports
IV. any unresolved medical or social issues (e.g. family concerns)
V. what you are worried about and perhaps suggestions for what should be done if your concerns occur
VI. plans for future care

❑ Clearly document who will be taking responsibility and when (i.e. start and end times, and dates).

❑ Discharge summaries
At discharge, it is important to document the following:

⮚ the course in hospital, including treatments and complications or intercurrent problems

⮚ who was consulted and actions taken in response
⮚ investigations done and actions taken
⮚ investigations
⮚ with results pending
⮚ to be done after discharge and who is responsible for ordering these
⮚ who will be responsible for follow-up of those results
⮚ follow-up plans
⮚ what, when, who
⮚ discharge instructions
⮚ action taken to make relevant persons aware of the plans
 When to document
❑ It is best to document events as soon as possible following the event (contemporaneous). This is because memory about
details tends to fade with time, other events may occur, and there may be disputes concerning their sequence. For example,
it may later be important to know if certain symptoms or findings were present before or only after a particular caregiver's
intervention.
 Case: Delay in documentation

• Background
A patient is discharged from hospital. The discharge summary is not completed before the patient is re-admitted under
the same physician. This second admission is prolonged and complicated by several intercurrent illnesses and events,
ending in death.
When the physician completes the discharge summaries for both events, laboratory findings from the second
admission are included in the summary for the first.
• Think about it
How might this discharge summary compromise the physician?
• Outcome
At a subsequent mortality review, there was an inference of delay in responding to these results, with delayed
diagnosis and treatment.
Only after detailed review of both admissions was the true sequence of events established.
• Lessons learned
Delay in documentation can result in uncertainty about what actions have already been taken, with potential negative
consequences for both patients and providers.
 How to document
❑ Communication with other members of the team is optimized when:
1. a standard format (e.g. SOAP) is used
2. only standard abbreviations, or none at all, are used
3. notes are objective and relevant
4. writing is legible

Adhering to these principles is also important when your work is being assessed by an examiner for the College, an
expert, or a lawyer.

❑ SOAP stands for:

I. Subjective (e.g. history)
II. Objective (e.g. physical examination)
III. Assessment of the patient's condition
IV. Plan for further investigation or treatment
 Electronic medical records
❑ Electronic medical records (EMRs) offer real advantages in accessing the health information of your patients.

❑ Medical students should:

I. Spend some time to learn how to use the software.
II. Give the same attention to documenting patient care in an EMR as when using a paper medical record.
III. Be aware of any specific College, hospital, clinic, or office rules about documenting patient care, and making
additions, edits, and corrections to medical records.
IV. Never disable the software's audit capability with the intent to improve system performance, change information, or
for any other purpose.

❑ Decision support tools and alerts

• Many EMRs include tools to help with decision-making and to alert users to potential problems such as drug
interactions.
• These tools should never be disabled. The information should be considered to determine if it is relevant for your
patient.
• When using such tools, it is vital to write a clear note in the record that indicates the thought process leading to
the reason for having chosen an alternative treatment.
 Who owns the medical record?
❑ In 1993 the Supreme Court of Canada made it clear that:
A. the information in the medical record belongs to the patient. However,
B. the physical record belongs to the person or organization responsible for its creation, that is, the
hospital or a physician in private practice.

❑ What this means:

I. Patients have a right to see the content of their record at any time and for any reason, subject to certain
exceptions (e.g. if there is likelihood of harm to the patient).
II. Any inappropriate notations can be embarrassing to, or even grounds for litigation against, the writer.

❑ The owner of the physical record is responsible for controlling access by others in accordance with privacy law.
 Problems and pitfalls

❖ Informal interactions

Information given or received by telephone without documenting it is often forgotten, but can be vital to both patient and
doctor.
Similarly, informal discussion (for example in the corridor) may lead to a decision to do or not do something. If there is
an adverse outcome, the reason for that decision may be questioned. If there are no notes, it is likely the details will be
forgotten.

❖ Correcting the medical record

There are times when information is entered incorrectly — perhaps on the wrong patient's record by accident or perhaps
due to a misunderstanding or just a "slip of the pen." Corrections can be made, but must be done properly to avoid an
appearance of deliberate falsification.

⮚ On a paper record:
✔ Cross out incorrect information with a single line, date and initial it.
✔ The original information should still be legible.
✔ Write the correction and the date you write it.
✔ If there have been subsequent notes, place the correction after the latest, date it, note the date of the notation
being corrected and include the reason for the correction (new information, patient corrected self, etc.).
 Problems and pitfalls

NEVER make a correction or change an entry after learning of a complaint or legal action.

⮚ On an electronic record:
✔ Indicate the reason for the change.
✔ Enter the correct information.

An EMR should have an audit function that will indicate who made any entries or changes and when. If the EMR
allows deletion, it should store and permit access to deleted text.

NEVER allow others to use your password, use someone else's password, or make changes after learning of
a
complaint or legal action.
 Problems and pitfalls
❖ Lost, misfiled, or misdirected documents

A common cause of legal action in a doctor's office is failing to deal properly with lab or diagnostic imaging reports. It may
be because the test or investigation:
⮚ wasn't done
⮚ wasn't reported
⮚ report was not received
• was not sent
• was sent to the wrong place
⮚ report was not read
• was filed before reading
• was "at the bottom of the pile"
⮚ report was not acted upon
• significance not recognized
• incidental finding not related to reason for test
• patient did not return

Such problems can occur in hospitals, community services, clinics, and offices.

• Hospitals have a duty to file test results in the medical record in a reasonable time.

• Doctors in their own offices should have a system to track, file, and deal with test results.
 Case: A lost test report

• Background
A woman booked for tubal ligation (TL) has a pre-op exam at the hospital. A PAP test is done.
A week later she is admitted and the TL is performed uneventfully. The PAP test report is not included in the chart.
The patient does not see the doctor again and when the health authority closes the hospital all records, including lab
tests, are put into storage.
• Outcome
A year later the patient is found to have cervical cancer. The original PAP test report is located. It shows severe
dysplasia. The patient dies 18 months later.
• Think about it
What system processes might prevent this from happening again?
• Lesson learned
An effective tracking system in the physician's office would have identified that the PAP test result had not been
received. This would have alerted the physician to follow up the result. He would then have contacted the patient for
further care.
 Case: An important arrhythmia

• Background
An emergency physician diagnoses a concussion on a teenager who fell and struck her head after fainting. The
paramedics note a rapid dysrythmia that resolved. The emergency physician notes a borderline abnormal QT
segment on the electrocardiogram (ECG). He forwards a copy to the pediatric cardiologist for a second opinion.
The cardiologist highlights the abnormality and documents a possible long QT syndrome on the ECG report. There
is no direct communication between the two physicians.
The cardiologist intends to send the report back to the emergency physician. However, it is inadvertently sent to an
uninvolved physician with the same surname but different initials. The patient's family physician also does not receive
the cardiologist's report.
A year later, the patient suffers a fatal Torsades de pointes arrhythmia.
• Lessons learned
This case highlights several communication failures:
i. There was no direct communication between the emergency physician and cardiologist.
ii. The cardiologist did not phone or fax the emergency physician to advise him about the potentially serious ECG
abnormality and arrange for follow up.
iii. The ECG report was inadvertently forwarded to an uninvolved physician, who did not redirect it to the appropriate
physician.
iv. When the emergency physician did not receive the ECG report, he did not follow up with the cardiologist.
v. The family physician did not receive the ECG report.
1-That is incorrect
Particular patterns of injuries should raise your suspicions about potential child abuse. Physicians in all provinces and
territories have a mandatory legal duty to report their suspicion of child abuse.

2-That is correct
Every Canadian province and territory has legislation requiring physicians to report children who may be in need of
protection, including instances of suspected child abuse, to the appropriate child welfare authorities. Failure to report
constitutes an offence.
Physicians are protected against legal action for making the required report, if the report was not made maliciously or
without reasonable cause.

3-That is incorrect
However, an evaluation by social workers may be only part of the solution.

4-That is incorrect
Such medical conditions are rare. Depending on the clinical findings, it may be necessary to rule these out.

5-That is incorrect
Physicians in all provinces and territories have a mandatory legal duty to report their suspicion of child abuse.
1-That is incorrect
The legal framework for obtaining informed consent from a patient for a given operation, procedure, or treatment was
established by the Supreme Court of Canada in the case of Reibl v. Hughes. The "reasonable physician" standard was replaced
by the "reasonable patient" standard.

2-That is correct
Consider what a reasonable patient in the patient's position would have expected to hear before consenting:
• the nature of the problem
• the proposed treatment and the chances of success
• any significant risks
• any special risks particular to the situation of the patient
• significant alternative therapies available
• the consequences of no treatment
Try to set realistic expectations for the patient and family. A meaningful dialogue helps establish trust, and this is helpful later if
things do not go as planned.
Consider the impact of an adverse clinical outcome on the patient's ability to work or to the patient's lifestyle. Remember that a
physician's general demeanor and tone influences what the patient hears and remembers.

3-That is incorrect
Generally speaking, the more frequent the risk, the greater the obligation to discuss it beforehand. In addition, even uncommon
risks of great potential seriousness should be disclosed. The Supreme Court of Canada has indicated that even if a risk is "a
mere possibility" but if it carries serious consequences such as paralysis or death, it should be regarded as material discussed
with the patient.

4-That is incorrect
To make an informed decision, the significant risks of a procedure also need to be discussed. Invasive procedures (even
minimally invasive ones) may have significant risks.
5-That is incorrect
The informed consent process is more than a signature on a form. It is about building a relationship with the patient
and establishing expectations. Invite patients to participate in the decision-making process. The explanation given by
the physician — the dialogue between physician and patient about the proposed treatment — is the all important
element of the consent process.
The consent form is simply evidentiary, written confirmation that explanations were given and the patient agreed to
what was proposed.
1-That is incorrect

2-That is incorrect

3-That is correct
An emergency situation (severe suffering or an imminent threat to life or health of the patient) is an important exception
to the general rule that consent must always be obtained before treatment.
In an emergency, when the patient (or substitute decision maker) is unable to consent, a physician has the duty to do
what is immediately necessary without consent. Treatments should be limited to those necessary to prevent prolonged
suffering or to deal with the imminent threats to life, limb, or health.

4-That is incorrect
However, if the patient is unable to communicate in emergency situations, the patient's known wishes must be
respected. Therefore, before proceeding and if the clinical condition allows, the physician will want to be satisfied that
no advance directives exist or other indications that the patient does not want the proposed treatment.
As soon as the patient is able to make decisions and regains the ability to provide consent, a proper and "informed"
consent must then be obtained from the patient for additional treatment.

5-That is incorrect
In an emergency when the patient (or substitute decision maker) is unable to consent, a physician should not delay in
doing what is immediately necessary. Consultation to help deal clinically with the management of a patient may be
appropriate or prudent.
1-That is incorrect
Confirm that the wife is the SDM. The SDM has the right to participate in decisions on withholding or withdrawing
life-sustaining treatment. However, the SDM must act in compliance with any prior expressed wishes of the patient,
or in the absence of any expression of will, in accordance with the best interests of the patient.

2-That is incorrect
Obtaining advice on prognosis or help with treatment, particularly from providers that know the patient, may be
helpful in some cases.

3-That is incorrect
Physicians should act in the best interests of the patient. There is no obligation to provide treatment that is futile. In
some circumstances consensus on how to proceed may not be reached with an SDM or family, and it is necessary
to apply to a court (or an administrative body) for directions.

4-That is correct
Confirm that the wife is the SDM. Clarify with the SDM the medical condition, prognosis, and patient's wishes, and
then provide your recommendations on how to proceed.
The best interests of the patient are paramount when making end-of-life decisions.
The patient may have an advance directive (sometimes referred to as a living will), with explicit instructions relating
to consent or refusal of treatment in specified circumstances. End-of-life decisions should be documented in the
patient's medical record.

5-That is incorrect
Obtaining information and advice, particularly from those who know the patient, may be helpful in some cases.
1-That is incorrect
Obtaining information and advice, particularly from those who know the patient, may be helpful in some cases.

2-That is incorrect
A detailed explanation of the pathophysiology is likely excessive, however, some explanation of the disease using
terms the patient will comprehend is required.

3-That is incorrect

4-That is incorrect

5-That is correct
When being discharged, patients should be advised how to recognize:
• the symptoms and signs indicating complications may be developing
• the urgency of the response required
• where best to seek medical attention
1-That is incorrect
Consent to treatment may be implied or it may be specifically expressed either orally or in writing.
Consent may be implied in many circumstances either by the words or the behaviour of the patient or by the
circumstances under which treatment is given.
Expressed consent in written form should be obtained for surgical operations and invasive investigative
procedures.

2-That is correct
Material and special risks are discussed. Material risks include risks that occur frequently as well as those that are
very serious, such as death or permanent disability.
A patient's special circumstances might require discussion of potential but normally uncommon risks of the
investigation or treatment.

3- That is incorrect

4-That is incorrect
Information resources should be seen as an adjunct and not a substitute to consent discussions. For relatively
standardized treatments and investigative or therapeutic procedures, background information about what is being
proposed may be provided in the form of, for example, information sheets, brochures, or electronic resources.
These should invite questions about the treatment and indicate there will be an opportunity for further discussion
after the resource has been reviewed.
Often, consent explanations must be tailored to the particular circumstances of the individual patient.

5- That is incorrect
 1- That is incorrect
Generally, a capable minor would need to consent to the involvement of parents in healthcare decisions. If a parent is
present, and depending on the nature of the presenting complaint, it may be important to ask to speak with the minor
alone so sexual activity and other sensitive issues can be addressed.
In some situations and depending on the nature of the medical condition and the complexity of any proposed
treatment, it is often prudent to stress the importance of involving the parents, and to obtain permission to do so.

2- That is incorrect
An individual is considered to have the necessary capacity to give valid consent if the person is able to understand the
nature and anticipated effect of a proposed medical treatment and alternatives, and to understand the consequences
of refusing treatment.
In addition, in Québec the consent of the parent or guardian or the court is necessary for those under 14 years of age.

3- That is incorrect

4- That is correct

5- That is incorrect
Generally, a capable minor would need to consent to the involvement of parents in healthcare decisions. If a parent is
present, and depending on the nature of the presenting complaint, it may be important to ask to speak with the minor
alone so sexual activity and other sensitive issues can be addressed.
In some situations, and depending on the nature of the medical condition and the complexity of any proposed
treatment, it is often prudent to stress the importance of involving the parents, and to obtain permission to do so.
1- That is correct
Patients should be informed about the participation of medical trainees in their care. Some patients might refuse. This
is the patient's prerogative.
When delegating, the supervising physician must decide on the appropriate level of supervision under the
circumstances, given the training level and experience of the trainee.
Trainees should recognize their limitations and not hesitate to voice any concerns about performing a task unfamiliar to
them, or to ask the appropriate questions to clarify what is expected.

2- That is incorrect

3- That is incorrect

4- That is incorrect

5- That is incorrect
1- That is incorrect
There should be no attempt to obtain a blood sample for the police in these situations without the patient's consent or
a warrant issued by a Justice of the Peace. However, there can be clinical reasons to measure the serum ethanol
level.

2- That is incorrect

3- That is incorrect

4- That is incorrect

5- That is correct
In general, there is no legal duty to respond to inquiries made by the police. To comply with the requirements of
confidentiality, physicians should respond to police inquiries such as these by respectfully reminding police that
physicians must keep patient information confidential. There should be no attempt to obtain a blood sample for the
police in these situations without the patient's consent or a warrant issued by a Justice of the Peace. However, there
can be clinical reasons to measure the serum ethanol level.
For routine police inquiries, physicians should respectfully request the police obtain a search warrant to see the
patient's medical record.
1- That is incorrect
Important test findings and interpretations should be included in the medical record The ECG findings alone do not fully explain
the rationale for a physician's decision making but are a component of a sound decision.

2- That is correct
Costochondritis is a more common diagnosis in a younger patient who appears well. MI in this age group is very unusual. It is
difficult to justify admitting all patients with chest pain with a low probability of CAD for observation and further investigation. The
patient's initial denial of cocaine use meant clinical suspicion was lowered and the decision to discharge was reasonable.

The defense is always aided by good documentation. In this case the following helped confirm that the initial assessment was
done well:
• important historical information including any risk factors
• the overall appearance of the patient and important physical findings
• the tenderness of the chest wall and the reproduction of pain, although in retrospect these findings likely misled the
physician
• as appropriate, the differential diagnosis including any serious clinical conditions that have been considered. A brief
statement in some cases on why a particular condition was not pursued or was ruled out will help explain clinical reasoning
and judgments.
• important test findings (e.g. the ECG interpretation)
• documented discharge instructions. On the initial visit, this patient was provided information on symptoms and signs specific
to chest pain that should prompt reassessment. It is helpful to state and document if the diagnosis or clinical situation is
uncertain so the patient has the proper expectations.

3- That is incorrect
The lack of a family history of CAD supports the rationale for the decision to discharge the patient. However, it is a component of
the rationale for decision making and not the best answer.

4- That is incorrect
We are not told whether the patient is distressed in this case. However, it is generally wise to consider serious or potentially life
threatening diagnoses and determine whether it is appropriate to investigate further.

5- That is incorrect
While documentation of advice given to patients is important, this is not the best answer for this case.
1- That is correct
The lung nodule was a secondary finding and not related to the main clinical reason for ordering the investigation; this is likely
why it was lost during follow-up. The patient was not made aware of the abnormality.
Canadian courts expect the ordering physicians to appropriately follow up on the results of investigative tests, unless other
arrangements are made. National clinical practice guidelines also suggest communication of critical or unexpected findings
between radiologists and ordering physicians.

2- That is incorrect
It is not practical to keep patients in hospital for further investigation if this can be accomplished safely in the ambulatory
setting.

3- That is incorrect
The patient was made aware of the aspirated foreign body but not the incidental finding of the lung nodule. Although
communication of the finding and its importance would have made the necessary follow-up more likely to happen, there is a
better answer for this case.
Try again

4- That is incorrect
There is a better answer in this case. However, documentation in a consultation report, in a progress note or in a patient's
problem list of an important finding and who has agreed to follow up could potentially avoid what happened in this case.
Documentation of when and how findings have been communicated can also help identify where systems of care have broken
down so these can be fixed.
Documentation can help defend a claim of negligence (professional civil liability in Québec) to show that what was done was
appropriate and reasonable in the circumstances.

5- That is incorrect
Mandatory follow up of all discharged patients is not practical. The hospital in this case reviewed the systems and processes for
the follow-up of test reports and identified a number of failures. Several improvements were proposed, including the
introduction of a "tickler system" to prompt the notification of reminders to patients for follow up.
1- That is incorrect
A review of the patient's past medical records is helpful in most cases. The records in this case might have reinforced the
nurses' opinions of a malingering patient exhibiting drug seeking behaviour, and misled the physician.

2- That is correct
The physician kept an open mind and did not permit cognitive biases such as bandwagon effect (diagnostic momentum) or
attribution effect from deterring her from searching for other pathology.

3- That is incorrect
In this case the physical examination of the abdomen was exceptionally difficult and could not be relied upon given the
patient's distress.

4- That is incorrect
Although the radiologist interpretation of the images was an important component of the successful diagnosis, there is a
better answer for this case.

5- That is incorrect
In this case the patient's name on a list of patients with drug seeking behaviour kept in the emergency department would
have compromised the physician's objectivity. Physicians are advised to remain alert to their obligation to protect patient
confidentiality when considering the creation of lists of patients attending the emergency department for any specific
reason.
 CMPA:
Managing risks
 Objectives

❖ After completing this domain you will be able to:

I. Outline some of the challenges and pitfalls in diagnosis.
II. Describe 3 risks in surgical care.
III. List 5 ways to reduce risks related to medications.
IV. List 4 ways to foster a better doctor-patient relationship.
❖ Steps to diagnosis

❑ Arriving at a diagnosis is often complex, involving multiple steps:

✔ taking an appropriate history of symptoms and collecting relevant data
✔ physical examination
✔ generating a provisional and differential diagnosis
✔ testing (ordering, reviewing, and acting on test results)
✔ reaching a final diagnosis
✔ consultation (referral to seek clarification if indicated)
✔ providing discharge instructions, monitoring, and follow-up
✔ documenting these steps and the rationale for decisions made

❖ Differential diagnosis
• Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient's
symptoms and signs — is an important part of clinical reasoning. It enables appropriate testing to rule out possibilities
and confirm a final diagnosis.

• The list might be prioritized by likelihood and urgency.

• Courts view the formulation and documentation of a differential diagnosis as evidence of a physician's competence,
prudence, and thoughtfulness.
 Case: A 58-year-old man with back pain

• Background
An obese Caucasian male, with a history of hypertension and smoking, complains of severe lower back pain that has
lasted four days.
The back pain is accompanied by occasional vomiting and radiates intermittently to both lower quadrants of the abdomen.
The increased severity of back pain had awoken him on the morning he sees his doctor.
Vital signs are normal except for a mild elevation of the systolic blood pressure. Dr. A assesses the patient at 0500 hours and
finds no significant physical abnormalities. Femoral pulses are strong and symmetrical. A flat plate X-ray of the abdomen is
read and later confirmed as normal. A complete blood count (CBC) is normal.
• Background continued
The preliminary diagnosis by Dr. A is musculoskeletal back pain. Narcotic analgesics are administered.
At shift change the patient's care is transferred to Dr. B, who reviews the patient and agrees with the previous diagnostic
impression of mechanical back pain.
Dr. B subsequently discharges the patient with a prescription for analgesics and the instruction to find a family doctor for
follow-up care.
• Outcome
Two days later, the patient is found dead at home.
An autopsy reveals a ruptured abdominal aortic aneurysm (AAA) with 3,000 cc of blood in the retroperitoneal space.
The patient's family threatens a legal action against Dr. B, alleging failure to diagnose the condition and failure to provide
adequate discharge instructions.
• Think about it
What can we learn from this case?
• Lessons learned
Leaking AAA may mimic renal colic, mechanical back pain, and diverticulitis/gastroenteritis.
In particular, AAA might be considered in the differential diagnosis of an older patient with symptoms suggestive of renal
colic.
 Case: A 58-year-old man with back pain (continued)

Severe radiating pain is a common symptom. Syncope and vomiting may also be associated with AAA.
A patient with persistent symptoms may warrant a new evaluation. As appropriate, alternative diagnoses including the
"worst case" possibility should be considered.
Patients with pain require analgesia. Even if appropriate doses of narcotics control the patient's pain, it may still be
prudent to review the patient to determine if the diagnosis is being masked by the analgesia. When appropriate doses
of narcotics fail to control pain, the patient's diagnosis should be reassessed.
In appropriate clinical circumstances, the medical record should indicate that the diagnosis with the worst prognosis, in
this case AAA, was considered and was pursued if reasonable to do so.
The rationale for not investigating should also be clearly documented.
❖ The CMPA's experience
• The presence of certain "red flag" findings may prompt experienced physicians to accept or rule in a serious
specific diagnosis. Yet even experienced physicians are often surprised by the range of the symptoms and signs
of diseases.
 History taking and data collection

❖ In a legal action, peer experts will be critical if insufficient information had been obtained from the patient.

1. Have you taken an adequate history of the patient's health condition and provided the patient with the opportunity
to express his or her current health concerns?

2. If the patient is unable to provide a history (e.g. language barrier, capacity issue, etc.), have you consulted those
who may be able to assist in obtaining the history?

3. Have you adequately assessed any relevant risk factors, including family history, which might help in diagnosis?

4. Are there any red flag symptoms?

5. Have you determined what the patient has already done to manage his or her symptoms?

6. If assessing a patient over the telephone, have you obtained sufficient history to be able to provide a professional
opinion?

7. Have you read the notes taken by other healthcare professionals (e.g. nurses, paramedics)?

8. Are pertinent medical records, test results, and consultation reports available and have they been reviewed?
 Physical examination

❖ In a legal action, peer experts will be critical if they consider the physical examination to have been cursory given
the patient's symptoms.

1. Have you performed an appropriate physical examination?

2. Is it necessary to take the vital signs, and have you accounted for any abnormalities?

3. Have you assessed the patient appropriately for the clinical complaint (e.g. to examine the abdomen of a patient
with new onset abdominal pain, the patient is undressed and gowned, lying prone)?

To avoid misunderstanding, explain the reasons for the physical examination, particularly of the genitalia. Consider
having a chaperone present for intimate examinations.
 Differential diagnosis

❖ Developing a list of possible conditions that might produce a patient's symptoms and signs is an important part of
clinical reasoning.

1. If a serious diagnosis comes to mind based on a patient's symptoms, have you considered the likelihood of it and
whether it needs to be ruled out by testing or referral?

2. Because many serious disorders are challenging to diagnose, have you considered ruling out the worst case
scenario?

3. As a medical student, have you discussed possible diagnoses with your supervisor? (Many supervisors prefer
discussing a differential diagnosis prior to having it entered in the medical record by the student.)
 Formulating a diagnosis

❖ Relying solely on the classic features of a disease may be misleading. That's because the clinical
presentation of a disease often varies: the symptoms and signs of many conditions are non-specific
initially and may require hours, days, or even months to develop.

1. Do you have sufficient understanding of the clinical presentation to offer an opinion on the
diagnosis?

2. What other diagnosis could it be? How might the treatment to date have altered the clinical pattern?
(When assuming the transfer of care of a patient, reformulating the differential diagnosis may be
prudent, especially if the clinical picture is evolving, the diagnosis is not yet firmly established, or the
clinical care to date has not resolved the concern.)

3. If the patient returns with persistent symptoms or fails to respond to the therapy as expected, have
you considered starting over with a new evaluation and look at alternative diagnoses?

4. Have you considered using diagnostic decision support tools (sometimes part of electronic health
record systems)?

5. Are you distressed by the patient's condition or behaviour? (Allowing yourself to become anxious by
a particular case may cloud your judgment and inhibit an accurate diagnosis.)
 Ordering investigations

When deciding whether to use an available — albeit limited — healthcare resource, use sound medical judgment and
act in your patient's best interests.

1. Are laboratory tests, biopsy, diagnostic imaging, or other investigations indicated?

2. Are you familiar with the current clinical practice guidelines for the investigation of a suspected condition?

3. Have you requested the appropriate investigation? Is the test available in a timely manner? If not, have you
considered alternatives and discussed this with the patient?

4. Does your completed diagnostic imaging requisition contain pertinent clinical information to help the radiologist?

5. Does your completed requisition contain the pertinent clinical and specimen information as well as the correct
patient identifiers?

6. Is it possible the patient is pregnant? If it is a possibility, has it been ruled out with an appropriately timed pregnancy
test? Is the investigation contraindicated in pregnancy? Has the patient been informed of the risks and benefits of
the proposed investigation or treatment for herself and the fetus?
 Follow-up of investigations
There are many possible reasons for the failure to follow up on investigations.

❖ The Swiss Cheese model

Safeguards in the system of care are like slices of cheese with holes representing possible failure points.

I. Patient factors
The investigation may not be done because the patient:
▪ is too busy
▪ does not appreciate the need for the investigation
▪ loses the requisition

II. Not reported

The investigation is not reported because:
▪ the specimen is lost
▪ the requisition is separated from the specimen
▪ there is a technological failure resulting in batches of reports not being sent
 Follow-up of investigations
III. Not read
The investigation is not read by the referring physician because:
▪ the report was filed in error
▪ the doctor is on holiday
▪ a different doctor is on duty (e.g. emergency physician)

IV. No action
The investigation is read but no action is taken by the referring physician because:
▪ the significance of the abnormality is not recognized
▪ it is assumed the action is someone else's responsibility:
- it is not my patient
- it is a secondary finding, and not related to the main clinical reason for ordering the investigation
- someone else is better qualified to follow up
▪ the physician recognizes the abnormality and need for follow-up but is unable to contact the patient

V. No review/follow up
Reviewing test reports
▪ Have the results of investigations been reviewed?
▪ Have you read the investigation report carefully and considered whether further investigation or referral is needed?
▪ Have you correctly interpreted the meaning of test and imaging reports, and clarified any areas of uncertainty about the
findings or who is responsible for follow up?
▪ If applicable, have culture and sensitivity reports been reviewed?
▪ Have you followed up with the radiologists' recommendations for further diagnostic tests?
 Case: No news is good news
• Background
A 55-year-old woman has a screening mammogram as a component of her annual health exam. The radiologist
dictates the report as "lesion in left upper quadrant suspicious for malignancy, recommend needle biopsy."
The report is transcribed but not sent to the referring physician.
The patient assumes no news is good news and does not follow up.
The radiologist assumes the report has been sent to the family physician.
• Outcome
One year later the patient presents to her family physician with a palpable breast lump.
Investigation, including biopsy confirms an invasive carcinoma with lymph node involvement.
• Think about it
How might this delay in diagnosis have been prevented?
Who do you think might be accountable for the follow-up of the mammogram?
• Lessons learned
The courts have ruled that when ordering a test the physician must be satisfied there are systems in place, both
in the office and the laboratory/facility, to reasonably ensure the results of the test are received in a timely
manner. In this case, both the family physician and the diagnostic imaging centre have responsibility for following up
on the mammogram.
The more serious the implications of an abnormal result, the more promptly the result should be delivered to the
referring physician. The protocol or system must also provide for appropriate steps to be taken to report the results to
the patient and to arrange necessary follow up.
 Case: Failed follow-up of a biopsy

• Background
A family medicine resident excises and sends to pathology an irritated nevus on the thigh of a 27-year-old teacher
in the ambulatory care clinic.
No follow-up appointment is arranged as the resident is not worried about the diagnosis.
• Outcome
One year later the patient returns to the clinic because he has developed a black spot in the scar of the previous
biopsy.
The supervising physician discovers the previous biopsy report, filed at the back of the patient's medical record,
indicating a malignant melanoma and recommending a wide excision.
• Think about it
Could this happen to one of your hospital patients?
When dictating the patient's discharge summary do you confirm that all investigation reports have returned, been
reviewed and acted upon?
• Lessons learned
Lab and diagnostic imaging tests are of no value if they are not performed, reported, received, read, and acted
upon.
Is there an effective tracking system in place in your practice or facility to review diagnostic tests in a timely fashion?
 Case: Radiology department chief seeks advice

• Background
The chief of a hospital radiology lab calls the CMPA for advice regarding the handling of critically abnormal
investigations which have been ordered by walk-in clinic physicians who are not available to receive the
results, particularly outside regular office hours.
There is no mechanism in place in these walk-in clinics for urgent matters to be reported to a responsible physician.
The problem is further compounded by the fact that patient contact information is often inaccurate on requisitions.
• Think about it
What advice would you give to the chief of radiology?
Do you think urgent critical results may need to be communicated directly to the patient by the radiologist in this
circumstance?
• Suggestions
CMPA advice is based on court decisions:
While the report to patients is usually the duty of the ordering physician, the laboratory or facility may be expected
to take necessary steps to notify patients in cases of emergency when the ordering physician is not available.
Reasonable efforts should be made to contact the patients. It is recommended that the chief discuss with hospital
authorities the need for revised procedures to ensure that patient contact information is accurate.
The chief of radiology also plans to contact the clinics to discuss the issue and find a suitable solution.
 Follow-up of patients
❖ Discharge instructions, monitoring, and patient follow-up

❑ When discharging a patient ask yourself:

• Have you informed the patient of the possible diagnosis or differential diagnosis, and the need and process for follow
up?

• Have you explained the clinical situation to the patient?

– Be objective and accurate.
– Don't make broad statements without good support.
– If unsure, state the diagnosis is not yet determined.

• Have you given the patient discharge instructions that include potential symptoms and signs of a complication, the
urgency of seeking additional care and where to find that care?
– It is generally useful to check that the patient appears to understand what you have conveyed and to address
any questions, to involve family members if permitted by the patient, and to consider providing educational
handouts.
– The patient should feel welcome to return for re-evaluation.

• Is a system in place to facilitate timely follow-up of investigations and patients?

• If you aren't sure about the clinical situation, let the patient know. Don't speculate, but rather wait for more
information. Consider whether a consultation would be helpful.

• Have arrangements been made for appropriate follow-up and, if warranted, referrals to other healthcare resources?

• Has follow-up of the investigative plan been adequate, and do you have a clear understanding of who will be the most
responsible physician for the ongoing management of the patient?
 Follow-up of patients
Should the attending physician be notified of the patient's condition?

• At follow-up visits, should the assumed diagnosis be questioned? Are there new symptoms or signs? Is the patient's
progress as expected given the clinical management?

• Has the transfer of care and delineation of responsibilities been communicated to all relevant parties, and
documented in the medical record?

❖ Referral and consultation if the diagnosis is unclear

• If the diagnosis is unclear, ask yourself:

• Is referral to an appropriate consultant necessary to help establish a diagnosis?

• Have you referred the patient in a timely fashion? (It may be necessary to contact the consultant directly if
warranted by the patient's clinical situation.)

• Have you provided the consultant with sufficient information?

• As a consultant, have you taken the appropriate history, performed a physical exam, and ordered the appropriate
additional investigations? Have you provided a timely consultation letter to the referring physician?

• Are the follow-up plans, and roles and responsibilities of each physician clear to both the physicians and the
patient?
 Case: Failure to follow up a patient following an MRI

• Background
A 47-year-old businessman, with a recently diagnosed large liver mass, is referred to a gastroenterologist.
Physical examination is unremarkable. The gastroenterologist informs the patient the mass is probably a
hemangioma and does not generally require any particular treatment.
Nevertheless, the physician sends the patient for an MRI and blood work, instructing the patient to return when he
has completed the tests.
• Outcome
The gastroenterologist does not contact the patient as he is certain the patient will follow up, having been
instructed to do so.
Nine months later the patient is diagnosed with pancreatic cancer and liver metastasis.
• Think about it
How might this delay in diagnosis have been prevented?
• Lessons learned
The more serious the abnormality and possible consequences on the patient's health, the more urgent it is for the
physician who is aware of the result to take action.
It may be appropriate to directly contact the ordering/referring physician if a critical or unexpected result is found.
Physicians ordering investigations have a duty to communicate the results to the patient and to make reasonable
efforts to ensure appropriate follow-up is arranged.
If applicable, provide information to the consultant from whom you sought advice.
Provide the information to the referring physician. (In this case the gastroenterologist failed to contact the patient).
As a student, notify your supervisor of abnormal test results.
 Case: An investigation for anemia

• Background
A family physician refers a 52-year-old male to an endoscopist for investigation of an iron deficiency anemia and
occult blood in the stools. A colonoscopy is performed, however, the procedure is terminated due to patient
discomfort. Visualization is achieved only to the level of the mid-transverse colon.
The patient is advised to follow up with the endoscopist, but no appointment is given.
Three weeks later, the endoscopist dictates a consultation note stating "a barium enema will need to be arranged to
rule out a lesion in the right colon."
The patient does not receive the appointment for the barium enema and does not follow up with the endoscopist. He
believes the endoscopist wanted the test done prior to seeing him.
• Think about it
How could this delay in diagnosis have been prevented?
• Outcome
Experts who were subsequently asked to comment on this case were not supportive of the care given by either the
family physician or the endoscopist:
Endoscopist expert: "...with the referral and subsequent to the incomplete colonoscopy, the onus of responsibility
specific to investigations, including the barium enema, was the primary and direct responsibility of the consultant."
Family physician expert: "...the (family physician) owed a duty of responsibility, given the time frame of the test not
being done, to ensure that this test had been requisitioned or to direct the patient to contact the consultant. Failure to
pursue either option falls below the standard of care."
The legal action was settled on behalf of both the family physician and the endoscopist.
 Documentation
o A complete medical record is beneficial for both the patient and physician because good documentation facilitates
further care by others and helps demonstrate the physician's attention to detail should medical-legal difficulties
arise.

❑ Does the patient's medical record capture both the temporal course of care, including reassessments, and the
progression of your diagnostic reasoning?

❑ Have you sufficiently documented the following in the medical record?

1. patient identification
2. the date, and if important, the time of the assessment
3. pertinent positive and negative history and risk factors
4. relevant positive and negative physical findings
5. differential diagnoses or the diagnosis
6. diagnostic testing decisions
7. treatment plan
8. consent discussions
9. discussions with consultants
10. patient discharge and follow-up instructions
11. your signature and level of training

o The rationale for your diagnosis and treatment plan should be evident in the documentation. When indicated,
perform a reassessment and add this to the medical record.
 Documentation
o Ask yourself whether another clinician would understand how you reached your diagnosis and whether you
documented sufficient detail about your treatment plan.

o It is always easier to obtain peer expert support when a differential diagnosis has been documented and pursued
if reasonable to do so, or where appropriate, a serious diagnosis was considered and the reasons for ruling it out
were documented.

o It is important to note in the medical record not only when the patient has problems, but also when the patient is
doing well, as this helps track the patient's recovery. This is particularly true post-operatively.
❖ Phases of surgical care

• Operative treatment has potential for serious adverse outcomes and significant medical-legal risks.

• Attention to all phases of surgical care are important to reduce risks:

I. pre-operative assessment
II. indications for surgery
III. consent discussion
IV. technique of the surgery
V. post-operative care and follow-up
 Phases of surgical care

I- PRE-OP

1- Pre-operative assessment
• Consider the information provided by the referring provider.
• Obtain an adequate history.
• Do a physical examination.
• Undertake any appropriate investigations.
• Make or confirm the diagnosis.
• Document your clinical findings and diagnostic impression.
Case example
A patient has been referred by a family physician for removal of a skin lesion on the back. The patient has not previously been seen by the
general surgeon at the outpatient surgical clinic. When the name is called in the waiting room, an elderly woman comes forward. The
surgeon proceeds to remove a lesion from her back. The nurse soon becomes aware this is the wrong patient; the elderly woman was to
have a breast biopsy.
A legal action is later settled. The College is critical of the surgeon for not undertaking a pre-operative assessment and consent
discussion.

2- Indications for surgery

• Are there indications for surgery?
Case example
A patient with inflammatory bowel disease receives brief treatment with medical therapy. Surgery is performed and the patient develops
several complications that cause significant disability.
A lawsuit follows. It is not possible to find support for the early use of surgery, as peer surgical experts feel the patient did not receive an
adequate trial of medical therapy before proceeding to definitive surgery.
 Phases of surgical care
3- Informed consent
• The most important part of the consent process is the discussion between the patient and doctor,
followed by documentation of the discussion in the medical record.
Case example
The patient should be informed of the various treatment options and their risks and benefits. The consent
discussion should be noted in the medical record; the consent form is not the consent.
If a complication is rare, but would be of significance (life-, limb- or health- threatening), the patient should be
informed.

II-OPERATIONS
❑ Operation / Surgical technique
✔ Confirm the correct patient, operation, and side to be operated on.
✔ It may be useful to review the medical record.
✔ Exercise care to protect vital structures such as nerves and vasculature.

Each surgery has unique risks. For example:

✔ When doing spinal surgery, double-check the level.
✔ In certain abdominal surgeries, beware of ureteric injuries and document, when appropriate, any efforts to
visualize or preserve the ureter.
 Phases of surgical care

III-Postoperative
❑ Post-operative care and follow-up
Complications can occur even when the surgery has gone well.
• It has proven difficult to defend the post-operative care when there is a lack of attendance on the patient.

❑ Follow-up
✔ Problems can arise during off-hours and weekends.
✔ If the most responsible surgeon is not available while the patient is still in hospital, nursing staff should know who
is covering and how to get in touch with them.
✔ Patients should have information about who to contact after they are discharged.
✔ When going off duty, the surgeon should communicate the clinical status of his or her patients to the physician
who is covering.
 Phases of surgical care

IV-Documentation
❑ Documentation
The operative note should include details of:
✔ the technique
✔ anatomical findings and variants
✔ difficulties encountered in the procedure
✔ confirmation that sponge and instrument counts were correct

The note should be dictated as soon as reasonably possible. It can be more difficult to defend care if operative reports
are dictated only after a post-operative complication has been recognized. It is also more difficult to defend the post-
operative care if the physician does not note the progress of the patient in the medical record.
It is important to document:
✔ the progress of the patient
✔ when problems start
✔ what is being done
 Case: Post-delivery care of a young woman

• Background
A young woman in her first pregnancy has initially progressed well in labour, but she is failing to progress in the second
stage.
The patient has been pushing for nearly three hours when the obstetrician on call arrives. He has never met this young woman
before. As the patient is tired, he recommends delivering the baby by forceps.
Forceps delivery of the head is followed by shoulder dystocia, which the surgeon is able to successfully manage.
Inspection of the perineum and vagina reveals a fourth degree tear. The delivering obstetrician repairs this using a standard
procedure, and then transfers the patient back to her attending obstetrician for postnatal management.
Neither physician discusses the tear with the patient.
The tear does not heal well and the patient needs further surgery.
• Outcome
The new mother complained to the medical regulatory authority (College) about the on-call physician, citing the following
concerns:
She would have insisted on a caesarean section if she had known the forceps could cause a recto-vaginal tear.
Postpartum care was unsatisfactory.
No one told her about the serious nature of the tear, or its possible long-term consequences.
The College had no criticism concerning the first two complaints relating to the physician's care. However, it did have concerns
about the lack of communication with the patient.
The College stated that "best practice" would have been for the doctor to make sure, before the patient was discharged,
that she was made aware of the circumstances of the tear and repair, as well as the potential complications that might
arise.
The College pointed out that "patients are entitled to be informed of all aspects of their healthcare," including a right to know
about complications that have occurred.
• Lessons learned
When a complication occurs, it is important to decide who should discuss it with the patient, and when.
Usually this is the most responsible physician, but when more than one physician is involved, good communication between the
physicians helps ensure the patient receives both good care and adequate information.
 Case: Check the nurse's notes

• Background
A young pregnant woman develops acute gallbladder symptoms. When the symptoms do not respond to conservative
measures a surgeon is consulted.
Together the surgeon and obstetrician decide to induce labour as early as possible and to follow with definitive gallbladder
surgery. However, a spontaneous delivery occurs and is managed by a nurse before the physician can arrive. The
obstetrician delivers the placenta and notes a mucosal tear, which he believes does not need to be treated.
A study the next day confirms cholelithiasis, and two days post-partum a laparoscopic cholecystectomy is carried out. The
patient tolerates that procedure well, but several weeks later complains of passing stool through the vagina.
The patient ultimately requires repair of a recto-vaginal fistula by a colorectal surgeon. She sues both physicians, alleging
failure to recognize and treat the fistula in a timely fashion.
• Outcome
The nurses' notes for the day following delivery showed the patient had complained to the nurses of passing gas through
the vagina.
The obstetrician stated it was not his habit to read nurses' notes and he did not do so on this occasion. The surgeon who
performed the cholecystectomy also stated he did not read nurses' notes.
The patient said she clearly recalled speaking to the obstetrician about her symptoms.
Experts stated that late repair is typically more complicated than an early repair, often requires revision, and causes more
pain and difficulty. Had either of the doctors read the nurses' notes, it is likely the diagnosis would have been made and the
repair would have taken place earlier. Instead the patient suffered prolonged discomfort and embarrassment before
undergoing a difficult repair.
The experts could not support the standard of care provided, and a settlement was paid on behalf of the obstetrician.
• Lessons learned
Nurses' notes often contain valuable information that can help physicians in the management of patients.
The physician who performs an assessment or procedure may be found responsible for an adverse outcome, even if care is
transferred to another physician.
Communication among members of the care team facilitates safe and effective patient care.
 Case: Post-op discharge instructions

• Background
A 62-year-old man undergoes an uneventful arthroscopy and meniscectomy of his left knee.
On discharge from the day surgery the patient receives written instructions to attend the hospital emergency
department if he has any trouble with his leg. The orthopaedic surgeon also verbally instructs the patient to call his
clinic office if he has any problems.
Three days later, the patient calls the clinic and notifies the receptionist of swelling of the knee and shortness of breath.
The receptionist reassures the patient and suggests applying ice and elevating the leg.
The next day the patient dies from a massive pulmonary embolus.
• Outcome
In the subsequent legal action, the patient's wife alleged the receptionist provided inadequate recommendations, and
the reassurances had discouraged the patient from seeking additional medical care.
The trial judge dismissed the action against the orthopaedic surgeon, but the decision was reversed on appeal.
The Appeal Court believed the surgeon had a duty to inform the patient about the risk of pulmonary embolism. The
judgment noted that an uninformed patient would not be able to establish a link between a minor procedure on the
knee and breathing difficulties.
The plaintiff was awarded compensation.
• Lessons learned
In this case, the Appeal Court stated that post-operative information given to patients is part of the physician's duty to
follow up.
 Checklists in surgical care
❑ Checklists may:
✔ Foster a patient safety mindset.
✔ Improve communication across the patient care team.
✔ Confirm the required tasks are completed.

❖ Canadian Patient Safety Institute Surgical Safety Checklist

Three distinct procedural stages are identified on the CPSI Surgical Safety Checklist:
Briefing — before induction of anaesthesia
Time out — before skin incision
Debriefing — before patient leaves OR

❑ The checklist outlines key safety steps for members of the OR team — surgeons, anaesthesiologists, and nurses —
to follow during each of the three stages. The "designated checklist coordinator" reads aloud each task or item and
confirms that OR team members have performed or addressed each one before proceeding.

❑ Patient safety experts encourage customization of the surgical safety checklist to address the unique needs of a
surgical discipline and practice environment.

❑ The roles and responsibilities of each team member as they pertain to the checklist should be clear. Each team
member is responsible to contribute to the completion of the checklist for each patient. If not performed satisfactorily,
each individual risks being held accountable for his or her role in failing to comply with the checklist.
 Briefing case: Patient information confirmed

• Background
An elderly nursing home resident with Alzheimer's disease falls and fractures her hip. Surgery is scheduled for later that
day.
Consent for the procedure cannot be obtained as no family members are present, and the contact telephone number is
incorrect. The emergency department (ED) nurse is aware the consent has not been signed, but she does not advise the
orthopaedic surgeon.
On arrival in the operating room (OR), the nurse reviews the pre-operative checklist. She inserts a check mark in the box
beside "OR consent," even though no signed consent exists.
The surgeon does not personally verify the consent form before induction of anaesthesia.
• Outcome
Post-operatively, a family member complains that the family had not been advised of the planned procedure and no
consent for surgery had been obtained.
• Think about it
What steps should the team members have taken to confirm that consent for surgery was obtained?
• Suggestions
The ED nurse should have advised the orthopaedic surgeon that there was no signed consent.
The OR nurse should have verified that consent for surgery existed before checking off the "OR consent" box on the pre-
operative checklist.
The orthopaedic surgeon should have verified the consent for surgery when reviewing the patient's clinical documentation
before induction of anesthesia.
The OR team should have verbally confirmed the consent for surgery during the briefing phase.

• Lessons learned
Although other healthcare professionals may play a role in patient consent, the obligation to obtain informed consent
generally rests with the physician who is to carry out the treatment or investigative procedure. [REF]
In situations where the patient is not capable of giving his or her own consent, the consent discussion must take place with
the substitute decision-maker (for mentally incapacitated patients) or a parent or guardian (for minor patients). [REF]
 Briefing case: Antibiotic prophylaxis
• Background
A general surgeon performs an appendectomy on an obese, diabetic patient. No antibiotics are prescribed before
the surgery.
The patient's appendix ruptures intra-operatively.
Despite the administration of antibiotics for three days following surgery, the patient develops serious complications
including intra-abdominal abscess, sepsis, and multi-system failure.
The patient is left with permanent physical disabilities.
• Outcome
The patient initiated and won a legal action.
The court concluded that the general surgeon's failure to prescribe pre-operative antibiotics prior to removal of
an inflamed appendix breached the standard of care.
• Lessons learned
Had a surgical safety checklist been used, the OR team may have recognized during the briefing stage that
antibiotics had not been administered.
 Time-out case: Surgeon, anaesthesiologist, and nurse
verbally confirm

• Background
Prior to right ankle surgery, an orthopaedic surgeon discusses the procedure with a patient and marks the site of
surgery with a felt-tipped marker.
On the patient's arrival in the OR, the surgeon stands on the left side of the OR table. Without checking the marked
site, she places a roll under the patient's left hip.
Following the surgeon's lead, the OR nurses help apply the tourniquet and then prep the left leg with antiseptic
solution. The OR team does not verbally confirm the site of surgery.
Shortly after the skin incision on the left ankle, the anaesthesiologist advises the surgeon that she is operating on the
wrong side. The surgeon promptly sutures the incision and proceeds to perform the intended surgery on the right
ankle.
When the patient wakes up, the surgeon informs the patient about what happened.
No related long-term consequences result.
• Think about it
What steps should the OR team members have taken to confirm the site of surgery before skin incision?
• Suggestions
The orthopaedic surgeon should have visually checked the marked site before positioning the patient's hip.
The nurse should have personally checked the marked site before prepping the skin.
The OR team should have verbally confirmed the site during the time-out stage.
• Lessons learned
Surgeons have a shared obligation to ensure they operate on the correct site, side, and level, and perform the
intended procedure on the correct patient.
It is helpful to review the medical record and patient before the surgery and mark the correct surgical area.
Marking the site is particularly important for procedures that involve laterality (i.e. left versus right or medical versus
lateral), multiple structures, or multiple levels (i.e. digit, skin lesion, or vertebra).
Debriefing case: Nurse reviews with team: instrument,
sponge, needle counts
Background
A gynecologist performs an emergency laparotomy when bleeding difficulties are encountered during lysis of uterine
adhesions.
Multiple sponges are placed into and removed from the abdominal cavity to control the bleeding, which stops with the
application of pressure to the bleeding site
During the sponge count, the nurse reports that one sponge is missing. The gynecologist locates and removes the missing
sponge and closes the wound.
Two days later, the patient develops a fever and abdominal distention. A CT scan reveals five sponges in the abdomen,
which are then surgically removed.
Outcome
An intra-operative abdominal X-ray prior to wound closure confirms there are no further sponges in the abdomen
Experts were of the opinion that the retained laparotomy sponges adversely affected the patient's pre-existing fertility
problem.
Think about it
What else might the gynecologist have done when the nurse reported a missing sponge during the surgical count of the
emergency laparotomy?
Suggestions
Steps the gynecologist could have done include:
✔ perform a manual sweep of the abdomen to ensure no additional sponges remained
✔ consider performing an abdominal X-ray prior to wound closure, particularly due to the emergent nature of the
laparotomy
✔ Factors that increase the risk of retention of a foreign body include:
✔ obesity
✔ emergency procedures
✔ unplanned changes to the procedure
✔ surgeries involving multiple openings or multiple stages
✔ poor visualization of the surgical site
Awareness of these risk factors should alert the OR team to the increased possibility of retention of a foreign body.
Lessons learned
Hospitals have policies and procedures that outline the items that need to be counted, the required documentation, and
measures to be taken in the event of a discrepancy.
 Debriefing case: Nurse reviews with team: Important
intra-operative events

• Background
A general surgeon encounters technical difficulties with an automatic EEA stapler during a low anterior resection
with primary colorectal anastomosis.
Unaware that one of the stapler parts, the anvil, had been retained in the bowel, the surgeon manually sutures the
anastomosis. The OR nurse reports the sponge and instrument counts as being correct.
The anvil later migrates, causing total disruption of the anastomosis.
• Outcome
The foreign body is subsequently removed surgically.
Subsequent colorectal anastomosis is unsuccessful, and the patient is left with two stomas.
Experts believed the anvil was a contributing factor in the disruption of the anastomosis.
• Think about it
What safety measures could the OR team have taken before the patient left the OR to to ensure the anvil was not
left in the colon?
• Suggestions
As the person who placed the anvil into the proximal colon, it was the shared responsibility of the general surgeon
to ensure it was not forgotten prior to manually suturing the anastomosis.
The OR nurse should have inspected the stapler and informed the general surgeon before the end of the
procedure that part of the instrument was missing. This safety step is particularly important as the EEA stapler has
several detachable parts.
• Lessons learned
All surgical instruments should be accounted for and inspected for completeness, particularly if the instrument
breaks, is disassembled during the procedure or has the potential to detach.
When an instrument does not functioning properly, it should be removed from use until it is repaired or replaced.
❖ Using medications safely

❑ Harm from healthcare delivery can occur at any stage in the medication process:
✔ prescribing the medication
✔ transcribing the prescription
✔ preparing and dispensing the medication
✔ administering the medication
✔ monitoring the patient for therapeutic and adverse effects of the medication

❑ Patient factors
✔ known allergies
✔ current diagnosis and co-morbidities
✔ medical history
✔ current medications
✔ pertinent laboratory values
✔ treatment plan

❑ Medication factors
✔ indications for the medication
✔ contraindications and precautions
✔ potential interactions with other medication or food
✔ potential adverse effects and actions to take if they occur
 Case: Sound-alike or look-alike medication
names
• Background
A 67-year-old patient with a history of a mood disorder, mild dementia and intermittent alcohol abuse complains of
depression and insomnia. The psychiatrist changes her antidepressant to clomipramine at bedtime.
The patient's symptoms improve, so the psychiatrist advises her to continue the same medication. After approximately
six months of treatment, the patient is hospitalized due to generalized muscular rigidity, a fine tremor, difficulty moving,
and confusion.
The psychiatrist reviews the patient's actual medications at that time and notes that the pharmacist has been
dispensing chlorpromazine instead of clomipramine. The patient's symptoms gradually improve with no long-term
effects after stopping the chlorpromazine.
• Think about it
To prevent this dispensing error, how should the psychiatrist have written out the medication prescription?
• Lessons learned
Experts commented that the prescription was illegible.
Experts suggested this adverse event (accident in Québec) might have been avoided if the psychiatrist had written
legibly and considered writing both the generic and brand names: clomipramine (Anafranil), chlorpromazine (Largactil).
The pharmacist should have considered contacting the psychiatrist for clarification.
 Using medications safely
❖ When prescribing medications, consider the following:
1. Are you familiar with the medication?
2. Are you familiar with your patient's other medications and potential interactions?
3. Do you know the correct dosage and appropriate route of administration in the circumstances of the particular
patient?
4. Have you explained the risks, benefits, side effects and potential alternatives to your patient (i.e. obtained
informed consent)?
5. Have you instructed your patient on what symptoms might indicate difficulties and how and when to seek
additional medical care should complications occur?
6. Have you prescribed the correct medication? Are your verbal orders clear and your prescriptions legible? (The
names of many medications sound alike and may look alike when written.)
7. Do you use the readback when ordering medications over the telephone?

Timely and effective communications with the dispensing pharmacist may also assist in avoiding medication problems.
 Medication reconciliation
❑ Medication reconciliation is a process in which accurate and complete medication information for the patient is
communicated at all transitions of care — from healthcare facility admission to discharge. Since the process
involves multiple healthcare professionals (e.g. physician, nurse, pharmacist), effective team communication is
essential.

❖ Stages of the medication reconciliation process

The medication reconciliation process should be completed at each stage of the patient's hospitalization:
• Admission: Evaluate each of the patient's home medications and determine if they should be continued,
modified, or discontinued.
• In-hospital transfer: Evaluate whether the patient's present hospital medications should be continued and
whether home medications should be resumed, modified, or discontinued. Note: Transfer refers to a change in
service, level of care (including post-operative), or hospital unit.
• Discharge: To avoid duplicating, omitting, or prescribing unnecessary medications, cross-reference the patient's
home medication list with the most recent medication administration record to compare and evaluate all:
– pre-hospital medications
– medications started or modified in hospital
– planned post-discharge medications
 Medication reconciliation
❖ Medication reconciliation safeguards

Experts have suggested in the CMPA case files that the following medication reconciliation safeguards be considered:
• Obtain an accurate and complete list of the patient's current home medications upon admission.
• When possible, confirm the medications and dosages with the patient or family or substitute decision-maker.
• Refer to the patient's home medications list when writing orders at admission, transfer, and discharge.
• When discharging a patient, compare and evaluate all pre-hospital medications, medications started or modified
in hospital, and planned post-discharge medications. Clarify any discrepancies.
 Case: Resident unaware of patient's anticoagulated
status at admission

• Background
An elderly long-term care facility patient on warfarin falls and sustains a large head laceration, but does not lose
consciousness. Facility staff provide a list of the patient's current medications to the paramedic who, in turn, gives the
list to the emergency department (ED) triage nurse.
Although the nurse notes in the ED medical record all of the patient's medications, including warfarin, she does not
verbally communicate this information to other ED personnel. The ED resident does not review the patient's list of
home medications, so he is unaware of the patient's anticoagulated status.
After examining the patient and suturing the laceration, the ED resident discharges the patient back to the long-term
care facility.
• Outcome
No imaging is ordered because the ED resident believes there is no clinical indication for it.
The patient subsequently dies of an undiagnosed subdural hemorrhage
• Think about it
What do you think contributed to this adverse event (accident in Québec)?
• Lessons learned
A better patient outcome might have resulted if the triage nurse had notified the ED resident and other ED personnel of
the patient's anticoagulation medication.
If the ED resident had reviewed the patient's list of home medications in the ED record, he would have noted the
patient was on warfarin and might have ordered further diagnostic investigations (e.g. International Normalized Ratio
[INR] level, head CT scan).
 Medications for children
❑ Children are at increased risk for adverse drug events for many reasons:
I. Substantial differences in body surface area, weight, and organ maturity (e.g. between neonates, toddlers,
adolescents).
II. The need for individualized dosage calculations based on weight or body surface area, age, and clinical condition.
III. Immature physiological systems in younger children that affect medication absorption, metabolism, and excretion.
IV. Limited dosing range.
V. Lack of information on indications and dosing (due, in part, to a lack of clinical trials in children).
VI. Inability of children to communicate the adverse effects of a medication.
VII. Varying degrees of experience among healthcare professionals caring for paediatric patients.

❑ The Institute for Safe Medication Practices Canada (ISMP Canada) has identified the top five medications that
frequently result in serious adverse drug events in paediatric patients:
i. morphine
ii. potassium chloride
iii. insulin
iv. fentanyl
v. salbutamol
Morphine and fentanyl are responsible for over half of the adverse drug events among the top five medications.
 Medications for children
❖ Safety measures based on the CMPA experience
Experts in the closed medical-legal cases believe certain adverse events (accidents in Québec) related to medications
might be prevented if the physician:
• researches unfamiliar medications
• bases the medication dosage on the patient's current weight
• uses legible handwriting on the prescription
• double-checks the calculation of a medication dosage
• when indicated, tapers the dosage before discontinuing the medication
• labels medications clearly
• documents the administration of a medication
• provides clear instructions to the patient when an existing prescription is modified
• monitors the efficacy of a medication, identifies potential adverse effects, or reevaluates the child's condition before
renewing a medication

❖ Risk management suggestions

The following considerations to manage risk are based on the expert opinions in a review of the CMPA's medical-legal
case files:
• Have you calculated individual doses based on the child's weight or body surface area and clinical condition?
• Are medication reference materials or treatment algorithms readily available and is the information current and
clear?
• Are consultant recommendations clear, particularly when divided medication doses are indicated?
• Have you verified the medication, dose calculation, solution concentration, and route of administration?
• Have you considered the concerns of other healthcare professionals about a medication dose?
• Are your prescriptions legible?
• If a change is required to an existing medication order, whether handwritten or by computer order entry, have you
made the correction according to established documentation principles?
• Have you monitored the efficacy of a medication, identified potential adverse effects, or re-evaluated the child's
condition before renewing a prescription?
• Are your medical records accurate, up to date, and written at the time of the patient encounter (contemporaneous)?
 Case: No leading zero or decimal point for a
medication

• Background
A resident diagnoses gastroesophageal reflux following her assessment of a six-month-old infant.
Based on the weight and length of the baby, the resident determines the correct dose of Maxeran®
(metoclopramide) is 0.2 mg PO QID before feeds. However, she fails to write a leading zero and a decimal point
before the number "2" on the prescription.
• Outcome
The pharmacist dispenses the "2 mg" dose as per the prescription. After receiving six doses of 2 mg, the infant
develops a dystonic reaction, which requires hospitalization.
• Think about it
How could the resident have prevented this prescription error?
• Suggestions
The resident should have carefully double-checked the prescription before giving it to the parent. Had he
performed this simple safety check, he probably would have realized the decimal point was missing from the
intended dose.
Regular use of a leading zero may have prompted him to notice the decimal point was missing on the prescription.
• Lessons learned
Writing medication orders and prescriptions requires your full attention.
Every medication order and prescription should be legible.
When the intended dose has a decimal point, be especially careful to insert the decimal point clearly.
Use a leading zero before a decimal point for doses that are less than one, (e.g. 0.2 mg).
Never use a trailing zero by itself after a decimal point (e.g. 5 mg).
Carefully double-check that the prescription contains all of the required elements before giving it to the parent or
adolescent.
 Case: Omission of critical information on a
prescription

• Background
Following a thorough clinical assessment of a two-month-old infant, a family physician diagnoses a non-resolving
upper respiratory tract infection. He intends to prescribe amoxicillin 125 mg/5 ml strength solution, 2.5 ml, which would
equate to 62.5 mg, three times per day for five days.
However, he actually prescribes 125/5 ml three times per day, which is twice the recommended dosage for the infant's
weight.
After the mother leaves the office, the doctor realizes his error in dosage and notifies the mother.
The mother subsequently complains to the medical regulatory authority (College).
• Outcome
The College recommended that the physician weigh infants and children before prescribing medications to avoid
medication errors in the future.
• Think about it
Why is the weight of an infant or child so important when prescribing medications?
How could this prescription error have been prevented?
• Suggestions
Weight-based dosing is an integral part of paediatric care. To calculate the correct medication dose, the baby's current
weight is required. This is especially important with younger children due to immaturity of their organs.
The physician should have calculated the dose of amoxicillin based on the baby's weight and age.
The physician should have carefully double-checked the prescription before giving it to the mother rather than waiting until
the mother and baby left the office.
• Lessons learned
Obtain the child's weight prior to prescribing any medication.
Determine the appropriate dose of the medication based on the child's weight, age, and clinical condition.
Use mg/kg or mg/m2 as the basis for your dose calculations.
Double-check that all of the required elements are included on the prescription before giving it to the parent or adolescent.
 Medications for the elderly
❑ Patient factors that must be considered when prescribing medication for the elderly include:
✔ age-related physiologic changes that can affect the absorption, distribution, metabolism, and elimination of a
medication, which in turn predispose elderly patients to medication side effects and drug interactions
✔ multiple co-morbidities, often chronic in nature
✔ cognitive impairment
✔ decreased functional ability, including vision and hearing problems
✔ taking multiple medications

❖ High-alert medications

The Institute for Safe Medication Practices (ISMP) identifies the following medications as being high risk for the elderly:
• warfarin
• insulin
• opioids
• digoxin

A review by the CMPA of medication adverse events (accidents in Québec) in the medical-legal files for patients over
the age of 65 identifies the following areas of concern:
✔ neglecting or inadequately performing a patient evaluation prior to prescribing a medication
✔ incorrectly dispensing or administering a prescribed medication by other healthcare professionals (e.g. a
transcription error related to legibility resulted in a fentanyl patch being applied daily instead of q 72 hours)
✔ prescribing or administering an incorrect medication dose (e.g. methotrexate was ordered daily instead of weekly
for rheumatoid arthritis)
✔ delaying or failing to prescribe or administer an indicated medication
✔ prescribing a medication with relative contraindications, most often in the context of allergy or off-label use
✔ inadequately assessing side effects
✔ omitting regular monitoring of drug levels or other measures of efficacy
In addition, there was a lack of documentation of consent discussions for medications.
 Case: Sedating an elderly patient

• Background
A 79-year-old man with symptomatic cholelithiasis is prescribed a narcotic analgesic intramuscularly (IM)
for pain while awaiting surgery. The patient's history includes cognitive deficits, anxiety, panic disorder and
obsessive-compulsive disorder, for which he is taking antipsychotic medications and an anxiolytic.
When the patient becomes very agitated, the physician prescribes additional antipsychotics and anxiolytics PRN.
Over the next 12 hours the patient receives excessive doses of both sedating drugs.
Despite these medications the patient remains intermittently agitated, and physical restraints are required.
The patient develops pneumonia, and suffers respiratory failure. At the request of the patient's family, no
resuscitative measures are performed.
The patient dies two days later.
• Outcome
A legal action ensued.
• Suggestions
Further investigations to identify the cause of the patient's severe agitation should have been conducted before
administering the excessive doses of medication.
Experts stated that while the patient's anxiety, aggressiveness, and dementia-like behaviour contributed to the
complexity of the situation, excessive doses of the antipsychotics and anxiolytics contributed to the patient's
death.
• Lessons learned
When a patient's mental state deteriorates, it is important to investigate the possible causes of the
deterioration before prescribing chemical or mechanical restraints.
Include the maximum recommended dose as part of the medication order.
 Case: Inadequate assessment of an elderly patient

• Background
An elderly diabetic woman presented to a walk-in clinic complaining of dysuria and urinary frequency.
The woman had various medical conditions and was taking multiple medications including Diabeta (glyburide), Cozaar
(losartan), Adalat (nifedipine), and Coumadin (warfarin).
Following assessment by the clinic physician, the patient was diagnosed with cystitis and prescribed an oral
quinolone antibiotic.
The next day, the patient suffered a hypoglycemic reaction and was treated in the emergency department.
• Outcome
A medical regulatory authority (College) complaint followed.
The College concluded that the clinic physician's medical record was incomplete as it did not include the list of the
patient's multiple home medications. Any of the patient's medications could have potential drug interactions with
quinolone, hypoglycemia being one.
As well, as the patient presented with a non-complicated urinary tract infection, quinolone was not the first choice of
antibiotic.
• Think about it
What should the physician have done when assessing the patient that could have prevented the hypoglycemic adverse
drug event from occurring?
• Suggestions
The physician should have reviewed the patient's co-morbidities and home medications to identify any potential drug
interactions before prescribing an antibiotic.
• Lessons learned
When prescribing a new medication to an elderly patient, it is important to consider potential drug interactions with other
medications the patient is taking.
Documenting a complete list of the patient's current medications in the medical record helps to trigger a review of
potential interactions with new medications.
 Opioids
• According to ISMP Canada, narcotics, or opioids, is the class of medications most frequently reported in
adverse drug events resulting in harm.

❖ A CMPA study

A CMPA review of legal actions involving physician-prescribed opioids showed a significant number of patients died. A
number of other patients suffered hypoxic brain injury.

❑ Factors that increase the risk of adverse drug events from narcotics include:
1. multiple products and concentrations
2. various routes of administration, (e.g. oral, subcutaneous, intravenous, neuraxial, transdermal)
3. a range of dosage forms (tablets, liquids, patches), some with potentially confusing suffixes
4. time-release elements (e.g. immediate release [IR], sustained release [SR], extended release [XR])
5. look-alike and sound-alike names (e.g. morphine versus hydromorphone)
6. look-alike packaging and labeling
7. mechanical problems with infusion and patient-controlled analgesia (PCA) pumps
8. the need for increased patient monitoring

❑ The CMPA study identifies the following specific areas of concern:

I. insufficient monitoring of vital signs, respiratory status, pulse oximetry, and level of consciousness in patients at
high risk of respiratory depression
II. prescription issues leading to the administration of a more potent dose
III. incomplete discharge instructions
 Case: Inappropriate prescription of an opioid

• Background
A 14-year old boy with infectious mononucleosis complains of difficulty swallowing due to his sore throat. The family
physician prescribes fentanyl transdermal patch at 25 mcg/hour. He also recommends hospital admission if the
medication is not effective within four hours.
The pharmacist questions the dosage, but she does not contact the family physician about her concerns as she often
finds it difficult to reach this physician. Rather, she advises the mother to monitor her son closely once the fentanyl patch
is applied.
The mother checks on the boy as the pharmacist instructed until he goes to sleep.
The next morning she finds him to be unresponsive.
Resuscitative efforts are unsuccessful.
• Outcome
The coroner's report attributed the cause of death to be respiratory arrest secondary to fentanyl use.
• Think about it
What could have been done differently to prevent this adverse drug event?
• Suggestions
The family physician, especially if unfamiliar with the medication, should have confirmed the correct dosage.
It would have been helpful if the pharmacist had contacted the family physician to discuss the concerns about the
dosage.
• Lessons learned
Always consider patient factors, such as co-morbidities, that may affect the dosage or necessitate closer monitoring for
adverse opiod effects. In this case, the contributing factor was the boy's enlarged tonsils which could potentially have led
to obstruction of the airway.
Provide adequate information to the patient or family members about the risks and potential adverse effects of prescribed
opioids, and the actions to take.
Respond to calls from pharmacists who seek to clarify your prescriptions.
 Case: High dose of morphine prescribed

• Background
A 65-year-old patient complains that Tylenol #3 is no longer effective for chronic osteoarthritic pain.
The family physician prescribes MS Contin (sustained-release morphine sulfate) 60 mg PO twice daily.
Seven days later, the patient develops respiratory failure.
The patient responds well to treatment.
• Outcome
Experts were of the opinion that high doses of narcotics and possibly an underlying lung disease resulting from
smoking were among multiple factors that contributed to the respiratory failure.
• Think about it
What are some of the patient factors to consider before prescribing an opioid such as MS Contin?
• Suggestions
Experts advise physicians to consider the following patient factors when prescribing an opioid:
✔ age
✔ weight
✔ degree of pain
✔ co-morbidities
✔ analgesic history
✔ whether the patient is opioid-tolerant
✔ whether the patient has a pre-existing pulmonary condition or a skeletal disorder that affects respiratory function
 Anticoagulants
❑ Anticoagulants are of great clinical benefit, but they can present challenges to care.

❑ Based on the expert opinions of the medical-legal cases related to anticoagulants, considerations to manage risk
include the following:
✔ Are you aware of your patient's conditions that may warrant the use of an anticoagulant?
✔ Have the appropriate diagnostic investigations been performed and reviewed?
✔ Have you considered the current clinical practice guidelines for prescribing and managing anticoagulants for both
active treatment and prophylaxis?
✔ Have you considered potential interactions with other drugs or natural health and food products?
✔ Would consultation with a specialist be helpful?
✔ Has communication between physicians during the transfer of care of patients on anticoagulant therapy been
adequate?
✔ Has communication with your patient about the anticoagulant therapy and the monitoring requirement been
adequate?
✔ If your patient is taking oral anticoagulant therapy, have you arranged appropriate follow-up and INR monitoring?
Is a systematic process in place to review the INR results, adjust the dosage as appropriate, and document the
dose change?
✔ Does the medical record reflect the discussion about risks in anticoagulant therapy and other treatment options?
 Case: Inadequate monitoring of a patient on an
intravenous heparin infusion

• Background

Day 1
A patient who has been on life-long anticoagulant therapy for a mechanical aortic heart valve, is admitted for a
cerebral angiogram with lumbar puncture (LP) to investigate a neurodegenerative disorder.
The warfarin is stopped, and an intravenous (IV) heparin infusion is administered until six hours prior to the procedure.
Following completion of the LP, the angiogram has to be postponed due to other emergent cases.
Due to concern for a stroke, the neurologist instructs a resident ("resident A") to restart the heparin infusion without a
bolus.
Later that evening the patient complains of low back pain; an oral analgesic is administered.
Day 2
The following morning the neurologist does not see the patient during rounds.
That afternoon the nurse contacts another resident ("resident B") because the patient is complaining of back and hip pain.
The resident prescribes opioids without assessing the patient.
Later that night the nurse notifies resident B that the patient is nauseated and vomiting; an antiemetic is prescribed.
Day 3
Early the next morning the patient is unable to void, and a urinary catheter is inserted. A third resident ("resident C"), who
is responsible for conducting rounds, has to respond to an emergency, so the patient is not reassessed that morning.
That afternoon, the patient becomes agitated and restless. Resident C is notified and prescribes lorazepam.
A few hours later the same resident is advised the patient cannot stand up. He sees the patient immediately and stops the
heparin infusion.
An urgent MRI reveals an anterior epidural hematoma.
The patient is also diagnosed with cauda equina syndrome and is left unable to walk.
• Outcome
Experts were of the opinion that this patient was at high risk for bleeding following the LP.
Given the patient's potential for bleeding, experts were also critical that the residents did not monitor the patient's
neurological status.
 Case: Inadequate monitoring of a patient on an
intravenous heparin infusion (continued)

• Think about it
How could this serious adverse drug event have been prevented?
• Suggestions
The residents and nursing staff could have been more aware of the patient's potential for bleeding and the importance
of monitoring her neurological status.
Had members of the medical team assessed the patient on daily rounds or when notified of the patient's ongoing
complaints, someone may have suspected the patient was developing an epidural hematoma or cauda equine
syndrome.
• Lessons learned
Sometimes it is difficult to appreciate the whole picture when multiple healthcare providers care for a patient.
Considering a patient's symptoms in isolation may not prompt the healthcare provider to consider a more serious
problem, particularly when the patient symptoms seem minor or expected post-procedure.
Patients on anticoagulant therapy with warfarin require monitoring. However, when a patient is at increased risk for
bleeding, it is important that this information is communicated to all members of the healthcare team.
If circumstances prevent patient reassessment when initially informed of a concern, try to reassess the patient within
an appropriate time frame or alert a colleague to assist you.
 Case: Failure to prescribe VTE prophylaxis

• Background
A patient is diagnosed with bilateral hallux rigidus and undergoes surgery to repair one side. Post-
operatively, the patient is treated for deep vein thrombosis (DVT) by another physician.
At a follow-up appointment the patient informs the orthopaedic surgeon of the DVT.
A year later the patient returns to the orthopaedic surgeon to have surgery on the other foot. The surgeon has no
record of the patient's previous DVT in the patient's chart.
The surgery is uneventful and the initial post-operative visit is unremarkable.
Three weeks later the patient dies from pulmonary embolus (PE), secondary to DVT.
• Outcome
Experts were of the opinion that, because the patient previously had a DVT, the orthopaedic surgeon should have
provided adequate thromboembolism prophylaxis.
The documentation in the medical record was inadequate as there was no notation of the patient's DVT following
the first surgery.
• Think about it
What should the orthopaedic surgeon have done that might have prevented the patient's death?
• Suggestions
The orthopaedic surgeon should have documented the patient's post-operative DVT in the medical record when
the patient advised him she had been treated for this complication following the first surgery.
• Lessons learned
Assess each patient for risk of VTE and prescribe adequate thromboprophylaxis if required.
Document relevant clinical information in the patient's medical record at the time of the patient encounter. In this
case, had the orthopaedic surgeon documented the patient's post-operative DVT at the follow-up appointment, it
would have prompted him to prescribe thromboprophylaxis prior to the second surgery.
❖ More good practices

❑ Your demeanour

1. Be polite.
2. Dress professionally.
3. Introduce yourself and any new physicians or trainees.
4. Apologize if the patient has been waiting.
5. Try to provide your full attention to each patient. Dissatisfaction can stem from the impression that a physician is
too busy, or simply does not care.
6. Don't make demeaning, insensitive or dismissive comments or joke about the patient's appearance, medical
condition, and circumstances. Never use profanity.
7. Don't take your frustrations out on the patient.

❑ Interacting with family

When communicating with patients, involve family members early on (with the patient's permission).
 More good practices
❑ Dealing with a lack of resources

Courts have been critical of conscious decisions by physicians not to pursue a particular course of treatment to contain
costs. This is different from situations in which a physician simply cannot provide the treatment due to a lack of
resources.
• Explain to the patient the reasons for any delays in care.
• If a patient's expectations are unrealistic, try to establish the goals of care. Explain what can and cannot be
accomplished.
• Respond to calls for assistance and advice when you are expected to be available or on call.
Unusual or life threatening circumstances, or the lack of immediately required resources may require you to sometimes
provide care beyond your usual clinical skills. Consider whether alternatives are available.

❑ When things are not going well

If a patient voices a concern or makes a complaint, acknowledge and thank the patient for speaking up, and take time
to appropriately address any issues.
1-That is incorrect
Many new medications are introduced to medical practice each year, many with great benefit to patients. A
physician should consult trustworthy pharmacology references, clinical practice guidelines, or knowledgeable
colleagues for information if uncertain about a medication's applicability, dosage, and monitoring requirements.

2-That is correct
Deferral of treatment until more information could be obtained about an unfamiliar medication might have
avoided the over-sedation in this case. For example, the pediatrician could have improved care by
communicating directly with the consultant to obtain advice.

3-That is incorrect
The pediatrician could have contacted the specialist to obtain advice regarding the medication.Both consultants
and referring physicians have responsibilities in the consultative process. Referring physicians should provide
sufficient information to permit the consultant to assist in the care of the patient. Similarly, the consultant should
provide timely letters to the referring physicians. The most responsible physician for ongoing investigations and
monitoring of the patient should be clearly identified.

4-That is incorrect
While this may have played a role in this case, the pediatrician should not have ordered the increased dose of an
unfamiliar medication.

5-That is incorrect
While this may have played a role in the child's over-sedation, it is unlikely to be the primary reason for the
medication adverse event (accident in Québec).
1-That is incorrect
It is true the low incidence of TTP and its early non-specific symptomatology may contribute to diagnostic delay.
However, other factors in this case may have been more responsible for what happened.

2-That is incorrect
If symptoms or test results do not improve, the differential diagnosis can be reviewed, further tests ordered or
consultation obtained. In this case, follow-up may not have occurred for a number of reasons.

3-That is correct
This may have been the most important factor, resulting in the failure to follow up and repeat the platelet count. In this
case, the physician considered the initial somewhat low platelet count to be related to the side effect of the patient's
medication.

4-That is incorrect
Systems and protocols to support timely review of all test results are essential. The delay in following up the slightly
low initial platelet account may not have had a significant impact in this case, but may be used in legal proceedings to
cast doubt on the physician's quality of practice.

5-That is incorrect
This could also be an important factor. When patients have multiple medical conditions, the challenge is to recognize if
non-specific symptoms may be due to an unsuspected problem. The lack of compliance to her treatment for diabetes
might have created a bias in which the fatigue was attributed to her poorly controlled diabetes.
1-That is correct
This child had bacterial meningitis. She was sent home again and was very ill by the next day. Given the repeat visits and concern of
the parents, the development of a differential diagnosis would have been prudent in this case.
A differential diagnosis of meningitis is prudent with fever of unknown etiology. If a significant condition is unlikely but suspected,
consider how it should be ruled out. In some poor outcomes and in many medical-legal cases related to diagnosis, the physician did not
order further testing or consultation, despite the persistence of symptoms.

2-That is incorrect
Although educational handouts help patients recall the information discussed in the informed discharge process, this is not the best
answer in this case. Physicians may be uncertain of the diagnosis for some patients on the initial and even later visits. These patients
should be made aware of this uncertainty — what is known and not known — so that any continuation, escalation or change in
symptoms would prompt re-evaluation. An important aspect of this communication is to make the patient feel welcome to return and
comfortable about seeking further re-evaluation

3-That is incorrect
It is not helpful to suggest to parents that they are over-reacting. Experienced clinicians listen carefully to parents. This case involved
multiple visits and assessments by different physicians. This can be helpful in potentially providing different perspectives; on the other
hand, continuity of care may be lost.
In cases such as this, no one may see "the big picture." A pattern of persistent or worsening symptoms and repeated discharges from
care without a confirmed diagnosis should trigger a fresh assessment of the patient.

4-That is incorrect
Follow the clinical practice guidelines for the appropriate use of antibiotics in children with fever. In this case it is important to reassess
the patient, and reconsider the differential diagnosis before beginning antibiotics.

5-That is incorrect
Although this is a good answer it is not the best answer in this case, as it is best to develop a differential diagnosis prior to arranging
further testing or seeking additional input.
When investigating problems without a clear diagnosis, consider the worst likely condition. Document the rationale for your decisions.
1-That is correct
If a condition does not improve as expected with standard therapy, it may be helpful to reconsider and broaden the differential
diagnosis.

2-That is incorrect
Patients may prefer the convenience of telephone consultations. However, repeated telephone assessments pose risk,
especially if the patient is not improving as expected.
Consider using a "second call / third call" rule: after a second call for the same problem, consult another physician or speak
directly with the patient; after a third call for a persisting or worsening problem, see the patient in person.

3-That is incorrect
In this case, the skin diagnosis was not confirmed and the condition was not improving with standard therapies. An earlier
formal consultation might have led to a final diagnosis sooner.
Simple questions about the diagnosis and treatment of patients can often be effectively and efficiently dealt with in informal
"corridor" discussions between colleagues. More complex problems are better suited to a formal consultation with a specialist,
enabling an assessment to take place in a proper setting with sufficient time allotted.

4-That is incorrect
It is true that many conditions are difficult to diagnose initially. Depending on the clinical case, some conditions may even
require a trial of therapy, before further investigations take place, to rule out other pathology.

5-That is incorrect
When a patient's clinical condition does not improve, physicians are encouraged to directly reassess the patient, reconsider the
differential diagnosis, discuss the condition or possibilities with the patient, and possibly refer the patient to a consultant. Such
consultations may take time.
Dismissive comments that minimize a patient's complaint or that appear to blame a patient risk creating resentment and
dissatisfaction.
1-That is incorrect
The family history is important information to have. In this case the patient's mother had died of breast cancer at age 45.
The experts reviewing this case suggested an up-to-date history with risk factors and family history can determine the
need for diagnostic or screening investigations.
Some offices use questionnaires to streamline how information is captured and periodically patients complete these to
make sure data is up-to-date.

2-That is incorrect
The physician ordered routine screening rather than diagnostic mammography. This led to inadequate imaging in this
case.
The diagnostic imaging request form should include the reason for the test, pertinent history, and any physical findings.

3-That is correct
If the workup concerning the patient's complaint about the breast lump had gone to completion in ruling out cancer, the
cancer might have been detected earlier with the potential for an improved clinical outcome. A legal action related to breast
cancer may be decided in favour of the patient if the workup did not go far enough to rule out breast cancer in the
circumstances.

4-That is incorrect
Follow-up of previous complaints can help ensure things do not fall through the cracks. When the patient returned when
she was pregnant, the patient was not asked about any continuing breast symptoms. This might have triggered further
examination or testing.

5-That is incorrect
This patient was reassured by the physician's inability to feel a breast mass, by the physician's comments, and by the
negative mammography study.
Caution is required in reassuring patients they do not have a serious medical condition. Consider if all of the proper
investigations have been done, and encourage the patient to bring forward any ongoing concerns.
 CMPA :
Human factors
 Objectives

❖ After completing this domain you will be able to:

I. Define human factors.
II. Describe the possible effect of cognitive biases when formulating diagnoses.
III. Explain the importance of situational awareness.
IV. Outline two risks related to using equipment and technology.
❖ What is meant by human factors?

❑ Human factors encompasses many areas including:

• A person's ability to think, reason, and make decisions
• A healthcare provider's mental and physical state can interfere with analysis of problems, planning and
communicating treatment decisions, and the ability to work in a team.

❑ Cognitive abilities can be affected by such factors as:

1. lack of sleep, anxiety, anger, sadness
2. cognitive and affective biases
3. situational awareness
4. alcohol, drugs, and prescription medications
5. physical health conditions and depression

❑ Workplace factors
Interruptions, irrelevant conversations, and noises can be distracting and affect performance.

❑ Ergonomics and how people use equipment and technology

The design of equipment and user interfaces can either facilitate or interfere with their proper use.
❖ Failure to diagnose

⮚ Failure to diagnose is a common allegation in legal actions.

⮚ Non-specific and atypical presentations of diseases are common.
⮚ Cognitive biases can interfere significantly in the ability to reach a correct diagnosis.

❑ The courts will not evaluate your decisions against a standard of perfection. Rather, your decisions will be
evaluated in light of what a reasonable and prudent physician would have decided in similar
circumstances.

❑ Many things can influence the assessment of a patient.

These can be grouped into three categories
as shown in this table.
❖ Influences on reasoning

❑ Cognitive bias is a way of thinking that influences reasoning and decision making, sometimes resulting in
inaccurate judgments.

❑ Cognitive biases (distortions of thinking) and affective biases (intrusion of the physician's feelings) may
interfere significantly with reaching a correct diagnosis.

❑ Irrespective of which method is used to arrive at a diagnosis, all diagnostic decisions are susceptible to cognitive
biases. Many of these biases are inter-related: more than one bias can affect the diagnosis for an individual
patient.
 Influences on reasoning
❑ In recent years, many cognitive psychologists and physicians have studied diagnostic reasoning and decision
making. What have they found?

✔ Novices generally use a slower, analytical approach to reason out a diagnosis, often by gathering more
information.

✔ Experienced physicians often use an intuitive, pattern recognition approach — arriving rapidly and almost
subconsciously at a best match for the patient's symptoms and signs, based on the physician's mental library of
cases and syndromes. So when an experienced physician sees a skin rash, or a patient has a particular
combination of symptoms and signs, or the physician recognizes a clinical syndrome or toxidrome, "pattern
matching" is made to clinical templates previously established through the physician's experience. If no match
occurs or the presentation is ambiguous, the physician may revert to analytical reasoning which requires a more
deliberate, methodical approach.

✔ While bias may affect all aspects of human reasoning, intuitive thinking is generally the most vulnerable.
Many cognitive and affective biases are inter-related and more than one bias can affect the diagnosis of a patient.

✔ Diagnosis by pattern recognition is quick, often very effective and usually correct, but is prone to interference
by cognitive and affective biases that may occasionally mislead even the most experienced physicians.

✔ Expert diagnosticians know when to revert from pattern recognition to analytical reasoning.
 Common cognitive biases

❖ Anchoring
❑ Focusing on one particular symptom, sign, or piece of information, or a particular diagnosis early in the diagnostic
process and failing to make any adjustments for other possibilities — either by discounting or ignoring them.

Examples

1. A 48-year-old woman with known osteoporosis presents with severe back pain after a day of vigorous gardening. A plain
X-ray shows a vertebral compression fracture. Her physician attributes the fracture to her osteoporosis.
The physician's failure to consider other diagnoses results in a delay in the diagnosis of metastatic carcinoma.
The physician "anchored" on the osteoporosis diagnosis rather than developing a differential diagnosis to explain the
fracture.

2. A 22-year-old man presents during flu season with nausea, vomiting, and abdominal pain. The patient does not have
diarrhea. The abdomen is soft and mildly tender diffusely without rebound, and with normal bowel sounds.
The patient is diagnosed with gastroenteritis as the physician focuses on the vomiting and de-emphasizes the abdominal
pain and absence of diarrhea. The patient is discharged.
Appendicitis is diagnosed two days later.

▪ How to think better

✔ Gather sufficient information.
✔ Develop a differential diagnosis.
✔ Consider the worst case scenario.

▪ Reconsider the diagnosis if:

✔ there are new symptoms or signs
✔ the patient without treatment is not following the natural course of the assumed illness and is not improving
✔ the patient is not improving as expected
 Common cognitive biases

❖ Premature closure

❑ Uncritical acceptance of an initial diagnosis and failing to search for information to challenge the provisional
diagnosis or to consider other diagnoses.

Example

• A patient presents with a sudden, severe headache and vomiting following a banquet. The patient believes this is
due to food poisoning.As the neurologic examination is normal, the physician accepts the patient's provisional
diagnosis. The patient deteriorates and a leaking cerebral aneurysm is eventually diagnosed.

▪ How to think better

✔ Gather sufficient information.
✔ Develop a differential diagnosis.
✔ Identify any "red flag" symptoms and investigate appropriately. Consider the worst case scenario — what you
don't want to miss.
✔ Consider consultation with a colleague or specialist.
 Common cognitive biases

❖ Search satisfaction

❑ When one abnormality has been found, calling off the search and failing to look for others.

Example

• A trauma patient is rushed to the OR with a ruptured spleen. Fortunately he survives the surgery; however, he
continues to complain of severe lower abdominal pain. Three days post-op a fractured pelvis is diagnosed. This
finding had already been discovered on the initial radiological examination following arrival in the emergency
department but had been overlooked due to the ruptured spleen.

▪ How to think better

✔ Having identified one abnormality, ask yourself if there is anything more going on?
 Common cognitive biases

❖ Zebra retreat
❑ If it's uncommon, this isn't it — backing away from a rare diagnosis.

Example

• A 28-year-old woman on the birth control pill presents with calf pain following a slip at work. Her family physician
diagnoses a calf muscle strain.The patient dies two days later from a massive pulmonary embolus. Muscular
strain following an injury is a more common diagnosis, however, in this case the diagnosis should have been
Deep Vein Thrombosis (DVT).

▪ How to think better

✔ Physicians are often taught "if you hear hoof beats, think horses not zebras," and generally this is good advice.
But, by considering the worst case scenario diagnosis and then ruling it in or out, you will be less likely to
misdiagnose the patient.
 Common cognitive biases

❖ Bandwagon effect (diagnostic momentum)

❑ Diagnostic labels may stick to a patient. If everyone else thinks it, it must be right!

Example

• The nurses in the emergency department ask you to see and quickly discharge Miss Jones. They explain that she
is a "regular" in the department and is seeking narcotics.Tonight Miss Jones presents again with abdominal pain.
Fortunately, you perform a thorough history and physical exam and diagnose a ruptured ectopic pregnancy.

▪ How to think better

✔ Assess patients appropriately.
✔ Consciously decide to arrive at your diagnosis or differential diagnosis independent of the labels applied by
others.
✔ Taking a diagnostic "time out" to reconsider the differential diagnosis may be helpful.
 Common cognitive biases

❖ Attribution error
❑ A form of stereotyping: explaining a patient's condition on the basis of their disposition or character rather than
seeking a valid medical explanation.

Example
• An intoxicated homeless man presents with a large ulcer on the plantar surface of his right foot. As he is unclean,
unkempt and without shoes, you assume the ulcer is traumatic in origin and there would be little chance of
improvement given his lifestyle. Further investigation reveals he is not intoxicated, but rather diabetic. With
appropriate therapy and support the patient is able to manage his diabetes as well as heal the foot ulcer.

▪ How to think better

✔ Every patient and every healthcare provider are unique individuals.
✔ Unfortunately, we may be biased toward a patient with a particular illness, particularly a psychiatric illness, or drug
or alcohol addiction.
✔ Avoid the rush to stereotype a patient based on culture, gender, illness or disability, religious or sexual orientation,
and so on.
✔ Acknowledge that you may not have the best rapport with a specific patient and take particular care with the
impact of this on your decision making and judgment.
 Common cognitive biases

❖ Authority bias
❑ Declining to disagree with an "expert."

Example

• The hospital you are working in as a medical student is short of beds. The senior resident sends you to the
medical ward to quickly discharge a 67-year- old patient admitted the day before with COPD. You are told the
patient has improved and can "go home" to follow up with the family doctor. When you go to see the patient, the
family members take you aside and voice their strong concern about discharging the patient. You decide to re-
examine the patient, and find the patient in mild respiratory distress. You repeat the vital signs and the patient
now has a temperature of 39 C. Concerned, you telephone the resident, and learn that this is something the
family doctor should deal with. What should you do now?

▪ How to think better

✔ All members of a team should have a voice and any team member should speak up respectfully if there is a
concern about the safety of a patient.
 Common cognitive biases

❖ Availability heuristic
❑ Recent or vivid patient diagnoses are more easily brought to mind (i.e. are more available) and overemphasized
in assessing the probability of a current diagnosis. A heuristic is a mental shortcut.

Examples

• In influenza season, it is tempting to consider all patients with fever and myalgias as having influenza. Similarly,
you may see every slightly irregular light brown nevus as a potential melanoma after you were surprised by an
unexpected diagnosis of melanoma in a recent biopsy. This can lead to inappropriate biopsies of clinically benign
lesions.

▪ How to think better

✔ Be aware of the influence of recent diagnoses on your diagnostic acumen.
1. On the one hand, watch for red flags, or symptoms or signs inconsistent with a common, less serious
diagnosis.
2. On the other hand, don't over-investigate or over-treat based on an unexpected recent diagnosis in another
patient.
❖ Knowing what is going on around you

❑ Situational awareness is considered one of the most important non-technical skills of a physician.

❑ Situational awareness refers to a person's perception and understanding of the dynamic information that is
present in their environment. It is keeping track of what is going on around you, and includes anticipating what
might need to be done.

❑ Team situational awareness is "task- and team-oriented knowledge held by everyone in the team and the
collective understanding of the unfolding situation.“

❑ There are 3 components of situational awareness:

1. getting information
2. understanding the information
3. thinking ahead
 Knowing what is going on around
you
❖ Eastern Airlines flight 401

❑ One night in 1972, Eastern Airlines flight 401 en route from New York to Miami crashed into the Florida
everglades. One hundred and one passengers and flight crew died. Some survived. The captain, first officer, and
flight engineer were all highly qualified and experienced.
• An investigation of the crash determined the crew, while attempting to deal with a malfunctioning landing gear
light, did not notice the autopilot was no longer on. Unknown to the crew, the plane slowly descended. An air
traffic controller enquired if all was well, but did not alert the crew to the plane's low altitude. By the time the crew
noticed, it was too late.
• An investigation indicated poor crew leadership and teamwork, likely coupled with fatigue, resulted in the crash.

❑ The airline industry subsequently developed the "crew resource management" approach. This approach
ensures cockpit crews divide the work of problem solving, tasks are delegated, and someone is always flying the
aircraft.
 Knowing what is going on around
you
❖ United Airlines flight 232

❑ In another incident in 1989, United Airlines flight 232, flying from Denver to Chicago, is considered a textbook
example of successful crew management approach. The tail-mounted engine failed and fragments of metal cut all
of the plane's major hydraulic lines, rendering the airplane uncontrollable conventionally.This would previously
have resulted in a crash with the likely loss of everyone on board; however the flight crew reacted to the
emergency in a disciplined manner, making effective use of all of the resources available to navigate to an airfield.
Although the plane could not be slowed sufficiently and broke apart on landing, 184 of the 295 passengers
survived.

❑ The airline industry subsequently made significant safety improvements in the design of engines and control
systems.
 Case: Airway challenge in a trauma patient

• Background
A 22-year-old male in a motorcycle crash suffers a severe laceration to the neck extending into his trachea.
On arrival at the hospital at 0100 hours, he is alert, oriented with vital signs HR 110, RR 20, BP 130/70, GCS 15, P02
98% on low flow oxygen.
The emergency physician pages the anesthesiologist on call, and learns that the doctor will require 20 minutes to
arrive. The patient remains alert and oriented.
The emergency physician performs a rapid sequence induction protocol (sedation and paralysis). Several attempts at
intubation with c-spine control are unsuccessful. An endotracheal tube (ETT) is placed correctly after seven minutes.
The staff moves away from the patient to allow an AP chest and c-spine film to be done. During this time, the oxygen
saturation decreases significantly, and the ETT is discovered to be dislodged from the trachea.
The patient has a cardiorespiratory arrest.
• Outcome
Although he is successfully resuscitated after several minutes, the patient suffers extensive hypoxic brain damage.
• Think about it
Did the emergency physician sufficiently appreciate the potential difficulty in airway management?
Did the team remain aware of the patient's status at all times?
Did everyone think ahead?
Did the emergency physician and this healthcare team demonstrate situational awareness?
 Case: 76-year-old woman suffers respiratory arrest

• Background
A 76-year-old woman dislocates her hip in a motor vehicle crash.
The treating orthopaedic team wishes to perform a closed reduction as quickly as possible. The orthopaedic fellow
orders sedation with IV narcotic and benzodiazepine.
The patient quickly becomes drowsy. A nurse places the patient on oxygen and an oxygen saturation monitor.
Two medical students decide to watch the reduction procedure as a resident assists the fellow. After two failed
attempts at reduction, the fellow orders a repeat dose of the medications to further relax the patient. The fellow
attempts to reduce the hip, with the resident stabilizing the pelvis.
Everyone on the team is focused on the reduction.
Several minutes later, one of the medical students looks up to the head of the stretcher and notices that the patient
has stopped breathing.
• Think about it
How might this have been avoided?
Did the team sufficiently appreciate the potential for respiratory compromise in this elderly woman?
Did the team monitor the patient's status at all times?
Did the fellow and staff perceive there was a problem with the patient's breathing?
Did everyone think ahead?
Did the fellow and healthcare team demonstrate situational awareness?
 Practice situational awareness

⮚ Consider possible distractions and eliminate them.

⮚ Prepare for the unexpected — think ahead.

⮚ Switch from routine to analytical thinking and action.

⮚ Be alert to the condition of the patient.

⮚ Be alert to the condition of colleagues and co-workers.

⮚ Respond appropriately to potentially dangerous situations in the environment.

 Improve self-awareness and
mindfulness

⮚ Recognize your fatigue; attempt to get adequate rest.

⮚ Be alert to your emotions; step back and regain objectivity.

⮚ Recognize that stress may interfere with reasoning. The accumulation of lesser everyday work
and personal stresses may be as significant as the stress experienced in a single crisis.

⮚ Examine your thinking for cognitive biases.

⮚ Assess your physical health and consider the effect medications or other drugs may have on you.
❖ Using equipment and technology

❑ Causes of equipment failure:

1. design faults
2. improper or inadequate maintenance
3. damage due to mishandling
4. inappropriate use

❑ Experts giving opinions on these types of cases usually support physicians when:
✔ The procedure is indicated.
✔ The equipment is regularly maintained.
✔ The equipment is checked to determine that it functions properly.
✔ Reasonable precautions are taken to prevent injury.

❑ In your career as a physician, you may have opportunities to contribute to improvements in the design of
equipment.
 Case: Transient neurologic symptoms treated with
angioplasty

• Background
An interventional radiologist (IVR) is treating a patient for subclavian steal syndrome.
The doctor has extensive experience with the balloon angioplasty technique, but is using a new type of catheter
for the first time. He encounters some difficulty inflating the balloon.
When asked, the nurse confirms that the protective sheath has been removed. After further manipulation the
surgeon is able to inflate the balloon.
Months later the patient has to undergo surgery to remove the sheath which had not been removed — it had come
off while in the artery and had remained there.
• Outcome
The surgery required to remove the sheath was successful.
• Lessons learned
Analysis of the reasons for this event revealed several problems:
The sheath was made of clear plastic so its presence wasn't obvious (the IVR was familiar with one that had a
coloured sheath).
The IVR and nurse had not familiarized themselves with the new catheter.
The IVR accepted assurances the sheath had been removed, even though it could not be found.
The nurse did not indicate she could not find the sheath as she assumed it had fallen under a drape or onto the
floor.
When the balloon finally inflated, the IVR did not consider the possibility that his manipulations had allowed the
sheath to come off intravascularly.
Subsequently, a new protocol for using the equipment was introduced and the need to change the sheath to
colored plastic was communicated to the manufacturer.
 Case: A problem with liposuction equipment

• Background
A woman undergoes liposuction of her lateral thighs.
Prior to starting the procedure, the plastic surgeon is aware the handle of the liposuction device has a history of
problems and has previously been returned to the manufacturer for servicing on at least four occasions.
Early in the procedure, the plastic surgeon notes that the liposuction device is not functioning properly and the handle
is becoming warm. He lies the device down with the handle on the paper drape covering the patient's left calf for
approximately five seconds.
A burn results which eventually becomes full thickness.
• Outcome
The burn ultimately heals, but the patient is left with a scar.
• Lessons learned
Since the plastic surgeon was aware that the handle of the liposuction device had a history of problems, he should
have:
⮚ been extra careful to keep the warm handle of the device away from the patient or not have used this particular
device
⮚ asked the surgery clinic to replace the liposuction device
 Case: Failure to attend to malfunctioning office
equipment

• Background
A 30-year-old woman is reassessed by her family physician for worsening complaints of chest congestion, cough, and
shortness of breath.
The patient's chest is clear on auscultation. Her oxygen saturation (SaO 2) is 78%, which the physician attributes to a
malfunction of the monitor rather than severe hypoxemia.
The physician prescribes antibiotics and orders a chest X-ray for a presumed diagnosis of pneumonia.
• Outcome
When the patient returns one week later for persistent symptoms, her SaO 2 is 73% and the chest X-ray report reveals
marked abnormalities.
The family physician promptly refers the patient to a respirologist who diagnoses her with lymphangiomyomatosis (a
rare pulmonary condition characterized by smooth muscle proliferation resulting in small airway and lymphatic
obstruction) and secondary bilateral chylous pleural effusions, chylous ascites, and pulmonary hypertension.
• Think about it
When the patient's SaO2 was only 78%, the family physician assumed it was due to a malfunction of the monitoring
equipment rather than severe hypoxia.
How could the family physician have determined if the SaO 2reading was correct or the result of equipment failure?
What should the family physician have done about the SaO 2 monitor and reading at this point?
 Case: Point-of-care guidance and alert not functioning
properly

• Background
An emergency department (ED) physician reads a shoulder X-ray as normal for a patient who had fallen and injured
his shoulder.
The patient is discharged home.
Three weeks later, the ED physician receives the X-ray report describing a complete subluxation of the shoulder.
The patient is notified and referred to an orthopaedic surgeon.
• Lessons learned
So what went wrong?
The hospital had an electronic system in place between the ED and the radiology department for radiological
investigations.
When a radiologist reviewed an X-ray that originated from the ED, the ED physician's X-ray interpretation could also be
viewed on the computer. If the diagnosis differed from the ED physician's, the radiologist would electronically notify the
ED physician of the discrepancy.
There was a problem with the computer system and the ED never received the radiologist's notification.
• Think about it
What systems have you worked with for follow-up of investigations?
How might this have been prevented?
Case: When no point-of-care guidance or alert is set up

• Background
Neither the general surgeon nor the operating room (OR) team reviewed the preoperative chest X-ray prior to a patient
undergoing an uneventful laparoscopic cholecystectomy.
Two years later, a chest X-ray reveals a large pulmonary mass.
A retrospective review of the preoperative chest X-ray indicates the mass was clearly present at the time of surgery.
• Outcome
The patient subsequently dies from lung adenocarcinoma.
• Think about it
Neither the surgeon nor the OR team reviewed the chest X-ray preoperatively.
The radiologist did not send a preliminary report of the chest X-ray to the surgeon.
The chest X-ray report was entered into the hospital computer system three weeks after the surgery.
There was no entry in the electronic health record to alert the physician that a report was available for review or sign
off.
❖ Environmental issues

❑ Healthcare facilities are expected to be clean and hygienic. Unfortunately, there are times when care is provided
in less-than-ideal surroundings.

❑ A number of factors may be associated with an increased incidence of infections.

✔ It is important to wash your hands between patient encounters. (However, some workplaces have inadequate
facilities for hand-washing.
✔ Cleaning services may need improvement in others).
✔ The design of equipment may make maintenance difficult or complex.
✔ Overcrowding may also contribute to problems.
 Case: Patients infected with virus

• Background
A patient with refractory headache, vomiting, blurred vision, and light headedness is referred for an EEG as part of a
neurological workup.
The EEG is performed by an employee of a clinic owned by a neurologist. There is no evidence of seizure and the final
diagnosis is migraine.
One year later, the patient is diagnosed with acute hepatitis B.
An investigation of the clinic reveals many patients contracted hepatitis B from contaminated EEG needle electrodes at
the clinic. Although a sterilization protocol was in place, it was not followed.
• Class action
The patient joined a class action suit alleging unsterilized needle electrodes used for the EEG studies caused the
hepatitis B infections.
Class action is a lawsuit brought by a group of plaintiffs with a similar interest in a particular issue in a litigation.
• Outcome
Experts were critical of the infection control processes at the clinic.
The patients that had acquired hepatitis B at the clinic were paid compensation
 Case: A 10-day-old infant undergoing circumcision

• Background
A 10-day-old infant undergoes a circumcision in his family physician's office and later develops Fournier's disease
(gangrene of the perineum).
The patient requires reconstructive surgery of the penis and scrotum.
• Outcome
Inspection of the physician's office reveals there are workplace deficiencies including lack of hand-washing and
disinfecting protocols, equipment that is difficult to clean, lack of appropriate sterilization, and irregular cleaning of the
surroundings.
In this case, the physician ceased doing procedures of any kind until the deficiencies were rectified.
 Case: Problems with a sterilization machine

• Background
A gastroenterologist learns from the hospital that there has been a problem for one month with the sterilization
machine used to decontaminate endoscopes.
The machine is difficult to use. One of the drains had not been connected properly by the technicians, although other
parts of the cleaning process were working properly. Over this time a patient with known hepatitis C was scoped.
A risk analysis by specialists in infectious disease determines the incomplete sterilization process was sufficient to
eliminate bacterial pathogens, but might not eliminate hepatitis B and C viruses.
• Outcome
The gastroenterologist takes part in a multi-patient disclosure to all of the potentially affected patients. Patients
subsequently undergo appropriately-timed testing for viruses. All test results are negative.
Several improvements are made to the sterilization equipment and process, with better training for all technicians.
❖ The promise of human factors engineering

▪ Human factors engineering is used to design and evaluate safer and more effective tools, machines,
systems, tasks, jobs, and environments.

▪ Although it is unlikely that we can completely eliminate factors that contribute to patient harm, human
factor engineering principles can reduce the likelihood and impact of such failures.

❑ Design principles in healthcare settings

1- Forcing functions: makes it impossible to do a task incorrectly.

⮚ For example, the connectors to the oxygen and nitrous oxide gas containers can be designed to make it
impossible to physically connect them to the wrong cylinder.

⮚ Another example would be to design a connection for syringes of vincristine that would make it
impossible for the drug to be given intrathecally.
 The promise of human factors engineering

2- Constraints: make the right choices the easy choices and make it hard to do the wrong thing.
⮚ For example, removing potassium chloride from patient wards; removing hypotonic and
hypertonic electrolyte solutions from patient wards; storing look-a-like drugs in different areas or
developing distinctly different packaging.

⮚ Constraints do not make it impossible to do the wrong thing like a forcing function, but they do
make it difficult and therefore allow for many opportunities for checks.

3- Simplification: the reduction in the number of steps in processes or procedures.

⮚ Because each step in a process of care may fail on occasion, processes with a greater number of
steps are generally more prone to failure than those with fewer steps.

⮚ When a process is extremely complex and inefficient, health providers are more likely to develop
routine workarounds to make it simpler, which may sometimes put patients at risk.

4- Standardization: promotes consistency and eliminates confusion.

⮚ For example, the use of a standard order form or a standard operating room setup.
 The promise of human factors engineering

5- Use of redundancies: such as double checking narcotic dosing prior to administering the drug to a patient.
⮚ Computers can facilitate the double check by alerting the provider to the wrong dose of medication or a
contraindicated medication

6- Avoiding reliance on memory: most people can hold only a limited number of pieces of information in their
memory at any one time.
⮚ Checklists such as the surgical safety checklist, checklists for central line insertion and for handovers help to
reduce reliance on memory and are increasingly being used for complex or high-risk procedures.

7- Creation and adherence to patient safety habits: for example, patients can be encouraged to bring their
medications to every office or hospital visit so that it becomes a consistent pattern of behaviour.

8- Use technology wisely: while information technology has transformed the way we work and live and is an enabler
of improvements to patient safety, it is not a guarantee.
 The promise of human factors engineering

❑ Technology will not achieve the promise it holds for patient safety if:

1. providers become desensitized to the alerts and turn them down or off
2. providers are not trained adequately to fully use the systems
3. the technology significantly interferes with normal work flow, for example, if computer terminals are at the end of a
hall instead of in each examining room
4. the systems are poorly designed
(In one example, a pathology department developed a bar coding system to ensure each pathology slide was
correctly linked to the right patient specimen. To avoid error, the technologists were instructed to print out each
bar code one at a time when fixing the individual slides. However, the bar coding label printer was so slow that the
technologists printed out all the bar codes for their workstation for the day, circumventing the safety precaution.)
5. everyone becomes over-confident in the system and does not know how to function if the system is down.

❑ Technology is an enabler and holds great promise for safe care. To achieve this promise, the technology should
be designed for, and evaluated by, the healthcare provider who will be using it.
Case: Failed alerts in an electronic health record (EHR)

• Background
A 37-year-old construction worker is employed in northern Canada. He develops severe radiating back pain
following heavy lifting. He is seen by a physician locum in a walk-in clinic.
The physician enters the history and physical examination, including weakness of the dorsiflexion of the right foot, into
the new electronic health record at the clinic. He makes a diagnosis of an acute herniated lumbar disc, orders a CT
scan, prescribes analgesics, and discharges the patient with arrangements for follow up.
The CT scan is done two weeks later and read the same day. The radiologist identifies a destructive process in the
spine. The report is emailed to the physician, however, it is never received.
Nine days later the patient's condition becomes much worse, he is admitted to hospital, and spinal tuberculosis is
diagnosed.
The EHR had a diagnostic decision support tool; however, the audit system indicates the physician spent only 1.5
seconds reviewing the suggested possible diagnoses. He was not familiar with its use and considered the list of
possible diagnoses, which included spinal tuberculosis, too time consuming to read.
The EHR had a tracking system for investigative reports which was not being used by the clinic as they had not been
trained on how to work with it.
The EHR also had a system for patient follow-up which the staff had not yet learned to use. The patient safety alerts
had been turned off to enable the system to run faster.
• Think about it
Why didn't the EHR prevent the delay in the diagnosis of the patient's spinal tuberculosis?
• Lessons learned
The physician and staff did not have adequate training on the EHR and were not aware of all the patient safety
advantages it could provide.
The tracking system for investigations and patient follow-up was not being used.
The decision support tool was considered too time consuming to use and was ignored.
1- That is incorrect
The physicians, nurses, and pharmacist were all highly competent professionals.
For efficient workflow, most hospitals use standardized times for routine administration of medication. This CPOE defaulted
to the closest standard time for administration of medications, but the physician did not know this. The pharmacist
recognized the problem but, in trying to rectify it, did not notice the date change. The nurses knew that antibiotics were
ordered but over the shift changes did not realize the patient was not receiving them.
Careful checking and rechecking of the medication orders might have helped.
Based on this event, the hospital made changes to the interface to the CPOE system. A clinical decision support alert now
notifies the pharmacists of inappropriate delays in the administration of medications.

2- That is incorrect
Multiple studies indicate that CPOE improves inpatient medication safety, but there can still be problems. One challenge is
"alert fatigue" in which a high number of alerts causes providers to ignore or override alerts without adequately considering
if they are clinically relevant.

3- That is incorrect
It is true the healthcare team could have communicated better. There was a failure to recognize that a patient with a life
threatening illness had not received antibiotics. This might not have occurred if the care plan had been communicated
better across the team and the antibiotic was understood to be a priority of treatment.
The overreliance on technology at the expense of direct communication can lead to false assumptions. Reliance on
electronic communication alone may not be sufficient, particularly in urgent and emergent situations.

4- That is incorrect
Although harm from medication unfortunately occurs relatively frequently there is a better answer for this case.
 5- That is correct
The delivery of safe healthcare depends in part on the vigilance of providers. Nevertheless, human fallibility means that
vigilance will periodically fail. Good systems of care anticipate such failures and incorporate safeguards.
Although CPOE systems may help improve medication safety, a significant human factors issue in this case is the
design of the user interface of the CPOE.
As is common, a "cascade" of factors in this case contributed to what happened. These included the lack of team
communication regarding the care plan and the checking of medications.
In a court of law, providers may be found liable for a patient's poor clinical outcome if it is proven they were negligent in
using the system. This highlights the importance of receiving orientation and training, making reasonable efforts to
understand how the system works, and reporting safety issues if they arise. Suppliers and healthcare organizations
may be found liable if negligence (civil liability in Québec) is proven in the design of their systems, the provision of
appropriate orientation and training, or the failure to correct recognized deficiencies.
 CMPA :
Adverse events
 Objectives

❖ After completing this domain you will be able to:

I. Explain the difference between a medical error and a matter of judgment.
II. Describe the important elements of the disclosure road map.
III. Describe at least 2 common approaches to quality improvement.
IV. Discuss 4 ways a physician can constructively cope with stress due to poor patient
outcomes, complaints or legal actions.
❖ Error

❑ An error is an action (plan, decision, choice, and action or inaction) that, given the information available and the
patient's clinical condition at the time, was done wrongly or performed incorrectly in those circumstances, and
therefore resulted in an adverse event (accident in Québec), or a near miss.

✔ An example of an error would be operating on the wrong patient, which therefore results in an adverse event.

✔ Another example would be drawing up the wrong medication for a patient but catching the error prior to the
administration of the drug. This latter error would be considered a "near miss."

❑ "Error" may also be misunderstood to mean the care provided was substandard or negligent in law.

❑ Errors may or may not be negligent.

 Exercise of judgment
❑ The term error in judgment is used frequently in medical practice but this term is a misnomer. In fact, an error in
judgment is not an error; it refers to the exercise of judgment in clinical decision making.
✔ An error in judgment (or more accurately, a matter of judgment or the exercise of judgment) is a reasonable
decision or choice made carefully at the time, but in retrospect might not be considered by some as the best
choice or decision.

❑ After an examination and thoughtful analysis of a patient's condition, a physician is not necessarily in breach of
the duty toward a patient simply because the physician made a choice or a decision that was reasonable given
the circumstances.

❑ Delays in diagnosis may occur because many conditions must progress to a clinical degree where the
symptoms and signs suggest the diagnosis or at least indicate the need for further testing.
✔ Reaching a final and confirmed diagnosis often requires assessing a patient several times, sometimes over a long
period of time. Sometimes, however, system failures or problems in provider performance, or both, contribute to
the delay.
 Case: A middle-aged man coming into ER with chest
pain

• Background
A middle-aged male who smokes presents to the emergency department for evaluation of sudden onset of left-sided
chest discomfort. His symptoms include dyspepsia, and numbness and tingling in the left arm and leg.
Blood pressure is normal in both arms, the cardiovascular and neurological examinations are normal, and repeated
ECGs and serial cardiac markers remain negative.
After 8 hours of observation, the patient is discharged home to follow up with his family physician.
The patient continues to have intermittent chest pain, especially on inspiration.
Three days later, when examined by his family physician, the patient is febrile and a chest X-ray infiltrate suggests
left lower lobe pneumonia. He is started on antibiotics.
Three days later — 6 days after the initial hospital visit — the patient is seen by the family physician again and referred
to an internist.
The internist documents a blood pressure that is the same and is within normal limits in each arm, no cardiac murmurs
or rubs, and a normal neurological examination.
Another chest X-ray reveals a patchy consolidation in the left lung base. Laboratory work and an
ECG remains normal, apart from a mildly elevated white blood count.
The internist also diagnoses pneumonia but changes the antibiotics to cover a wider spectrum of organisms.
• Think about it
What do you think about the clinical care so far?
• Outcome
Two days later the patient collapses at home and cannot be resuscitated. A ruptured dissection of the
descending thoracic aorta is found at autopsy.
 Case: A middle-aged man coming into ER with chest
pain (continued)

The many unusual features of the case, such as:

• the pleuritic nature of the pain,
• the signs and symptoms suggesting pneumonia,
• the normal blood pressure in both arms, and
• the absence of a cardiac murmur
would understandably make aortic dissection difficult to suspect prior to any further clinical deterioration.
 Error and blame

⮚ Do not rush to blame healthcare providers or patients.

⮚ When discussing an unexpected patient outcome, the use of the term "error" should generally
be avoided, especially before all the facts are known.

⮚ "Error" often misrepresents the reasons for clinical outcomes, and implies blame toward an
individual that is often inappropriate, especially if judged prematurely.

⮚ An inappropriate focus on provider error ("blame and shame") and a punitive approach is now
recognized as being unfair. Such an approach ultimately inhibits the reporting of adverse events
(accidents in Québec) and consequently the system changes that may be required to prevent
similar events from occurring in future.
 Violations
❑ Violations usually refer to deviations from policies and procedures that help facilitate clinical care. Although
violations may be intentional, the harm to a patient that sometimes results is not intentional.

❑ Types of violations include:

I. routine: cutting corners

II. necessary or situational: the policies or procedures are inappropriate to the specific patient's circumstances
III. rogue: reckless behavior without concern for the well-being of others

• People often find ways of getting around workplace processes that are viewed as unnecessary or impeding
workflow. Such "workarounds," which are common in healthcare, are nonstandard methods to bypass or deal with
a recognized problem in a system or process of care.
• While a workaround may benefit an individual patient by fixing a problem specific to that case, the dysfunctional
system or process of care is typically not corrected and not reported, continuing the risk for future patients.

❖ Normalization of deviance

⮚ Normalization of deviance is the gradual acceptance of cutting corners and workarounds over time.
 Violations

❖ NASA and the Challenger space shuttle

• In the 1970s the United States began to build reusable spacecraft to transport people and cargo. The shuttle
Challenger flew 9 successful missions before the rocket began to break apart seconds after a takeoff in 1986,
killing all 9 astronauts aboard.

❑ The subsequent investigation revealed:

I. NASA was under great pressure to launch
II. it was a colder than usual day
III. large rubber O-rings in the booster rocket failed in the colder weather, allowing hot gas to leak and damage
other essential components

• Engineers had known for several years there were flaws in the O-ring design and materials. The team came
to accept this lower standard (normalization), believing the success of previous launches meant future
success. The use of substandard O-rings became routine and the engineers forgot the potential
consequences if the O-rings were to fail.

• The tragedy was predictable.

• The engineers did not speak up because they were lulled into complacency. "We wished that we had the
foresight to stand up collectively and say, 'Look, it's too cold a day to launch, we just ought to wait for a
warmer day.' In retrospect it seems so simple; at the time, it just didn't happen."
 Violations

❖ The impact of normalization of deviance in healthcare

❑ Violations of recognized standards of practice for patient care can become "normalized" or routine over time.
Here are some common examples:

⮚ Not washing or sanitizing hands before and after examining patients.

⮚ Not gowning and taking appropriate infection control measures.

⮚ Disabling alarms on patient care equipment such as ventilators.

⮚ Disabling alarms on security doors in psychiatry or geriatric wards.

⮚ Ignoring or turning off alerts in an electronic medical record (EMR).

 Case: A child in the operating room

• Background
A toddler requires general anaesthesia in a small community hospital.
The anaesthesiologist, the operating room (OR) team, and hospital administration are all aware there is an ongoing
problem with the available capnometer which necessitates silencing the monitor alarms.
Despite this, the anaesthesiologist does not check the alarms for function or volume prior to surgery, and does not set
alarm limits appropriate to the patient's age on the other monitoring equipment (e.g. oxygen saturation,
electrocardiogram).
• Outcome
Following induction, the nasotracheal tube dislodges from the trachea.
The child develops hypoxia that goes unnoticed because the alarms are not audible.
Cardiac arrest follows, resulting in anoxic brain damage, bilateral blindness, and aphasia.
• Think about it
How could this harm be avoided?
• Suggestions
Knowing there is a problem with the capnometer:
• The hospital should fix the equipment problem.
• The anaesthesiologist should check the alarms on the other monitoring equipment (e.g. oxygen saturation,
electrocardiogram) to ensure they are functioning properly, set ageappropriate alarm limits, and set the audible alarms
at a sufficient level.
Knowing there is a problem with the capnometer:
• The anaesthesiologist should pay closer attention to the visual indicators on the monitoring equipment.
• Both the anaesthesiologist and other members of the OR team should observe the child more closely for signs of
hypoxia and cyanosis.
 Pitfalls of looking back

❖ Hindsight bias

❑ Hindsight is 20/20. Knowing an undesirable and unexpected clinical outcome has occurred increases the
belief that it was predictable, therefore preventable and related to carelessness or poor clinical care .

❑ Some medical conditions are difficult to diagnose. Looking back on previous assessments of the patient, the
symptoms and signs that signal the final diagnosis stand out clearly and now may seem obvious. However, those
assessing the patient earlier had the challenge of picking these signals out from the totality of all symptoms and
signs experienced by the patient at that time.

❑ We can try to avoid hindsight bias by considering how factors such as the natural evolution of a disease,
additional clinical information, and improvements in the technology used for clinical testing can affect
retrospective assessments.
 Pitfalls of looking back
❖ Hindsight bias

❑ BEFORE arriving at a final diagnosis

✔ It is often unclear, at least initially, how the pieces of a puzzle fit together. Similarly a constellation of non-specific
symptoms and signs can appear, at first, to be puzzling or to represent other clinical conditions.

✔ Physicians must work through this challenge with appropriate assessments and testing. However, it often takes time
for the clinical condition to evolve to a point where it can be recognized.

❑ AFTER determining the final diagnosis

✔ Looking back: reflective learning is a good thing

✔ Having solved a puzzle, the important pieces are now more easily identified and remembered.

✔ Similarly, a physician reflects on how a disease presented and remembers the pattern for next time.

❑ AFTER a delay in making a diagnosis or a misdiagnosis

✔ Looking back: The distortion of hindsight bias

✔ When the final diagnosis is known, the red flags — the important symptoms and signs signaling the diagnosis —
appear obvious to others. This ignores the initial challenge of picking these out earlier in the course of an illness when
things were much less clear.
 Case: A 56-year-old woman with breast cancer

• Background
A breast nodule is seen on a screening mammogram and investigations prove cancer.
The radiologist reviews the patient's previous mammograms and notes micro-calcifications and architectural distortion
are present on a mammogram done two years earlier.
• Outcome
Not all breast cancers can be identified on mammograms.
Some mammograms show very subtle or even no detectable signs of malignancy, for example, a mass, micro-
calcifications, architectural distortion, or an asymmetric or developing density.
Some malignancies are completely obscured by overlying and highly dense glandular and fibrous tissue.
• Lessons learned
It is common for radiologists to compare the current mammogram with one or more prior studies.
After a diagnosis of cancer, changes in the breast architecture that reflect the development of the cancer can be more
easily identified.
Knowing where to look, one may, in hindsight, identify subtle changes in breast architecture that, at the time, were
below the threshold of detection of a competent radiologist.
This is not an indication of negligence (professional civil liability in Québec) or a measure of poor performance.
The reality is that a disease must progress to a certain point to be recognizable within the sensitivity of the diagnostic
imaging used.
Sometimes, having done your best to eliminate hindsight bias, you may believe a lesion seen on a previous study
should have been "obvious."
An obvious missed lesion is generally considered to be one that most radiologists would have recognized on the
previous study.
 Learned intuition

❑ "Learned intuition" refers to the phenomenon when a person has learned a complex process and it later
seems intuitive. The person does not easily recall the difficulty he or she had when first trying to learn the
process.

❑ When someone else new to the process has difficulty with it and makes a mistake, others can be critical of the
individual when, in fact, the problem may stem from poor orientation or training.

❑ Examples of such processes include:

✔ ordering medication
✔ ordering a blood transfusion
✔ arranging a test or diagnostic imaging study
✔ a handover of care
 Fundamental attribution error

❑ People tend to interpret the actions and behaviours of others based on the other person's characteristics
and personality, but explain their own actions and behaviours based on situational factors.

❑ For example, after an adverse event (accident in Québec):

✔ "That doctor (or nurse or pharmacist) doesn't know what he's doing".
✔ "That happened because I was too busy and got interrupted all the time."
 Self-serving bias and excessive self-blame

❑ Some people consider their successes to always result from their own strengths or personal factors, but deny
responsibility for their failures, attributing such failures to situational factors beyond their control. This is self-
serving bias.

❑ Self-reflection is a constructive response to an adverse event (accident in Québec) and can stimulate learning
and improvement.

❑ However, a common response to unexpected outcomes among physicians is excessive self-blame and censure,
an exaggerated sense of responsibility for poor patient outcomes that in reality are beyond the physician's control.

❑ From a court judgment:

✔ "Dr. A is obviously a highly skilled gynecologist who treats his patients with great care and success. His patients
are lucky to be under his care ... My impression is that he viewed this accident from the perspective of a
perfectionist."
❖ What is disclosure?
❑ A process by which an adverse event (accident in Québec) is communicated to the patient or the patient's
family, or both.

❑ Patients and providers both experience considerable emotional distress at the time of these incidents, making
disclosure discussions particularly difficult, and requiring advanced communication skills.

❑ Healthcare providers have an ethical, professional, and legal obligation to disclose adverse events.
 Disclosure using "Adverse event" terminology

❖ When to disclose if using "Adverse event" terminology (Canadian Disclosure Guidelines - CPSI
2008)

⮚ If analysis indicates harm resulted from...

1. Natural Progression of the medical condition (disease processes) – Discuss with patient

2. Healthcare delivery - an adverse event

o inherent risk of an investigation or treatment
o system failure (s)
o provider performance issue (s)
o combination of these
- Disclose to patient

⮚ Other types of events

1. Event reached patient (the event touched or entered the patient)

a. Potential for harm — Disclose to patient
b. No potential for harm — Generally disclose to patient

2. Close call (did not reach patient) — Disclose if ongoing safety risk for that patient, or if the patient is already aware
 Disclosure using "Patient safety incident" terminology

❖ When to disclose if using "Patient safety incident" terminology (WHO ICSP, Canadian Disclosure
Guidelines - CPSI 2011)

⮚ If analysis indicates harm resulted from...

1. Natural Progression of the medical condition (disease processes) — Discuss with patient

2. Harmful incident from healthcare delivery

a. Recognized risk inherent to an investigation or treatment — Discuss with patient
b. Harmful patient safety incident — Disclose to patient

⮚ Other types of patient safety incidents

1. No harm incident (Reached the patient) — Disclose to patient

2. Near miss (Did not reach the patient) — Generally need not disclose to patient unless ongoing safety risk for that
patient, or patient is already aware
 Comparing terminologies

❖ Using "Adverse event" terminology (CPSI 2008)

⮚ Adverse events are broadly defined as harm resulting from healthcare deliver. An adverse event may result from the
following possibilities:

✔ inherent risk of an investigation or treatment

✔ system failure (s)
✔ provider performance issue (s)
✔ combination of these

- Disclose to patient

❖ Using "Patient safety incident" terminology (CPSI 2011)

⮚ Harmful incidents are separated into two categories. Harmful incident from healthcare delivery results from:

1. Recognized risk inherent to an investigation or treatment — Discuss with patient

2. Harmful patient safety incident

✔ system failure (s)
✔ provider performance issue (s)
✔ combination of these

- Disclose to patient
 Disclosure of accidents and incidents in
Québec
❑ The Act respecting Health Services and Social Services in Québec defines the terms accident and incident, and
clarifies the need for disclosure of such events to patients.
❑ The Code of Ethics of Physicians in Québec states that the physician must "inform his patient or the latter's
representative of any incident, accident or complication which is likely to have or has had a significant impact on
his state of health or personal integrity."

❖ Accident
In Québec law (An Act respecting Health Services and Social Services), an accident is "an action or situation where a
risk event occurs which has or could have consequences for the state of health or welfare of the user, a personnel
member, a professional involved, or a third person."
An accident should be disclosed to the patient.

❖ Incident
In Québec law (An Act respecting Health Services and Social Services), an incident is "an action or situation that does
not have consequences for the state of health or the welfare of the user, a personnel member, a professional involved
or a third person, but the outcome of which is unusual and could have had consequences under different
circumstances."

❑ An incident, as the term is defined in Québec, may require disclosure if:

• the incident reached the patient but no harm resulted. Generally such incidents should be disclosed to patients.
• the incident did not reach the patient (i.e. the incident was caught in time) but the potential for harm existed. The
patient should be informed of the incident if there is a similar, ongoing safety risk for that patient, or if the patient is
aware of the incident and an explanation will allay concern and promote trust.
 Disclosure of accidents and incidents in Québec

❑ In Québec government-run institutions such as hospitals, the law requires the completion of a report in the
prescribed format, for both accidents and incidents. The report is kept with the patient's medical record.

❑ It is prudent to alert the patient to the incident, the report, and any subsequent preventive measures put in place.
This will reduce the likelihood of misunderstanding or mistrust if the patient views the medical record and report in
the future.

❖ Disclosure of harm in Québec

If harm due to...

1. Underlying medical condition — Discuss with patient

2. Accident — Disclose to patient (discuss)

If incident...

1. Reached the patient but no harm resulted — Generally disclose to patient

2. Did not reach the patient (caught in time) so no harm resulted — Disclosure may be indicated or prudent
 Case: Patient with cancer suffers from pain

• Background
An adult patient with cancer is suffering from severe pain.
As the first-year resident caring for the patient, you inadvertently order 10 times the required dose of a narcotic
due to a misplaced decimal point and the presence of a trailing zero.
The nurse administers the dose as ordered and the patient becomes very drowsy, apneic, requires a narcotic
antagonist, and temporary respiratory support.
Fortunately the patient makes a full recovery.
• Think about it
• Would you consider this to be an adverse event (accident in Québec)?
• Should the patient be told of the reason for the clinical emergency?
• Who should disclose this to the patient?
• Should the nurse be involved in the disclosure discussion?
• What would you say if you were disclosing this to the patient?
• Would you apologize?
• Outcome
The ordering and administration of the wrong dose of the narcotic was an adverse event because the patient was
harmed by healthcare delivery (i.e. the patient required additional care and monitoring).
 What is disclosure(continued)

❖ Following harm from healthcare delivery, patients have clinical, emotional, and information needs. Research
confirms that following an event patients want:

I. an acknowledgement that something has gone wrong

II. the facts that are known about what happened
III. an understanding of the recommended next steps in clinical care
IV. a genuine expression of concern, an apology
V. assurance that appropriate steps, if possible, are being taken to prevent a similar occurrence from happening to
others
 Disclosure road map
1. First things first: Attend to clinical care
• Address clinical needs and deal with emergencies
• Consider the next steps in clinical care
• Provide emotional support
• Document the adverse event

2. Plan the initial disclosure

• What are the facts
• Who will be involved
• When and where will the meeting occur

3. The initial disclosure meeting

• Provide the known facts
• Be sensitive
• Do not speculate or blame others
 Disclosure road map
1. First things first: Attend to clinical care

❖ Address clinical needs and deal with emergencies

⮚ The first priority is to stabilize and monitor the patient's breathing.

⮚ Seek help as appropriate.
⮚ Alert your supervisor of the emergency and the reasons for it.

❖ Consider the next steps in clinical care

⮚ Consider whether you are the appropriate individual or team to provide further care after an adverse event
(accident in Québec). You should consider transferring the care of the patient for any of these reasons:
✔ The patient requests or prefers it.
✔ The patient's condition requires care you cannot provide.
✔ You feel your emotional state may interfere with the provision of the care now required.

⮚ The reasons for a transfer of care should be discussed with the patient so they do not feel as if they have been
abandoned.
 Disclosure road map

❖ Provide emotional support

⮚ Patients and families experience a range of emotions following an adverse event.

⮚ Surprise at the occurrence of the adverse event may turn into mistrust, frustration, and anger.
⮚ It is important to meet the emotional needs of your patients. Let them know you will be there for them. The aim is
to support healing and restore trust.

❖ Document the adverse event

⮚ Document the facts in the progress notes:

✔ the clinical situation as it now exists
✔ the consent discussions, options, and decisions made by your patient or the family regarding any future clinical
investigations, treatments, and consultations and the rationale for these
✔ any care provided
 Disclosure road map
2. Plan the initial disclosure

❖ What are the facts

⮚ Before meeting with the patient, the attending physician determines the facts as known at this stage, decides who
will be present at the disclosure discussion, and establishes when and where the discussion will occur.

❖ Who will be involved

⮚ Medical students and residents involved in an adverse event should report it to their supervising physicians. They
should be encouraged to be present to observe the disclosure discussion as a learning experience.

❖ When and where will the meeting occur

⮚ The healthcare team should also decide when and where the initial meeting will occur.
 Disclosure road map

⮚ Depending on the nature of the event or the anticipated reaction of the patient, the attending physician may also
consider having others present (with the patient's permission) such as:
✔ family members (with the consent of the patient)
✔ other healthcare providers directly involved with the care
✔ skilled communicators, as necessary
✔ a translator if required (preferably not a family member)
✔ those required to meet any special needs of the patient (e.g. cultural, vision, hearing, spiritual needs)

⮚ The healthcare team should decide which team member would be most appropriate to lead the discussion.
Whoever is chosen to lead should be in a position to provide the necessary information to the patient and be able
to answer any clinical questions the patient may have.
 Disclosure road map
3. The initial disclosure meeting

❖ Provide the known facts

⮚ There is no such thing as a perfect disclosure discussion. Despite planning for the discussion and anticipating the
patient's needs, there is no script to follow.
⮚ Provide the known facts. Be careful not to jump to conclusions before all the facts are known.

❖ Be sensitive

⮚ Be sensitive to how much information is being provided and what your patient is ready to hear.
⮚ Patients should be allowed to absorb information at a rate they are comfortable with.
⮚ Remember to be genuine, sincere, and compassionate.

❖ Do not speculate or blame

⮚ Self-serving, defensive statements accompanied by blame for others will only increase tensions and are not
helpful.
 Apology
❑ Stating that you are sorry for the circumstances or the condition of the patient is appropriate at every disclosure
meeting. Genuine concern and regret by a caring physician and healthcare team will be appreciated by most
patients and families.

❑ How should you say you are sorry for a poor clinical outcome?

The answer depends on the reason for the outcome:

⮚ If it is the result of the progression of the underlying medical condition:

An expression of concern and sympathy is sufficient and will be appreciated by your patient and the family.

⮚ If it is the result of an adverse event (accident in Québec) related to an inherent risk of an investigation or
treatment:
An expression of regret should be provided, such as "I feel badly that this happened to you." An apology (with
acceptance of responsibility)should not be provided.

⮚ If it is the result of an adverse event related to system failures or provider performance, as determined
after careful analysis:
An apology should be considered by the responsible provider or responsible organization.

❑ The use of words that express or imply legal responsibility, such as negligence or fault, or reference to failing to
meet the standard of care, should be avoided and are not part of disclosure. Such legal determinations are
complex, and independent bodies such as the courts and medical regulatory authorities (Colleges) have the
responsibility to make these determinations fairly.
 Telling the patient

❑ What if the patient doesn't know an adverse event (accident in Québec) happened?
 Case: A 64-year-old with syncopal episode

• Background
A 64-year-old woman is admitted to hospital following a syncopal episode. She is diagnosed with heart block
and treated with a pacemaker. Prior to discharge, a chest X-ray is done to investigate her chronic cough. You
perform the discharge summary.
One year later she is diagnosed with advanced lung cancer. The chest X-ray, done during the previous admission,
had revealed a nodule in the left upper lobe of her lung. The chest X-ray report was present in the medical record
at the time you did the discharge summary but you did not see it. As a result, it was not followed up.
The thoracic surgeon believes this nodule could have been resected if it had been diagnosed at the time of the
previous admission. The patient would have had a better prognosis and would have required less invasive
treatment.
• Think about it
Would you consider this to be an adverse event?
Should the patient be told of the reason for the delay in the diagnosis of the lung cancer?
Who should disclose this to the patient?
What would you say if you were disclosing this to the patient?
Would you apologize?
• Suggestions
This delay in diagnosis is an adverse event and should be disclosed to the patient.
The thoracic surgeon should notify your attending staff or the most responsible physician at the time of the
patient's previous admission.
Your attending staff should have the disclosure discussion with the patient.
You are encouraged to offer to attend the meeting(s) to learn and to provide your own apology for your part in
what happened.
 Case: Young woman with black irregular nevus

• Background
You are working as a locum in a family physician's clinic. A young woman presents with a black irregular nevus
which she says has been increasing in size over the past year. She hadn't been too concerned about it as the
family physician had reassured her it wasn't anything to worry about.
You biopsy the nevus just to be certain there is no malignancy. Unfortunately the pathology shows a malignant
melanoma arising in a compound nevus.
• Think about it
Would you consider this to be an adverse event?
What will you say if the patient asks why this nevus wasn't biopsied earlier by her family physician?
Who should discuss this with the patient?
Would you apologize?
• Lessons learned
Most often, adverse clinical outcomes result from the progression of the patient's underlying medical condition.
The clinical appearance of this patient's nevus needed to evolve to the point at which a reasonable physician
would identify the need to perform a biopsy.
• Suggestions
An honest, simple explanation of the variable progression of the pathophysiology from nevus to melanoma should
be provided and should reassure the patient.
If the patient has additional questions, she may be referred to her family physician.
It is helpful to alert the family physician of the patient's concerns and the information you have already shared with
the patient.
The discussion should be supportive of the other healthcare providers and not judgmental of the care provided.
 No evident harm
❑ Sometimes unexpected occurrences in healthcare delivery result in no evident harm. This can occur in the
following situations:
✔ The event reached the patient (touched or entered the patient); no harm occurred at the time but a potential for
harm might exist in the future. This is referred to as a potential-for-harm event.
✔ The event reached the patient but no harm occurred at the time and no potential for harm realistically exists in the
future. This is a no-harm event.
✔ The event did not reach the patient because of timely intervention or good fortune. This is referred to as a near
miss.

❑ As a general approach, a near miss need not be

disclosed to the patient. Still, there are certain
exceptions. The patient should receive knowledge
of a near miss if there is a similar, ongoing safety
risk for that patient, or if the patient is aware of the
near miss and an explanation will allay concern and
promote trust.
 Potential for harm event case: A patient is exposed to
unsterilized equipment

• Background
A patient is exposed to medical equipment that has been inadequately sterilized.
The equipment has been used to treat other patients, some of whom are known to carry HIV infection.
• Suggestions
If a potential for harm from the event exists in the future, then generally this should be discussed with the patient. The
likelihood and severity of future harm should be considered.
You may wish to seek the advice of other clinical and ethical experts, and legal counsel.
You may also want to arrange for follow up, further clinical testing, and post-exposure prophylaxis treatment as
appropriate.
If the event reached the patient, typically a patient should receive knowledge of the event even if it resulted in no harm
You determine that a small risk of transfer of the virus from the equipment exists.
 No harm event case: A patient with allergy to penicillin

• Background
A patient has a known allergy to penicillin, and this fact is recorded on the medical record. Despite this, you administer
penicillin to the patient, yet there is no allergic reaction
• Suggestions
In this case, a discussion with the patient would enable the patient to understand an allergy may not exist.
It is not always easy to decide whether to make your patient aware of an event in which there is no harm. Ask yourself:
What facts would the patient want to know?
Another approach is to use the "substitution test" — would you want to know if you were the patient or if one of your
family members was the patient?
Near miss case: A near miss that need not be disclosed

• Background
You draw up a vial of penicillin to administer to a patient with a known allergy to penicillin.
As you approach the bedside you become aware of the potential medication problem, and do not give the drug. No
medication enters the patient.
• Suggestion
As no medication enters the patient, you need not discuss this near miss with the patient.
 Near miss case: A near miss that might be
communicated to a patient

• Background
Two patients on a ward have identical last names and you almost give a medication to the wrong patient.
The mix-up of patient names is recognized just in time and nothing is administered to the wrong patient.
• Suggestions
In this situation, it would be sensible to alert both patients to the fact that they share the same name so that the
patients themselves can be more vigilant, contributing to their own risk management.
It would also be important to make system improvements so a similar occurrence would be less likely in future.
 Student's role
❑ What should I do if I believe a mistake has harmed a patient?

⮚ Medical students may feel vulnerable when they witness what they believe to be harm from healthcare delivery
that has not been disclosed to the patient. Consider how your response can be constructive and respectful.

❑ The first question you should ask yourself is:

⮚ Do I really have enough knowledge to say this is an adverse event?

i. In any situation, what seems like an adverse event may, in fact, be reasonable evidence-based practice in the
patient's circumstances. Before reaching conclusions, you may wish to research the topic.

ii. If you continue to be uncertain about the care provided, you may wish to explore with your supervisor the rationale
for the decision, action, or inaction.

iii. If you remain concerned, it may be appropriate for you to discuss the event with a trusted mentor — being careful
to maintain the confidentiality of both the patient and provider.

iv. If you continue to believe something may have been amiss in the care of the patient, you may wish to discuss the
matter further with the program director or the undergraduate dean
 Documentation

❖ The progress notes should include the following details concerning the disclosure meeting:

I. time, location, and date of the meeting

II. name and roles of those present
III. facts presented in the discussion
IV. participants' reactions and responses
V. agreed-upon next steps
VI. any plan for providing follow-up and further information to the patient and family, if appropriate
VII. name and details of the patient's contact person
 Post-analysis disclosure
❑ After an appropriate analysis has taken place, any additional facts related to the reasons why harm resulted should
be discussed with the patient. These reasons may include:
✔ factors related to an underlying medical condition
✔ recognized and unavoidable risks inherent in an investigation or treatment
✔ system failures
✔ problems in provider performance
✔ a combination of any of these

❑ Post-analysis disclosure in community practice

• In office or clinic settings, the supervising physician or the physician managing the clinic is likely to lead this
discussion.
• Patients usually appreciate learning of any changes made within the practice to prevent reoccurrences of an adverse
event (accident in Québec).

❑ Post-analysis disclosure in hospital and institutional settings

• If the analysis reveals that the adverse event was the result of a system failure, the hospital or institution leaders (i.e.
management) are likely to be responsible for the post-analysis disclosure. They determine what information will be
disclosed to the patient at this stage.
• However, if the patient and the providers so choose, the hospital or institution should still provide the physician, and
other providers involved in the event, with an opportunity to participate in these discussions.
• Limitations on what information can be shared with patients may exist.
• The post-analysis disclosure in hospitals and institutions must consider any restrictions or requirements on
information exchange that might apply due to provincial/territorial legislation, regulations, institutional/hospital by-laws
and policies, and legal privilege.
❖ Systems thinking

❑ The traditional response to an adverse event (accident in Québec) has focused on identifying and blaming the
providers who had the last contact with the patient, resulting in calls for greater vigilance, better training, and
sometimes professional sanctions or firings.
✔ However, the same problem may recur in the future unless a real attempt is made to understand the
circumstances and context for the decisions and actions at the time of the event.

❑ By contrast, systems theory in patient safety emphasizes that focusing on the system rather than on the
individual will help prevent more adverse events.
✔ Patient safety experts argue that acting on the recommendations from a quality improvement review of the
system of care is one of the more effective approaches to improving patient safety in a hospital or healthcare
institution.
✔ Similar adverse events can be prevented over time by strengthening system protections, which will benefit future
patients.
✔ Providers are still responsible for the quality of their work within the system. The objective is to find the right
balance between improving healthcare and helping all providers prevent similar events in the future, while fairly
addressing any issues of individual provider performance and accountability. This more balanced approach is
often referred to as a "just culture of patient safety."
 Learning from near misses
❑ Near misses are opportunities to prevent harm to patients in the future.

• A near miss in aviation refers to 2 aircraft in flight narrowly missing a collision with each other.
• A near miss in medicine is an event that might have resulted in harm but the problem did not reach the
patient because of timely intervention by healthcare providers or the patient or family, or due to good
fortune. Near misses may also be referred to as "close calls" or "good catches."

❑ In a culture of safety, near misses are "free lessons.

❑ Near misses may occur many times before an actual harmful incident. Many avoidable deaths have a
history of related near misses preceding them.

• "High reliability organizations" view near misses as learning and improvement opportunities. Such
organizations ask: "How will the next patient be put at risk or harmed?", they value and acknowledge
input, and make appropriate improvements.
• Conversely, "low reliability organizations" are falsely reassured because no harm occurs and they
mistakenly conclude the system of care is safe. They wait for harm to occur.

❑ System failures or provider performance issues including provider error, or both, may lead to a near miss.
 Learning from near misses
❖ Why are near misses important?

⮚ They represent "error prone situations" and "error traps" waiting to catch other patients and providers.
⮚ There is less anxiety about blame as there are no liability concerns (because no one has been harmed).

❖ Why should near misses be reported?

⮚ Many hospitals have near miss reporting systems. Offices and clinics should encourage staff to report near
misses.
⮚ Reporting near misses helps to:
I. reduce risks for all patients by not waiting for harm to occur
II. trigger improvements in weak spots in the processes of care
III. alert other providers to possible vulnerabilities and gaps in training
IV. contribute to planning, recovery testing, and harm mitigation strategies following events that do result in harm

❖ Examples of near misses

⮚ Sometimes a medication is prescribed without considering the patient's allergies or potential for significant drug
interactions. In many, but not all, situations the patient or pharmacist recognizes the risk in time.
⮚ Here are some other examples of near misses.
 Case: Near miss prior to surgery

• Background
Mrs. G is scheduled for important surgery. She takes warfarin for treatment of atrial fibrillation.
It is discovered in the operating room that Mrs. G. had not stopped her warfarin as instructed.
The surgery is postponed
• Lessons learned
If this near miss had not been discovered, Mrs. G might have bled significantly during the operation, perhaps requiring
a blood transfusion and other treatment.
• Think about it
Can you think of ways to lessen the likelihood of such problems occurring for other surgical patients?
 Case: Near miss with paralyzing drug

• Background
During preparation for an operation, a vial of the neuromuscular blocking agent succinylcholine is inadvertently used
instead of sodium chloride as a reconstitution agent.
Both vials have a similar appearance.
The anesthesiologist catches the substitution before any drug is administered and reports the near miss to the hospital
• Outcome
The hospital contacted the Institute for Safe Medication Practices Canada (ISMP).
ISMP Canada subsequently distributed a safety bulletin on the potential mix-up.
The manufacturer then made significant changes in the packaging and labeling of succinylcholine.
 Case: Near miss related to wrong-sided surgery

• Background
A 60-year-old male is scheduled for surgery on his right knee.
After having checked the patient's medical record and confirming the site with the patient, the orthopaedic surgeon
uses a permanent marking pen to initial the right knee in the centre of the operative field.
The surgeon arrives in the operating room and the left knee has been prepped and draped.
• Outcome
The surgeon knows he must see the initials before making any incision or puncture. The problem is caught in time and
the correct knee is operated on.
An analysis of this near miss resulted in several improvements in safety in the operating room.
"Operate through your initials" is one of several approaches used to help prevent wrong-sided surgery: preoperatively,
the surgeon marks the initials of the surgeon's name on the site that is to be operated.
 Formal reviews

⮚ Two types of reviews of harm from healthcare delivery are typically used by leaders and managers in Canadian
hospitals: quality improvement reviews and accountability reviews.

❖ Quality improvement reviews

❑ Quality improvement (QI) reviews are designed to identify the reasons for adverse events or near misses by
examining the system and processes by which healthcare is provided.
❑ To be meaningful, QI reviews should include candid and detailed assessments by the providers involved. In addition
to reviewing known facts, it is often helpful to consider what could have happened or what the participants wished
had happened.
❑ Discussions may include hypothesizing and speculating about weaknesses in system processes. This can be a
useful way to identify possible reasons for the clinical outcomes and to develop strategies to try to prevent
reoccurrences.
❑ To encourage the full participation of providers, legislation exists in each province/territory that generally protects the
work of a quality improvement committee. This legislation reflects the public policy objective of encouraging
healthcare providers to participate in quality improvement.
❑ The QI review may confirm the clinical outcome resulted from the patient's underlying medical condition or the risks
inherent in an investigation or treatment. Conversely, the review may identify system vulnerabilities or failures.
❑ Following the analysis, the patient should be informed of new facts identified in the analysis of the event and the
conclusions about the reasons for the clinical outcome. The deliberations, or opinions and speculations discussed in
the review should not be disclosed. An apology may be warranted.
❑ Patients will often want to know what steps, if any, have been implemented to prevent similar harm to others, and it
is appropriate to share this information.
 Case: A 16-year-old male with leukemia

• Background
A 16-year-old male is diagnosed with leukemia.
During the last cycle of chemotherapy, his oncologist is running behind schedule and asks a junior resident to
administer three chemotherapeutic agents to the patient. The pharmacy sends all three drugs in the same medication
pouch. The resident has had little orientation to the oncology service and attempts to seek clarity from the supervising
oncologist without success.
All three drugs, already in preloaded syringes, are administered intrathecally. However, one of the drugs, vincristine,
should be given intravenously.
The healthcare providers involved promptly provide the parents with information about the clinical condition of their
son, giving them an initial understanding of the facts about what has happened, as well as emotional support.
• Outcome
Despite all rescue efforts, the young patient dies 3 days later. The coroner (medical examiner) is immediately notified.
• Think about it
Could a similar medication adverse event occur in your hospital? What would be the response of your leaders?
 Formal reviews

❖ Alternative approach
⮚ The preceding case describes a real occurrence in Canada. The following is a fictional description of how this serious
adverse event could be handled in a just culture of safety. The approach reflects what many patient safety experts and
the CMPA see as a fair and effective way to improve the quality of patient care and prevent other similar occurrences.

1- The leaders of the hospital do not rush to prejudge and blame the providers for what has happened. Rather, they try to
understand the circumstances and context for the decisions and actions during the event.
✔ A preliminary collection of facts shows there was no deliberate violation of policy or deliberate misconduct. The
resident's lack of knowledge or skills is considered largely a shortcoming in the orientation to the oncology service.
✔ The hospital determines the system of care needs improvement.

2- The hospital reassures the distraught parents that a QI review will be held and what they could expect to learn from it.

3 - The QI review is conducted by a properly constituted quality improvement committee.

✔ To gain a broader perspective, the hospital reviews a number of medication policies and practices.
✔ Knowing that the focus is on learning and that their remarks would not be used against them in other forums, several
physicians, nurses, and pharmacists, including those involved in the event itself, take part. The group avoids finger
pointing and blaming.
 Formal reviews
✔ Using the patient safety incident analysis approach, the healthcare providers speculate and hypothesize on what
could have been done differently in the system, both in this case and in the future.

4- The committee comes to an understanding of the facts about what happened and identifies several contributing system failures:
1. inadequate team communication
2. little orientation and supervision of new staff
3. confusing packaging and labelling of medications and syringes
4. no double checks for certain medications and routes by separate providers
5. less-than-ideal physical areas for preparing and administering high-risk medications
6. inadequate monitoring
7. lack of a policy for administering medications

5- The hospital makes a number of changes.

✔ The orientation for all new medical, nursing, and support staff is improved.
✔ The hospital also improves the procedure for delivering medications to the ward. It develops, tests, and implements policies
for handling high-alert medications.
✔ Syringes containing vincristine are now flagged with a warning against intrathecal use.
✔ Many other medication safety practices are introduced including better labelling, segregation of drugs that look similar (look-
alike medications) and have similar-sounding names (sound-alike medications), read backs, and clearer writing of drug
orders.

6- The hospital leaders and the providers involved give the parents a factual understanding of what has occurred, as well as
an apology. They discuss the steps that are being taken to improve the medication practices at the hospital.

▪ A similar tragedy has not occurred since, and serious medication adverse events have decreased overall.
 Case: A 45-year-old male with asthma

• Background
A 45-year-old male, being followed for difficult-to-control asthma, presents with cough and fever to his respirologist in a
hospital outpatient clinic. The clinical findings are sufficient to warrant a chest X-ray.
Antibiotics are prescribed for presumptive early pneumonia. The patient is discharged with instructions on symptoms to
watch for that would prompt him to seek further medical care. As for the X-ray, the patient is told that "no news is good
news," but if the report is positive then the patient would be telephoned.
The encounter is well documented in the medical record.
Months later, the patient returns because of worsening symptoms. At that visit, the report of the chest X-ray is
discovered in the medical record. An important finding suspicious for lung cancer has not been followed up.
• Think about it
What type of review should be undertaken to decrease the likelihood that a similar problem would occur to other
patients?
• Outcome
In this case, a quality improvement review is the preferred type of review. Given what is known, an accountability
review that would focus on the respirologist or other providers would not be appropriate.
The event is used as an opportunity to examine the existing administrative systems of several hospital departments
and how they follow up on test and diagnostic imaging reports.
The QI review identifies several potential failure points waiting to trap other patients and their providers.
The vulnerabilities are corrected.
 Formal reviews

❖ How to do quality improvement

❑ Many approaches exist for gaining an understanding of the system reasons for adverse events and near misses.
One of the most common approaches is patient safety incident analysis (or root cause analysis). This is a
systematic process for investigating an adverse event or near miss, which looks for underlying system failures and
develops recommendations for system improvements.

❑ Other approaches to conducting QI initiatives include:

⮚ Clinical Practice Improvement (CPI): A methodology for improving the process of care, focusing on the content
and timing of individual steps related to a patient's care.

⮚ Plan-Do-Study-Act (PDSA) cycle: A structured approach to determine if a change in a process of care results in
improvement. The cycle is composed of the following:
I. Plan — determine what to improve and how to test the change
II. Do — make the change
III. Study — observe and learn from the results of the change
IV. Act — refine what was done based on the test results

⮚ Failure Mode Effect Analysis (FMEA)

 Formal reviews

❖ Accountability reviews
❑ Healthcare providers in Canada are accountable to:
I. conduct themselves professionally
II. maintain their knowledge or skills without gaps
III. comply with known, relevant, realistic, and sound policy
IV. practice if healthy to do so

❑ From time to time, hospital or departmental leaders (i.e. chief of department) may conduct an accountability
review to focus on a specific provider's role in an adverse event. In a just culture of safety, when a deficiency in a
provider's performance is identified, education and support are the preferred remedies.

❑ Sometimes discipline and other sanctions may be necessary.

❑ When asked to do so, healthcare providers are generally obligated to take part in reviews of their own
professional work.
❖ Sources of stress

❑ Sources of stress for medical students, residents, and practicing physicians include:

I- Biological
• fatigue, due to hard work and lack of sleep
• lack of exercise
• poor eating habits
II- Psychological
• personality traits — highly responsible, conscientious, sense of guilt, compulsive, able to delay own gratification
III- School and work
• studies and exams
• call schedules
• heavy workload
• serious illnesses and/or social circumstances of patients
• solving ethical dilemmas
• interpersonal disagreements
• conflicts
• adverse events (accidents in Québec)
• complaints or lawsuits
IV- Personal
• financial pressures
• personal relationships
• family needs
 Case: Child with abdominal pain

• Background
A resident on her emergency medicine rotation assesses a young girl complaining of abdominal pain. After the initial
history and physical examination, she believes the young girl looks well, has no signs for concern on physical
examination and is likely suffering from constipation.
She discusses the patient with the emergency physician, who asks pertinent questions.
Knowing the resident's clinical skills and level of training, he believes she has assessed and diagnosed the patient
properly. He does not personally examine the patient, telling the resident to discharge her home.
• Outcome
The patient was readmitted the following morning with peritonitis from a ruptured appendix.
• Think about it
Is this a likely scenario in a busy emergency department?
How would you feel if you were the resident in this situation?
 Outcomes and adverse events
❖ Stress following poor clinical outcomes and adverse events (accidents in Québec)

▪ Few things make doctors feel as badly as learning that a patient has suffered harm from receiving medical care.

▪ The qualities that contribute to making you a good doctor — compassion, empathy, sensitivity and responsibility —
may cause you to feel distress when poor clinical outcomes and adverse events (accidents in Québec) occur.

▪ It is normal to be emotionally affected when a patient suffers from an illness or serious complication. Feelings of guilt
after a poor outcome are common. In retrospect, you may question your own care and wish you had done things
differently.

▪ Even when the risk was well known, had been explained to the patient, and all precautions had been taken, it is
inevitable that a compassionate doctor will question his or her judgment and actions. An objective review of the
events based on the facts will frequently demonstrate the actions taken at the time were reasonable and the
outcome, however devastating, was unavoidable.

▪ Following an adverse event, attend to the clinical, emotional, and information needs of your patient. Discuss with the
patient any steps which might be taken to mitigate the harm. The process for disclosing harm from adverse events
to patients and their families can be helpful emotionally to the physician as well.

▪ CMPA members are encouraged to call the CMPA for advice.

▪ Medical students should speak to their supervisors.

 Complaints and legal actions
❖ Stress following complaints and legal actions

⮚ Legal actions seldom name medical students.

⮚ A complaint or legal action does not mean you are a "bad doctor."
⮚ Legal actions and complaints are stressful for all concerned.
⮚ There are many common reactions to stress.

❑ The majority of legal actions by patients in Canada identify practicing physicians, but sometimes residents are
also involved.

❑ Legal actions seldom name medical students.

❑ A physician receiving notice of a legal action may feel indignant, wounded, or depressed about the allegations
made and the manner in which these have been stated.

❑ Receiving a complaint or being named as a defendant in a legal action does not mean you are a "bad doctor."
Even the most conscientious and competent physicians experience such difficulties.

❑ The experience of the CMPA indicates almost all physicians dealing with a medical-legal problem experience
stress.

❑ The results of this experience can be long lasting. However, the initial strong emotions generally subside with
time.

❑ Eventually, most physicians are able to view the medical-legal matter with a greater degree of equanimity and
detachment. They cope successfully with the stress and regain their sense of fulfillment and career satisfaction.
 Complaints and legal actions
❖ Common reactions to stress
Not unlike their patients, physicians experience stress in a range of ways:

I- Emotional
• anxiety and depression
• self-doubt and blaming oneself
• loss of self-esteem
• denial
• defensiveness and blaming others
• sense of loss of image
• helplessness — the sense of loss of power and control
• anger and frustration
• lack of trust in patients
II- Physical
• insomnia
• exhaustion
• generalized aches and pains
• headaches
• palpitations
• gastrointestinal symptoms
III- Behavioural
• rumination on the case (perseverance)
• need to talk about the complaint
• social withdrawal and internalization
• need to get away from work
• reduction in working hours
• wish to leave the practice or profession
• family disruptions
• use of alcohol or medications
 Coping
❖ Coping with the stress of patient outcomes, complaints, or legal actions

❑ When faced with unexpected poor clinical outcomes of patients, doctors often lose all objectivity when judging
their own performance in the circumstances. Hindsight bias provides a vastly different and often unfairly critical
perspective on a case.

❑ If you receive a complaint or statement of claim in a legal action, remember it is often not a totally impartial or
objective account of events.

❑ For example, the language used in statements of claim is usually harsh and critical, and may be taken from a
standardized template. The competence of the physician may be called into question. Even the physician's
character may be attacked.

❖ How to cope

1. Take care of yourself

2. Analyze the event objectively
3. Respond professionally to make improvements
4. Seek personal support
5. Seek resources and professional help
 Coping
1. Take care of yourself

▪ It is important to get enough sleep and to eat well — physical strength will help you to withstand mental stress.

▪ Exercise is beneficial, but it is also important to maintain your social life and not to slip into isolation and
despondency.

▪ Do not self-medicate or increase your consumption of alcohol.

2. Analyze the event objectively

⮚ Try to be objective. Be honest with yourself, but try to avoid hindsight bias.

⮚ Accept the facts as they are. Don't obsess about "what might have been.“

⮚ Be self-aware. If you are preoccupied with this event, the potential for further error is actually heightened. Set
limits for the time you will think about this, then take time off from thinking about it and remind yourself of all that is
going well.

⮚ Use the Best Friend Technique. This technique encourages you to treat yourself as you would treat your best
friend. If you made an error allow yourself the same understanding you would accord to others. There is no need
for judgment. It is important to learn from what happened and move forward.
 Coping
3. Respond professionally to make improvements

❑ Patients can be harmed from healthcare delivery, and sometimes similar events may be avoidable in the future.
Knowing you have responded professionally in the face of an unfortunate event or criticism can contribute to
reducing stress.

❑ Focus on what you can learn from the event. Constructively consider:
Your own personal performance, knowledge, or skills
✔ When assessing your own actions, are there any objective lessons to be learned?
✔ Are there any alternative actions that might be appropriate in a similar situation in the future?
✔ Is there a need for further education?

❑ The system and processes of care at the workplace

❑ Can you contribute to quality improvement?

o in your own office?
o in the hospital setting?
 Coping

4. Seek personal support

⮚ You do not have to "go it alone"

⮚ Stay connected. Maintain normal relationships with patients, colleagues, family, and friends.

❑ Some physicians keep their professional problems secret, feeling they are unique in their difficulties. They
deprive themselves of the support that friends, family, and colleagues would willingly provide.

❑ Reach out, talk to others, focusing on how you feel. If you are involved in a legal action, avoid discussing the
details of the case.

5. Seek resources and professional help

⮚ Seek professional counselling if necessary.

⮚ Physicians, medical students, and residents should seek help when feeling unduly stressed, whether from
medical-legal or other difficulties. There are several avenues available to you.

❑ Family doctor:
You may want to consult your family doctor about how you are feeling.

❑ Provincial physician health programs:

Physicians may consider using the services of a physician health program; there is one in every province in
Canada. Many of these provincial physician health programs also extend services to medical students and
residents.
 Coping
❑ For students, the faculty advisor, or office of the dean:
We suggest that you contact your faculty advisor or the dean's office of your medical school.

❑ Publications on physician stress:

Increased awareness of the issue of physician stress has spawned the publication of many books and guides to
assist physicians. Some of these are available on the CMA website.

❑ Contact the CMPA:

When members call the CMPA, they receive advice and solace from people who understand their situation.
Physician Advisors at the CMPA are physicians with clinical practice backgrounds and are experienced in
assisting doctors with medical-legal issues. They strive to help members keep their situation in perspective.
 Your lawyer

❖ Working with your lawyer

• During your career you may become involved in a complaint process or legal action requiring a defense lawyer.
The following tips can help you and also limit the stress involved:

I. Be prepared.
Imagine you are studying for your qualifying exams. This is just another similar challenge. Study the case, pore
over the file, know the details and take notes.
II. Do not avoid the problem.
Read the letters from and cooperate with the CMPA assigned lawyers. Force yourself to review the records and
chart.
III. Do not avoid the assigned defense lawyers.
Take calls from your lawyer (not the patient-plaintiff's lawyer), or return them promptly. Meet with your lawyer. Do
not worry about being embarrassed or being judged by them. This is their job, they see this all the time, and they
can help you. CMPA members are reminded that all communication with the patient and the patient's family should
be through the legal counsel assigned by the CMPA.
IV. Be prepared for hearings.
Ask yourself questions, and prepare answers. Learn about the process, order of events, physical layout of the
hearing room, where to sit, how to address those present, and how to testify. Know where you are going, and be
on time. Dress in business clothes. Look and act confident. Be calm, clear, and credible.
V. Understand and identify roles.
Your role is to explain and defend yourself. Their role is to question you. Do not personalize this; they are just
doing their job. Note: This is a different role than in patient care.
1-That is incorrect
Situational awareness refers to a person's perception and understanding of the dynamic information that is present in
their environment. It is keeping track of what is going on around you, and includes anticipating what might need to be
done.
Try again

2-That is incorrect
Hindsight bias refers to the situation in which knowing an undesirable outcome has occurred increases the belief that it
was predictable, should have been foreseen, and was therefore preventable.

3-That is incorrect
Authority bias is a cognitive predisposition that refers to declining to disagree with an "expert."

4-That is correct
Learned intuition refers to the phenomenon when a person having learned a complex process later considers it
intuitive despite the number of steps involved. The person does not easily recall the difficulty experienced when first
trying to learn the process. When someone else new to the process has difficulty with it and makes a mistake, others
can be critical of the individual when, in fact, the problem may stem from poor orientation or training.

5-That is incorrect
Heuristics are mental shortcuts. Availability heuristic refers to the overemphasis of recent or vivid patient diagnoses
when assessing the probability of a current diagnosis.
1-That is incorrect
Although harm most frequently results from the continuation of the patient's underlying disease process, in this case
the harm resulted from the inherent risk of the chemotherapeutic agent. A recognized complication such as this can be
reduced through medical research to develop better agents with fewer side effects.

2-That is incorrect
The infection in this case resulted from an inherent risk of an investigation or treatment: An expression of sympathy
and concern should be offered, such as "I am sorry you had this side effect." An apology with acceptance of
responsibility should not be provided.

3-That is correct
Certain complications or side effects may occur and are independent of who is providing the care. It is appropriate to
discuss this with the patient with an expression of sympathy such as "I am sorry you had this side effect."

4-That is incorrect
Even when the harm is determined to have resulted from a recognized risk inherent in the investigation or treatment
and an informed consent discussion preceded the event, most patients do not expect that the complication would
actually happen. A discussion is helpful.

5-That is incorrect]
Patients expect to be told about events in their healthcare delivery. The infection in this case resulted from an inherent
risk of the treatment: An expression of sympathy and concern should be offered, such as "I am sorry you had this side
effect."
1-That is correct
All Colleges in Canada expect that harm from heathcare delivery — whether it is from an inherent risk of an
investigation or treatment, or from problems in patient safety — would be discussed with patients.
The College in this case supported the care provided, but also made it clear the patient should have been made aware
prior to her discharge of the circumstances of the tear and repair, as well as any other potential complications that
might arise. It pointed out "patients are entitled to be informed of all aspects of their healthcare, including a right to
know about complications that have occurred."

2-That is incorrect
When a complication occurs, it is important to decide who should discuss it with the patient, and when. In medical care,
it will usually initially be the most responsible physician, but when more than one physician is involved, good
communication between or among the physicians will help ensure the patient receives both good care and adequate
information.

3-That is incorrect
It is generally better if the initial disclosure discussion occurs at the earliest practical time. Although not all the facts
related to the event will be available, the initial discourse is best done within 1 to 2 days after the event is recognized,
or when it is most appropriate for the patient and family. Subsequent disclosure meetings will provide further facts.

4-That is incorrect
Events that result in harm should be discussed.

5-That is incorrect

Generally disclosure is a clinical issue and only providers and their leadership are involved .
1-That is incorrect
Even though a small incision is used, laparoscopic surgery is a significant operation. An informed consent
discussion should not leave the patient with the impression that it is a minor procedure without the possibility of
significant complications.

2-That is correct
Empathy in medicine can be defined as "appreciation of the patient's emotions and expression of that awareness
to the patient." 1 Being empathic is an important quality of physicians.
Even with the best of medical care, a patient's outcome may not be what was originally desired or anticipated, and
in some cases may be entirely unanticipated. Patients expect to be informed about harm they have experienced,
whatever the reason for it, and this information needs to be delivered in a caring and empathic manner.

3-That is incorrect
The patient and family were upset because they felt the risks of surgery were not well explained, and the surgeon
seemed unwilling to explain what had happened when the complication did occur. The surgeon seemed uncaring.
Although this is a good answer, there is a better answer for this case.
Effective communication with patients and the healthcare team can improve patient outcomes and satisfaction.
Conversely, failures in communication may lead to patient harm, misunderstandings, complaints, and lawsuits.

4-That is incorrect
Good physicians recognize their limitations and do not hesitate to ask for help from colleagues. Good teams
practice drills together, so in a crisis they function better.

5-That is incorrect
Complications occur even in the best of hands.
The use of a surgical safety checklist can help teams anticipate the possible complications and have the right
equipment ready.
1-That is correct
An honest discussion with a patient about the occurrence of a recognized complication or an error may reinforce trust
and prevent allegations of a cover-up. Patients need to know such information to guide their decisions on further care

2-That is incorrect
The resident had difficulty with the saw vibrations and the surgeon did not take over. Staff surgeons and residents
need to recognize when the risk of patient harm outweighs the benefit for the resident of an opportunity to gain hands-
on experience.
When delegating, the supervising physician must decide on the appropriate level of supervision under the
circumstances, given the training level and experience of the trainee. Trainees should recognize their limitations and
not hesitate to voice any concerns about taking on a task unfamiliar to them, or to ask the appropriate questions to
clarify what is expected.

3-That is incorrect
The operative note in this case did not reflect the excessive bone removal or the poor fit of the implant. Later, the
patient interpreted this as a cover-up.

4-That is incorrect
The smaller-than-required implant meant the knee joint could dislocate more easily. The appropriate size might have
been better predicted and made available in the operating room that day.

5-That is incorrect
A patient's special circumstances might require discussion of potential but normally uncommon risks of the
investigation or treatment.
Patients should be informed about the participation of medical trainees in their care. Some patients might refuse. This
is the patient's prerogative.
1-That is incorrect
This event is a "near miss," as no harm to the patient resulted. As a general approach, a near miss need not be disclosed to a
patient, although there are certain exceptions.
A patient should receive knowledge of a near miss if there still is an ongoing similar safety risk for that patient, or if the patient is
aware of the near miss.

2-That is incorrect
A near miss is an event with the potential for harm that did not result in harm because it did not reach the patient, owing to timely
intervention or good fortune. It is sometimes called a close call

3-That is correct
A patient should receive knowledge of a near miss if there still is an ongoing similar safety risk for that patient, or if the patient is
aware of the near miss and an explanation will allay concern and promote trust. In this case, the patient should be made aware that
another patient with the same name is on the same ward. This will allow the patient to be alert to this risk. Staff should be alerted so
safeguards can be put in place. This case also reinforces the need for always checking that you have the correct patient.

4-That is incorrect
This event is a "near miss," as no harm to the patient resulted. In fact, near misses are important opportunities to recognize
weaknesses and put system safeguards in place to prevent actual harm events from occurring in the future.
Many hospitals have near miss reporting systems. Offices and clinics should encourage staff to report near misses.
The legal obligation to report near misses varies across provinces.
In Québec, the law requires the completion of an incident report for near misses in government-run institutions such as hospitals.
The report is kept on the patient's medical record. In such a situation, it is prudent to alert your patient to the incident, the report,
and any subsequent preventive measures put in place. This will lessen the likelihood of any misunderstanding and mistrust in the
future.

5-That is incorrect
This event is a "near miss," as no harm to the patient resulted. In this case, the inaccurate identification band poses an ongoing risk
to the patient and the inaccurate information should be corrected as soon as possible. In addition, the patient is likely aware of the
event and would be reassured by learning of the corrections.
Trainees should report adverse events (accidents in Québec) (or if using WHO ICPS terminology, "patient safety incidents"),
potential-for-harm, no-harm events, and near misses to their supervising staff physician.
In near miss events, the supervising physician can decide who should speak with the patient, depending on the nature of what has
happened.
Following an adverse event, however, the supervising physician should lead the disclosure discussions. Trainees should be
encouraged to take part in such discussions as a learning experience.
 CMPA :
Professionalism
 Objectives

❖ After completing this domain you will be able to:

I. Demonstrate the value of honesty, integrity, and respect in the practice of medicine.
II. Identify the importance of maintaining boundaries in good patient care.
III. Distinguish boundary crossings from boundary violations.
IV. Describe situations where a boundary crossing or violation has occurred.
V. List strategies to prevent boundary crossings.
VI. Respect the ethical obligation to report unprofessional physicians.
❖ Being professional

❑ Physician charter — Ten commitments

1. Professional competence
2. Honesty with patients
3. Patients' confidentiality
4. Maintaining appropriate relationships
5. Improving quality of care
6. Improving access to care
7. Just distribution of finite resources
8. Scientific knowledge
9. Maintaining trust by managing conflicts of interest
10. Professional responsibilities

❑ Attributes of professionalism include:

1) Honesty and integrity
2) Responsibility and accountability
3) Dedication to optimum performance
4) Maintaining and improving basic skills
5) Understanding limits of knowledge and abilities
6) Respect
7) Compassion
8) Empathy
9) Altruism
 Being professional
❑ Think of a specific role model you admire
What characteristics of this individual reflect the values, commitment, and aspirations of the medical profession?
What kind of behaviour would you want to emulate?

❑ Does your role model...

I. put the well-being of patients first?
II. respond to calls for assistance from learners?
III. actively seek feedback and learn from past experiences?
IV. provide constructive feedback?
V. demonstrate sensitivity to cultural, gender, or religious differences?
VI. enjoy teaching medicine?
VII. communicate effectively, fostering a sense of trust?
VIII. effectively advocate for patients and for safety?
IX. develop team relationships that demonstrate respect for trainees, peers, colleagues, and healthcare
providers?
X. manage conflict effectively?
XI. seek work/life balance?
❖ Practicing with integrity
❑ Integrity and trustworthiness are fundamental expectations of physicians.

❑ The Good Practices Guide contains many examples of the integrity expected of healthcare providers,
including:
✔ obtaining informed consent
✔ disclosure of, and responding to, adverse events (accidents in Québec)
✔ never altering the medical record after learning of an adverse event or medical-legal difficulty
✔ acknowledging the limits of one's ability by saying "I don't know" or "I am not sure"

❖ Honesty and integrity with patients

❑ Consider the following cases highlighting honesty and integrity with patients.
 Case: Taking advantage of a false assumption

• Background
A third-year medical student is introduced by her supervisor as Dr. A to a patient in the emergency
department. The supervisor does not explain either Dr. A's status as a medical student or her role in the
patient's care.
Having determined that the patient requires sutures to close a laceration on her forearm, the supervisor
asks the patient if she would mind if Dr. A performed the procedure. The patient seems indifferent as to who
does the procedure, stating that "one doctor is as good as the next."
The medical student realizes the patient believes she is an emergency physician. This makes the student feel
uncomfortable. However, knowing the suturing experience will help her in her surgery rotation and not wanting
to discourage the supervisor from providing additional learning opportunities, she does not correct the patient's
assumption.
• Think about it
Although hands-on learning opportunities are important, is it appropriate to mislead patients about your
educational status?
How does the failure to correct a patient's assumption about a student's status threaten both the patient's
safety and trust in the healthcare system?
How might the pressure to perform lead a medical student to consider compromising ethical values?
• Suggestions
Informing patients of a medical trainee's status is integral to both patient safety and respect for the patient.
Medical students and residents should introduce themselves and identify their educational status to patients .
The patient may refuse to be assessed or treated by a trainee for all or part of their care. Reasonable attempts
should be made to meet a patient's needs in these circumstances
 Case: Too rushed to think

• Background
A clerk on a surgery rotation is asked by the surgeon to discharge a patient. The surgeon informs the clerk that if he
completes the discharge in time, he will have the opportunity to assist with the next surgery, an appendectomy.
Having never had the opportunity to assist with a surgery before, the clerk is eager to participate and rushes through
the patient discharge instructions.
Despite being given clear instructions from the surgeon, the clerk, in his excitement and rush, fails to inform the
patient about appropriate follow-up, including signs and symptoms indicating a need for further medical care.
• Think about it
Are the clerk's actions unprofessional in this situation?
What other factors might be causing the clerk to act in this way?
What effect could the clerk's omission have on the discharged patient's clinical outcome?
What can the clerk or supervisor (surgeon) do in this situation to prevent patient care from being compromised?
• Lessons learned
Every patient deserves appropriate care and attention, and this is a responsibility of physicians and trainees.
While exposure to surgeries and other procedures may be exciting, it is unprofessional to compromise a patient's
care to further your training.
 Case: Request for a disability note

• Background
You are working as a clerk with a dermatologist in the outpatient department. You have carefully reassessed a patient
with a resolved contact dermatitis. You explain how to avoid contact with the offending allergen and reassure the
patient that she can return to work.
The patient asks the supervising dermatologist to sign a disability form for her to remain off work for an additional two
weeks so that she can go on a vacation. She threatens to take legal action if the dermatologist does not sign the form.
• Think about it
Should the dermatologist sign the disability form to avoid the threat of medical-legal difficulty?
What are the pressures on the dermatologist?
What could the dermatologist say to this patient?
• Lessons learned
Physicians are regularly asked to sign forms on behalf of patients to allow them to receive disability, sick leave, or
injury benefits.
Physicians are responsible to ensure the reports they prepare are timely, accurate, honest, and reasonable.
Even if a patient threatens legal action, a physician is obliged to refuse to provide an inappropriate report that conflicts
with their medical judgment.
 Honesty and integrity with
supervisors

❑ Consider the following case highlighting honesty and integrity with supervisors.

⮚ The medical record is a legal document and is expected to be accurate.

⮚ Any statements made by a healthcare provider should be objective and factual.

⮚ You will be judged on the facts and your actions.

⮚ Patient care may suffer if you give false information.

 Case: Providing accurate information to others

• Background
A first-year medical student is given an assignment to interview a patient and develop a case report for grading.
While writing the report the student realizes that he did not ask the patient about allergies. Knowing that the case
report would not be used in the patient's care but would count toward the student's final grade, he writes a fictitious
summary of the patient's supposed allergies and hands in the report.
The student achieves an exceptionally high mark and receives a comment from the tutor commending his
thoroughness.
Two years later, the former medical student, now a clinical clerk, is asked to see a patient and obtain a history.
Before reporting back to his supervisor, the clerk realizes that he did not ask the patient about her family history.
Anxious to finish up the day and start the weekend, the clerk thinks back to the time in medical school when he did not
get caught for falsifying data in the case report assignment.
The clerk records "no relevant family history" on the chart.
• Think about it
Do you think the clerk would have considered falsifying patient information if he had been caught doing so on his past
assignment?
What system and provider factors may drive individuals to compromise their integrity and potentially compromise
patient safety?
A fast-paced environment such as healthcare might require that students and physicians complete tasks more quickly
than would be ideal. What are some strategies that might help students to complete tasks thoroughly and accurately?
• Suggestions
Strategies that might help students to complete tasks thoroughly and accurately include:
✔ time management
✔ informing supervisors of obligations to be elsewhere at a certain time
✔ allotting some leeway time at the end of the day to relieve pressure when running behind schedule
❖ Avoiding discrimination

✔ Respect for both patients and healthcare team members enhances the quality of care.

✔ Colleges expect a high standard of conduct from physicians which extends beyond the clinical setting.

❑ The special relationship of trust between physicians and their patients, known as a fiduciary relationship, requires that physicians
always act in their patients’' best interests.

❑ Patient-doctor relationships carry an inherent power imbalance which may place patients in a position of vulnerability. Physicians are
responsible for behaving professionally and maintaining appropriate boundaries with patients at all times.

❑ As a practicing physician in Canada, your patients may be from cultures different from your own, and you need to recognize and respect
cultural differences. Cultural differences may also influence how professional boundaries are perceived, and being aware of this may help
prevent misunderstandings.
 Respecting difference and diversity
⮚ Achieving the ability to accept others' points of view and to adapt your attitude without judgment requires
continual conscious effort.

⮚ A patient's lack of adherence to treatment plans may have roots in cultural diversity.

❑ Multiculturalism is enshrined in Canada's constitution. The Canadian Charter of Rights and Freedoms guarantees
individual rights and freedoms to all Canadians and stipulates that those rights must be interpreted in the context
of cultural diversity. Provincial/territorial human rights codes similarly prohibit discrimination.

❑ Courts and regulatory bodies expect physicians to respect patient wishes about the care they receive. Patient-
centred care helps strengthen the doctor-patient relationship because:
✔ It considers a patient's values, beliefs, and wishes in the formulation of a treatment plan.
✔ It requires that physicians understand how a patient's socio-cultural background affects beliefs and behaviours.

❑ Being able to accept others' points of view and to adapt one's attitude without judgment is a journey.
Respecting difference and diversity
 Respecting difference and diversity

❖ Here are different levels of cultural understanding a physician can exhibit.

I - Cultural awareness is observing and being conscious of similarities and contrasts between cultural groups, and
understanding the way in which culture may affect people's approach to health, illness, and healing.

II- Cultural sensitivity is being aware of (and understanding) the characteristic values and perceptions of your own
culture and the way in which this may shape your approach to patients from other cultures

III- Cultural competence refers to the attitudes, knowledge, and skills necessary to become an effective healthcare
provider for patients of diverse backgrounds. Competence requires a blend of knowledge, conviction, and a
capacity for action.

IV- Cultural safety goes beyond cultural sensitivity to understanding the inherent power imbalance and possible
institutional discriminations against people of different origins. It implies that the care provider has reflected on her
own identity and the perceptions of them that others from different cultures may hold. Culturally safe practice
implies the ability to keep these differing perspectives in mind when providing treatment to the patient.

✔ Physicians cannot realistically be "culturally competent" with regards to every possible patient background,
although they can approach their patients in a way that demonstrates they are interested in discussing cultural
issues that affect their health and to reasonably accommodate their patients' values in formulating a treatment
plan.
 Case: Asking a mother to remove her veil

• Background
A plastic surgeon is seeing a child about a fingertip injury. The patient's mother is veiled so that only her eyes are
visible. The surgeon asks the mother to remove her veil so he can see who he is speaking with.
The mother takes great offence to this request and complains to the regulatory authority (College) that the plastic
surgeon had tried to frighten her and had made inappropriate comments.
• Outcome
The College requires the plastic surgeon to undertake sensitivity training.
 Boundaries for practice
❑ Attitudes toward healthcare and illness play a significant role in the doctor-patient relationship. Physicians with a
monocultural mindset may think their own culture is most important, while those with an intercultural
mindset try to understand the other culture and address issues that may interfere with the provision of good and
safe care. This approach helps patients feel safe to express their preferences.

✔ For example, the conventional western medical treatment of depression generally involves a
psychotherapeutic approach which assumes patients will calmly disclose their difficulties. A physician might
experience significant therapeutic challenges with, for example, a First Nations patient until the physician learns
that some First Nations people need to participate in a sweat lodge ritual before being ready to express feelings.

❑ While different people will have varying levels of comfort with difference and diversity, practicing with a
monocultural mindset increases medical-legal risk.

❑ While individual physicians have a right to their personal beliefs, there are nevertheless strict expectations about
what is and is not acceptable in practice and which boundaries physicians must respect.

❑ Each Canadian jurisdiction has human rights legislation that prohibits discrimination.
 Boundaries for practice
❖ Here are some various attributes on which discrimination is prohibited.

❑ Marital status: Being married, single, widowed, divorced, separated, or living with someone in a conjugal relationship
outside marriage.

❑ Ethnicity, race, ancestry, and place of origin: While race is a biological concept focusing on the physical characteristics
of individuals, ethnicity is usually self-ascribed and pertains to a group of individuals' shared ancestral traits which may
include race, language, culture, and ancestry.

❑ Sexual orientation: Refers to the sex of partners to which a person is sexually or romantically attracted.

❑ Gender expression: Describes how someone communicates gender (i.e. through clothing or communication style). It
need not be consistent with a person's gender identity or with societally-prescribed gender roles.

❑ Gender identity: Describes a person's self-identification as male, female, or transgender

❑ Sex: While "sex" pertains to biological or physiological characteristics that define men and women, "gender" pertains to
the attitudes, social roles, and behaviours a society attributes to a particular sex. Discrimination on the basis of sex in
some human rights legislation includes the fact that a woman is or may become pregnant.

❑ Family status:Being in a parent and child relationship.

❑ Disability: Refers to any degree of physical, mental, developmental or learning disability, impairment or dysfunction,
including a person's use of remedial appliances, devices, or guide animals.

❑ Citizenship: Refers to the country in which a person was born or given citizenship through naturalization. A person may
have more than one citizenship.

❑ Age: The length of time a person has lived to date.

 Boundaries for practice

❑ When considering refusing a person's request to become a patient or to receive a specific treatment, think
about whether the refusal might be perceived as discriminatory. To help establish diligence, document your
rationale for the decision and any discussions with the patient. Complaints to a regulatory authority (College) will
generally be reviewed in the context of Article 17 of the Canadian Medical Association's Code of Ethics which
states:
✔ "In providing medical service, do not discriminate against any patient on such grounds as age, gender, marital
status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion,
sexual orientation, or socioeconomic status. This does not abrogate the physician's right to refuse to accept a
patient for legitimate reasons."
 Case: Cancelling an appointment for surgery

• Background
A surgeon cancels an appointment for a patient who is HIV positive. After another surgeon performs the planned
procedure in the same clinic, the patient complains to the medical regulatory authority (College) that the cancellation
constitutes discrimination on the basis of a medical condition.
The first surgeon explains to the College that given the risk of post-operative infection, he believes surgery on HIV
patients should be done only in hospital, not in an outpatient setting.
• Outcome
The College ruled the physician had indeed discriminated against the patient on the basis of his medical condition.
 Case: The meet and greet

• Background
A family physician always has "meet and greet" interviews before accepting new patients.
After being rejected, one interviewee complains to the College.
The physician's response to the College is that the patient had multiple problems that she felt should be handled by
specialists
• Outcome
The College ruled the physician had indeed discriminated against the patient on the basis of the medical condition.
The College pointed out that the family physician could follow the patient's general condition and progress, while
conditions outside the physician's expertise could be referred to specialists.
 Case: Sexual orientation

• Background
A fertility specialist refuses to perform artificial insemination for a same sex couple.
The couple complains to the human rights tribunal in their jurisdiction.
The specialist's reason for refusing is that a previous same sex couple for whom the service had been provided had
involved the specialist in a legal action after the couple separated.
• Outcome
The human rights tribunal ruled that this was indeed discrimination on the basis of sexual orientation. They noted the
specialist readily provided the service to heterosexual couples, despite the fact such relationships can also break down
and engender litigation.
 Practicing according to your beliefs
❑ Discrimination is illegal.

❑ A physician cannot refuse to assess someone on the basis of a conscientious objection.

❑ In non-emergency situations a physician may refuse to provide treatment on the basis of his or her own conscientious
objections.

❑ Recognizing and addressing unconscious biases is important in providing culturally safe care. Although a physician
might have a conscientious objection to providing a specific treatment on the basis of religious or cultural beliefs (for
example, therapeutic abortion), it is generally not acceptable to refuse to assess the needs of a patient due to these
reasons.

❑ Regulatory authorities (Colleges) have generally stated that physicians are required to provide objective medical
information to their patients, which may include information about where patients can obtain the requested service.
⮚ In emergencies, physicians must act to save life or limb.
⮚ If not a medical emergency, physicians are not obliged to provide the requested procedure or service if they have a
moral objection.
⮚ College policies may require more than a simple refusal. In such cases, physicians must treat all patients with equality and
respect, and refer them to another physician who may be able or willing to provide the patient's desired care.

❑ A physician cannot be required to perform an illegal act, regardless of any agreement with, or conflict between, personal
beliefs and the wishes of a patient. Three specific acts are currently illegal in Canada and it is your legal obligation to
refuse to do the following:
1 - performing female genital mutilation procedures
2 - participating in euthanasia
3 - advising a patient on how to commit suicide
 The wide spectrum of culture

✔ Don't assume you know what your patients' needs are. Ask them how they want (or prefer) to be treated.

✔ As with cultural differences, language barriers have the potential to increase the chance of
misunderstanding.

❑ Cultures incorporate a mix of beliefs and behaviours through which people define themselves and conform to
societal values. Language, customs, rules, values, and even products and institutions are all culture-specific.

❑ People will conceptualize their illness and the required treatments differently, based on a number of factors
including:
1 - cultural background
2 - spiritual beliefs
3 - education

❑ A person's response to recommendations for care will be shaped by:

1 . the length of time the person has lived in Canada
2 . the person's capacity to adapt

❑ Even within one family, there may be significant differences in acculturation. Inter-generational tension
between first and second generation immigrants and their families is not rare.
✔ While members of an identifiable ethnic group may share common values, be careful to avoid stereotyping.
 The wide spectrum of culture

❑ What is the difference between a generalization and a stereotype?

✔ Whereas generalizations can be useful sources of information,
stereotypes tend to be limiting and are often judgmental
and negative.

❑ A person's culture might guide behaviour in ways that are

difficult for someone from a different background to understand.

❑ Differences between cultures can be conceptualized in terms of opposing characteristics, with individuals falling
somewhere along a continuous spectrum. For example, a person with a collectivist mindset is the opposite of
an individualist. Similarly, some people apply rules universally while others change the application of rules
based on situational information. In some cultures people communicate very directly while others are
indirect. Finally, some cultures place a high value on hierarchy while others are more egalitarian.
 The wide spectrum of culture

❖ Language barriers

❑ A patient may seem to be fluent in the physician's language, but if it is the patient's second or third language there
may be gaps in understanding. A trusted interpreter can help when appropriate, but physicians should be
cautious in using friends or family members who may apply their own biases onto the discussion. For instance, a
family member might be embarrassed to translate your questions about sexual activity, and the patient might be
reluctant to reveal the truth.
 Case: Mitral valve replacement surgery

A 65-year-old female needs mitral valve replacement surgery.

Use the sliding scale below to see how her information needs might change based on her cultural background.

1. The patient coming from a hierarchical culture may expect and accept that physicians have more power and
influence than she does. As such, she'll expect to be told what to do and to be supervised by the physician. She
likely would not consider taking the initiative to ask questions or challenge the physician's opinion even though she
may not understand or may inwardly disagree with the physician's suggestions.

2. Misunderstandings may occur if, for example, the physician is from a hierarchical culture and the patient is from a
highly egalitarian culture. The physician who doesn't have an understanding of these differences in values may
perceive the patient's assertions and questions as a lack of respect. Alternatively, a patient from a highly
hierarchical culture who is used to being told what to do, may be at a loss to decide if a physician from an
egalitarian culture asks them to choose from a variety of treatment options.

3. The patient coming from an egalitarian culture more likely has a sense of empowerment, is used to making
decisions in an autonomous way, and may seek background information. This patient will expect to be asked about
her preferences and expect to have the freedom to choose among treatment options. She will be quite comfortable
disagreeing with her physician and will be more likely to complain if her expectations are not met.

Hierarchical Egalitarian
1 2 3
 Case: Prescribing the wrong medication

In a moment of distraction, an emergency physician orders penicillin for a 13-year-old known penicillin-allergic female with a
streptococcal throat infection. The patient is given the medication and develops anaphylactic shock which is treated.
Use the sliding scale below to see how the physician might respond to the adverse event and how willing she might be to
disclose her role in the event, based on her cultural background.

1. The doctor coming from a collectivist culture likely cares deeply about belonging to a group and about feeling accepted
and respected by that group. As a collectivist, she is an approval seeker who deeply cares about the image she
projects to others. She might find it unthinkable to admit to having made a mistake, for fear of bringing dishonor to her
family or cultural group.

2. A conflict may arise when a physician who is very concerned about maintaining the honour of his family decides not to
disclose or to report an adverse event. While the physician's motivations may have been sincere, the Canadian
medical-legal context requires that physicians be honest about adverse events. A patient who discovers that a
physician willfully did not disclose an adverse event will likely be angry and lose faith in the physician. Similarly, if a
court or medical regulatory authority (College) were to become aware of a physician's willful non-disclosure, they could
take a very unfavorable view of the matter and issue sanctions or disciplinary measures.

3. The individualist doctor may be more motivated by self-improvement than the approval of others and does not see her
achievements or failures as reflective of her family's but rather of her own self. As such, the individualist physician may
not see disclosing adverse events as a reputation-threatening exercise, although she may nevertheless find it difficult.

Collectivist Individualist
1 2 3
 Case: Discussing a DNR order

You are admitting a 75-year-old terminally ill male to the hospital for dehydration secondary to his inability to adequately
eat and drink at home. His illness is very advanced and you wish to discuss end-of-life care and resuscitation status with
him. When you ask the patient and his family whether they would agree to a Do Not Resuscitate (DNR) status, they
answer, "Maybe, but it is difficult."
Use the sliding scale below to see how understanding a person's culture and communication style can help you decipher
that answer.

1. Families coming from a culture that values direct communication are likely comfortable telling you explicitly about
their wants, needs, and expectations. Honesty and straight-forwardness are valued, as is the correct use of terms.
Direct communicators may be perceived as blunt and have no difficulty saying "no.“

2. Physicians who are used to direct communication and are unaware of indirect communication modes may take
such families' answer as an agreement or acquiescence when, in fact, what they really mean is to say "no." People
who may normally be direct in their communication style may nevertheless become indirect when under stress.

3. Families coming from a culture with an indirect communication style will likely highly value the maintenance of
harmony and courtesy, in addition to honesty. Indirect communicators primarily want to avoid causing themselves
or anyone else any embarrassment. Their wish to continue respecting others will lead them to express themselves
by implying what they mean rather than by saying it directly. To an indirect communicator, the rudest answer to a
question is "no," so consider framing your questions in a way that would not require a yes or no answer.

Direct Indirect
1 2 3
 Case: A request from a new patient

A 64-year-old obese male with diabetes, congestive heart failure, a below knee amputation, hypercholesterolemia,
hypertension, and chronic hepatitis books an appointment to see a new family physician. Although he already has a
family physician, he lives too far away and the new physician's office is much closer. This physician's practice is so
busy that she has been considering closing it to new patients but she has yet to do so. Upon reading the patient's
history, the physician feels overwhelmed by the demanding medical needs of this patient and considers not accepting
him into her practice.
Use the sliding scale below to see how the physician's decision may be influenced by her own cultural background.

1. The physician who was raised in a universal culture will likely believe there are over-arching guiding principles that
apply to all situations and that can be used to determine the rightness or wrongness of specific beliefs and
practices. As such, the physician, despite feeling overwhelmed at the thought of taking on this new patient, will
nevertheless accept him into her practice because she realizes she cannot discriminate against him on the basis of
his numerous medical needs.

2. The situateionalist physician will argue that every situation is different and that absolute rules are inappropriate
because they are too inflexible. In this case, the situationalist physician might argue that she cannot possibly take
on a medically demanding patient because she had been planning on closing her practice anyway, or because it
would be unfair to her other patients, or because the patient already has a family physician.

Universal Situational
1 2
 Treating vs. helping to heal
✔ Every patient encounter is potentially cross-cultural in nature.

✔ When physicians treat people equally they ignore differences. When physicians treat people equitably, they
recognize and respect differences.

❑ Patients may subscribe to two types of healing: conventional western medicine and a medicine linked to
personal beliefs.

❑ Patients may often seek care from both a conventional western medicine physician and an alternative healer but
may not inform you of that fact.

❑ Misunderstandings can occur when culturally-shaped beliefs about health intersect with the accepted scientific
model of disease. These might manifest as
✔ discomfort with the discussion(s)
✔ non-adherence to treatment plans
✔ loss of trust in the doctor-patient relationship

❑ Patient behaviours that physicians often find frustrating include non-adherence to treatment plans and repeatedly
missing appointments.
✔ Rather than assuming there is a lack of cooperation, strive to understand the reason behind the behaviour.
 Treating vs. helping to heal
❑ There are several key areas in which culture and medicine intersect. The CIAO mnemonic illustrates how you
may incorporate these areas when interviewing patients.
✔ Asking the right questions in an empathic manner can provide an opening to explore barriers to communication
and treatment, and to determine whether cultural factors are playing a role.

❑ The golden rule that your parents may have taught you in childhood states:
"Treat others as you would like to be treated."

❑ To be an effective cross-cultural healer, strive to apply the platinum rule:

"Ask others how they want to be treated."
 When culture and duty clash

❑ Despite potential cultural differences, all physicians practicing in Canada have an obligation to be truthful about all
aspects of care, to provide the opportunity for informed consent, to disclose adverse events (accidents in
Québec), and to discuss end-of-life issues.

❑ There may be times when a physician's legal and professional duty to proceed in a certain manner will be at odds
with a patient's desired approach to care. Consider that in some cultures:
✔ Physicians are ultimate authorities who are to be obeyed and not to be questioned.
✔ It is considered inappropriate for physicians to tell someone that they have a terminal disease. The family is felt to
be the best judge of whether and when a patient should be informed.
✔ Patients' spouses or their extended family are expected to make decisions for a patient, even if the patient is
mentally capable (competent) to do so themselves.
✔ Women do not make their own healthcare decisions; instead, male family members do so on their behalf.
 Being asked to hide a cancer diagnosis

• Background
An elderly Chinese widow is operated on for a bowel obstruction. During surgery it is found that she has a
tumour of the descending colon, which is completely resected with no evidence of peritoneal or nodal spread.
The surgeon speaks to the patient's family while she is still recovering from the anaesthetic. Her eldest son
thanks the surgeon for the information and indicates that his mother should not be told about the tumour given
that no further treatment will be required.
• Think about it
How would you ensure that you meet your legal and professional duties as a physician practising in Canada,
while respecting the patient's and her family's cultural wishes.
• Suggestions
Meeting your obligations does not mean sacrificing respect for others' cultural traditions, beliefs, or wishes. You
can find balance by:
Offering to tell the truth and full disclosure to mentally capable (competent) patients. Respectfully acknowledge
the wishes of the family, but explain you have a legal and ethical duty to inform patients of the medical condition
and options for treatment.
Determining whether patients appear to understand the risks and benefits of not being fully informed about their
condition, including their entitlement to make their own decisions under Canadian law.
If possible, speaking to patients in private to ensure they are not being coerced into a decision.
Considering the involvement of a cultural broker to facilitate your mutual understanding.
• Lessons learned
Respect the patient's wishes and confirm the identity of the person to whom the patient wishes to delegate the
right to be informed or to consent to treatment. Document your conversation and don't hesitate to revisit the topic
as required. When necessary consider getting a second opinion from a colleague .
 Being told not to speak to the patient

• Background
A patient requires a cesarean section for failure to progress. Her husband refuses to let the male physician speak to
her about the situation, insisting that he must speak only to him.
• Think about it
How would you approach this situation in a culturally safe mindset?
What are the issues you need to address?
Practice writing a progress note which summarizes your discussions.
• Lessons learned
Whatever your clinical decision may be, documenting your rationale for it will allow others to understand the
circumstances you faced and thus how and why you came to make that decision.
 Requests based on cultural or religious
grounds
❑ In Canadian healthcare, it is deemed appropriate in most situations for a male physician to care for a female
patient. Nevertheless, in some cultures this is deemed inappropriate and perhaps forbidden.
✔ While there is no requirement for absolute accommodation of gender-based requests to change physicians, it is
both culturally sensitive and prudent to make reasonable efforts to address patient requests to be treated by
another physician. The discussion with the patient about this issue is preferably done at the outset of the
interaction so that there is sufficient time to make alternative arrangements. Consulting available policies of the
institution may also be helpful.

❑ If urgent or emergent care is required and a physician of the requested gender is not available:
✔ Discuss with the patient the nature of call schedules and the fact that a physician of the requested gender is
unavailable.

❑ Some patients may refuse all proposed accommodations or alternative arrangements and simply choose to be
discharged against medical advice. In such circumstances:
✔ Outline the risks involved in refusing care.
✔ Suggest that the patient seek care elsewhere.
✔ Offer to continue to treat the patient until alternative care becomes available.
✔ Document the discussion in the patient's medical record.
✔ You may, after discussing the risks of discharge, consider asking the patient to sign a written acknowledgement
that they have been advised of the risks of discharge and are refusing further medical care.
 Case: Patient refuses to see the physician

• Background
A 28-year-old pregnant woman presents to the female physician that she expects will deliver her baby.
The physician explains the policy for physician coverage of the labour and delivery unit which advises patients that
they must be evaluated and treated by the physician who is on call, regardless of gender, race, and so on.
The patient becomes very upset, as she believed this physician would be delivering her child. Due to her religious
beliefs she will not agree to a male physician under any circumstances.
• Think about it
What should the physician do next?
Is the hospital policy appropriate?
What are the potential risks for the physicians?
What are the options for the patient?
What if the patient requires urgent care at any point in her pregnancy?
• Lessons learned
When such situations arise, physicians may be placed in a difficult ethical and legal position, particularly when the
patient requires urgent care and there is a shortage of other available physicians.
While physicians following policies like the one in this case may not intend to discriminate against the patient, there is a
risk that this may be perceived as a form of discrimination.
 Finding the right balance
✔ Physicians are not obligated to provide absolute accommodation in all situations, but rather to reasonably
accommodate cultural diversity.
✔ While physicians recognize that professional standards vary among countries and cultures, they must meet
Canadian practice standards.

❑ Although it is laudable to respect every patient's cultural background and plan care around those values,
physicians need to strike the right balance between respect for culture and the provision of competent care.

❑ For example, in some cultures, it is considered taboo to address issues of mental health, sexuality, HIV, cancer, or
resuscitation status. Nevertheless, the practice of medicine in Canada recognizes that questions about sexual
orientation and other sensitive issues are appropriate when such issues are clearly medically relevant to
establishing the diagnosis or treatment plan.
✔ To decrease the chance of an allegation of discrimination, provide an explanation of the reasons for potentially
sensitive questions.
✔ Physicians should not avoid addressing a certain aspect of a patient's health because they are culturally
uncomfortable.
✔ Strive to educate patients in a respectful and sensitive manner, when patients' non-scientific beliefs may lead
them to make choices which may be detrimental to health.
✔ Aim to provide advice to patients and make decisions about treatment based on sound medical grounds and
principles.
 Case: An allegation of discrimination is dismissed

• Background
A pain specialist terminates a patient from his practice after discovering that the patient has been selling some of the
drugs he prescribed.
The patient complains to the College that this is discrimination on the basis of a disability.
• Outcome
The College found no wrongdoing on the part of the physician, who had carefully documented his assessment and
advice. The patient had also signed a treatment contract which included a warning that a breach would result in
termination.
The physician was deemed to have acted in accordance with the Code of Ethics, that is, terminating care for a
legitimate reason.
• Lessons learned
If it becomes necessary to terminate a patient from your practice, ask yourself if the reasons are "legitimate". (Refer to
your College guidelines or contact the CMPA for advice.)
Document any discussions with the patient.
 Case: Respecting a patient's questionable choice

• Background
A 45-year-old woman is found wandering a hotel lobby without clothes, yelling at other guests. Upon assessment at
the hospital, she is found to be acutely psychotic and not mentally capable (competent). Her husband indicates that
she is aware of her mental illness and that she has chosen to take vitamins and cleansing baths based on her beliefs
about the origin of her illness.
• Think about it
What considerations are important for you?
• Suggestions
The prudent physician should consider the standard of care for the clinical situation and be careful not to abdicate his
responsibilities to advise the patient or her substitute decision maker about that standard. Respectfully pursuing a
discussion with the patient's substitute decision maker and striving to educate him about the unscientific basis of their
choices and about the available conventional medical therapies is important, even if a cultural difference is present.
• Lessons learned
Physicians have a professional obligation to treat patients according to the recognized standard of care. Simply
accepting a clearly erroneous position without discussion may be unacceptable. The prudent physician should try to
understand the substitute decision maker's concerns, and educate the person about the appropriate medical therapies
and their scientific basis. In this case, once given the explanation the husband agreed to the indicated therapy.
 Case: Reasonably accommodating treatment

• Background
A 68-year-old devoutly religious woman undergoes evaluation just prior to the start of a period of fasting. She has a 10-year
history of poorly controlled Type II diabetes managed with oral hypoglycemic agents and diet. She is accompanied by her 8-
year-old grandson, who serves as her interpreter. The patient's diabetes is out of control and when you discuss the significant
risks of fasting and not taking her medications in a timely manner, she refuses to alter her planned fas
• Think about it
How would you approach the patient regarding those concerns?
Is relying on the 8-year-old grandson as an interpreter appropriate?
What other resources could you use in managing this patient?
• Suggestions
Devoutly religious patients may practise a complete fast (water and food) for a prolonged period. While exemptions from the
fast are usually allowed for health reasons, some patients may nevertheless interpret the taking of oral medications or even the
application of eye drops, as breaking the fast.
Your goal should be to partner with the patient to ensure she understands the importance of diet in the management of
diabetes. Rather than telling her to act in the way you think she should, make reasonable efforts to provide the information she
needs to make an informed choice. If the patient still chooses to fast, respect that decision and manage the patient as best as
you can. This may include providing information about on how to recognize the signs and symptoms of a possible complication
and how to seek care. Document all your efforts and the rationale for your decisions.
Relying on a young child to convey important health information is not appropriate. Finding a more suitable interpreter should
be considered.
• Lessons learned
Consider enlisting the help of another family member in discussions about a patient's care.
Consider obtaining the help of a trusted member of the clergy from the patient's community to translate and explain who is
exempt from the fast.
Consider referring the patient to a physician of the same faith as the patient to assist in discussions and to provide a second
opinion regarding the planned fast.
• Think about it
How much do you know about fasting or other cultural practices that may affect patient care?
❖ Lapses in the workplace

❑ We all have an expectation of reasonable and courteous behaviour from others. But sometimes lapses in civility
occur.

❑ People under stress may become upset and angry, especially when they are fatigued. Sometimes this goes too
far and most people recognize their own inappropriate behaviour, regret it and apologize.

❑ Learning from the experience and seeking help before things escalate and a pattern of behaviour develops is
important.
 Disruptive behavior
❑ In recent years, it is recognized that a small subset of healthcare professionals exhibit what is now referred to
as disruptive behaviour. Disruptive behaviour is rarely a single egregious act but is more often composed of a
pattern of behaviour.

❑ Disruptive behaviour can interfere with team and patient communication, team morale, and may adversely
affect patient care and satisfaction.

❑ Examples of disruptive behaviour from the CMPA's medical-legal files include:

✔ making comments in dismissive or derogatory ways to patients and other team members
✔ displaying insensitive, uncaring, or callous attitudes
✔ using inappropriate language (including profanity)
✔ bullying, threats, or angry outbursts
✔ demeaning, condescending, or aggressive conduct
✔ boundary issues
✔ inappropriate comments and conduct with medical regulatory authority (College) investigators

❑ Personal factors that may contribute to disruptive behaviour include:

✔ overwork and stress
✔ marital or other personal difficulties
✔ underlying psychiatric and medical conditions, often undiagnosed
✔ alcohol or drug use
 Disruptive behavior
❑ While the individual displaying disruptive behaviour may require an assessment, confounding factors and triggers
may exist in the workplace: for example, other providers or administrators displaying disruptive behaviour, turf
battles, and resource and funding issues.

❖ What is not disruptive behaviour?

⮚ Examples of behaviour that are not likely to be considered disruptive or unprofessional include:
✔ patient advocacy made in good faith, including professionally written alerts aimed at improving patient care or
facilities, and submitted to the appropriate individuals
✔ making a complaint to an outside agency
✔ testifying against a colleague

❖ Medical-legal consequences

⮚ Physicians who display disruptive behaviour risk medical-legal consequences including hospital or institutional
restrictions, regulatory authority (College) sanctions (e.g. licence suspension or revocation) and legal actions.
 Respect for others

❖ Professionalism beyond the clinical encounter

❑ Colleges expect a high standard of conduct from all physicians; that standard extends beyond the clinical setting.

❑ When commenting on behavioral issues, Colleges often use terms such as conduct unbecoming, egregious,
professional misconduct, or failing to meet the standard expected of the profession.

❑ People who are not patients, such as other healthcare professionals and the public, can also complain to the
College if they are dissatisfied with a physician's medical care or personal conduct.

❑ When a complaint is made by an individual who is not a patient, the potential consequences are the same as
when the complaint comes from a patient: dismissal of the complaint, counseling, written or verbal caution, or
referral to a committee such as a discipline committee or a physician wellness program.

❑ The following cases illustrate different types of complaints made by non-patients. In most such cases a
complaints committee will address the issue. In more serious matters, the complaint may be heard before a
disciplinary committee.
 Case: Nowhere to park

• Background
On a busy Saturday afternoon, a physician is looking for a parking spot at a shopping mall. Fortunately, a car is just
leaving a spot and the physician stops to wait until the space is clear.
Another vehicle approaching from the opposite direction is able to quickly turn into the vacant spot before the
physician. An argument and physical altercation takes place.
Subsequently, the driver of the second vehicle initiates a College complains
• Outcome
The College discipline committee found that the physician "...committed an act of professional misconduct in that he
engaged in conduct unbecoming of a physician." It further stated that "...abusive behavior towards others cannot be
tolerated or considered lightly. Such behavior undermines the public's respect for and trust in the profession."
The physician was reprimanded before the committee and the result was recorded in the College register.
In addition, the physician was required to pay the College for the costs of the proceedings.
• Think about it
Why is it necessary for physicians to be held to a higher standard of conduct than the general public in their personal
lives?
What would you think of your family doctor if you knew that the doctor had behaved unprofessionally in a non-clinical
setting?
Was the parking space worth the threat to the physician's license and professional reputation?
• Lessons learned
By statute and professional necessity, Colleges are required to hold physicians to a high standard of both professional
and personal conduct.
Professional consequences may arise from behavior or actions in either the professional or the personal sphere.
Complaints concerning professional care or personal conduct can lead to serious consequences such as the loss of
license, suspensions, fines, payment of costs, and loss of professional reputation.
 Case: Unhappy breakup

• Background
Four months after the breakup of a common-law relationship, a family physician receives notification of a College
complaint lodged by her ex-partner.
The complainant alleges that she had altered his medical record without consent, and that she regularly abuses
marijuana and alcohol.
• Think about it
What would you do if you found yourself receiving this complaint?
• Outcome
With assistance from legal counsel, the family physician was able to objectively and impartially refute all assertions in
her written response to the College. Supportive character testimonials were obtained from several of her colleagues.
At a meeting with the College registrar, the physician was composed, honest, and sincere.
The College dismissed the complaint.
• Lessons learned
Colleges consider the evidence carefully, which may result in exoneration of the physician.
❖ Conflict is inevitable

⮚ Conflict is normal, understandable, and inevitable.

⮚ Don't take it personally or make it personal.
⮚ Conflict can lead to positive change, learning, and growth.
⮚ Poorly handled conflict can be destructive.

❑ When people work with others, conflict may arise. Conflict that is well managed can lead to constructive changes
and opportunities to learn. By contrast, conflict that is allowed to fester and grow becomes destructive.

❑ Learning how to prevent and manage conflict and remaining professional when difficult situations occur are
important skills for physicians.
 Sources of conflict

⮚ Conflict arises from real or perceived differences in individual needs, interests, or values.
⮚ There are many possible sources of conflict in healthcare.
⮚ Conflicts due to differences in values and beliefs may be especially difficult to manage, as these values and beliefs
are often deeply held and intrinsic to one's personal identity.

❑ In healthcare, conflicts can arise with patients, families, physician colleagues, other healthcare professionals,
administrators, and others. There are 5 main sources of conflict: interpersonal relationships, information, interests,
organizational structures and roles, and values and beliefs.

I - Interpersonal relationships: Miscommunication,

strong emotions, stereotyping, repetitive negative
behaviour, destructive behaviours
II - Information: Lack of data, misinformation,
differing interpretations of data, different opinions
on relevance of data
III - Interests: Procedural, psychological, substantive
IV - Organizational structures and roles: Power differences,
unequal control of resources, unclear lines of authority,
time constraints, environmental constraints
V - Values and beliefs: Different world views, ideology,
culture, etc, different criteria for evaluating ideas
 Steps to prevent destructive conflict

❑ Clear communication is essential to prevent conflict.

❑ Verbalize your perspective clearly, in understandable language.

❑ Allow the other individual, be they a patient, colleague, family member, or other health care professional, to state
their perspective.

❑ Be open to questions. Seek clarification.

 Why is it important to appropriately
handle conflict?
❑ Conflict can affect the delivery of safe, quality care to patients.

❑ While those involved may not always concur on a diagnosis or plan of action, it is important that there is an
openness to discussion.

❑ Know to whom you can turn if there is conflict with the potential to interfere with safe patient care.

❖ A PGY1 obstetrics resident has just arrived for a shift. One of the patients has been induced at term because of
high blood pressure and slight proteinuria.
✔ Resident: "I really don't like the look of this tracing, but my attending told me to increase the oxytocin." Nurse: "We
tried telling him that the tracing was not great, too. I think he'll get really angry if anyone calls him back."
✔ The baby is born 45 minutes later with a cord pH of 6.8 and Apgar scores of 0, 1, 3 at 1, 5 and 10 minutes
respectively. The baby survives but is left with a profound neurological deficit.
✔ The parents start a legal action. Experts are critical of the resident, nurses, and attending physician. The case is
settled.
 Styles of handling conflict

❑ There are different styles of handling conflict.

❑ The choice of style depends on the participants, topic, timeline, and desired outcome.

❑ Different individuals have different predominant

styles of handling conflict. There are a variety of
conflict style inventories available. They generally
categorize the handling of conflict into 4 or 5 styles:
1- avoiding,
2- compromising,
3- controlling or competing,
4- collaborating, and
5 - accommodating.

✔ Each of the styles has a place in your repertoire as

they all have advantages and disadvantages
depending on the situation.
 Styles of handling conflict
I – Avoiding II – Compromising

⮚ Useful: ⮚ Useful:
• For issues of low importance • For issues that are time sensitive but of low
• When a delay is of no consequence importance
• When you need to buy some time • When parties are equal
• When emotions are so raw that discussion is not • When temporary solutions are needed
possible • When other solutions have failed
• When you already have control of the situation
• If you have little or no power ⮚ Downsides:
• Everyone may be dissatisfied
⮚ Downsides: • Real issues not addressed
• Lack of resolution • Solutions may be short-lived
• Issues may fester • Creative, collaborative options may never be found
• Others may become frustrated or confused • Viewed as indecisive
 Styles of handling conflict
III - Controlling or Competing IV - Collaborating

⮚ Useful: ⮚ Useful:
• When quick action required (emergencies) • For creative, long-term solutions
• When you are the most qualified decision-maker • To create a positive environment
• When reaching your goal is more important than • To sustain relationships
what others think • When the issue is too important to permit
compromise
⮚ Downsides: • When exploring or expanding into new areas
• Others feel ignored and may become resentful
• Others may never provide feedback ⮚ Downsides:
• Creative solutions may be lost • Time consuming
• Frustration if used in situations where prompt
decision needed
 Styles of handling conflict
V – Accommodating

⮚ Useful:
• For creation of goodwill
• When situations are of limited long-term importance
• When you can't defend your position
• When pushing your view would damage the
relationship

⮚ Downsides:
• Your input may be ignored
• Your influence may be restricted
• You may feel undervalued
 Styles of handling conflict

❑ Despite best intentions, physicians cannot meet all patient or family expectations. Conflict can arise when these
expectations are not met. All physicians encounter difficult behaviour and conflict with some patients or patients'
families.

❑ Difficult behaviours, be they with patients, families, staff, or colleagues may evoke negative reactions in
physicians. Physicians need to be aware of maladaptive responses to which they may fall prey, including getting
angry, blaming the other individual, being accusatory, and ignoring phone calls or emails. Physicians must strive
to remain calm and focus on understanding the other individual's behaviour and considering how best to respond.
 Methods for handling conflict

❖ 10 steps to help manage conflict:

1 - Know thyself (biases, triggers, etc) and be aware that conflict is a normal occurrence
2 - Be proactive in trying to prevent and resolve conflict
3 - Create a safe environment in which to address conflict
4 - Clarify needs and identify desired outcomes on all sides of the conflict
5 - Communicate effectively
6 - Be flexible in assessing the options and in problem solving
7 - Manage the impasse with calm, patience and respect, focusing on underlying needs, interests and concerns
8 - Know when to ask for help
9 - Encourage creative problem solving designed to reach a solution that meets at least some of the needs and
interests of all involved
10 - Reflect on the situation, process, and outcomes

❑ Communication and manner are paramount to handling conflict. It is important to address the problem while
respecting the individuals involved. Physicians involved in conflict should pay special attention to the use of non-
confrontational, non-blaming language and attend to non-verbal cues.

❑ Active listening is a key skill in de-escalating conflict. Individuals involved in conflict may see issues differently or
want different things, but through good communication, one should be able to identify the underlying common
interests. When in a conflict situation, physicians should focus on these interests rather than the stand that the
conflicting parties are taking.
 Methods for handling conflict

❑ The physician should focus both on their own needs and on the needs of the other individual and should use these to
explore options to which the conflicting parties can agree. Finding common ground validates the individuals involved
and is quite beneficial in finding a solution. It is often helpful to seek the help of a neutral party to mediate the conflict.

❖ 6 communication skills to use in de-escalating conflict:

1 - Active listening

2 - Attending to non-verbal cues

3 - Agreeing

4 - Acknowledging the other individual's feelings helps demonstrates empathy

5 - Apologizing may be helpful in certain situations

6 - Acting as a team and working together without blame or judgment

❑ Managing conflict is particularly challenging when the other individual is angry, aggressive, intimidating, or threatening.
Anger is always a secondary emotion. By understanding what is underlying an individual's anger, physicians can learn
to confidently negotiate many of these situations. When the other individual is agitated and confrontational, remaining
calm and speaking politely in a soft voice often helps to defuse emotions. The physician should ensure that the
discussion is non-judgmental and is taking place in a safe environment.
❖ Maintaining appropriate boundaries

❑ Patients depend on and trust their physicians. Consequently, physicians must ensure that they are professional at all
times and maintain appropriate boundaries with patients.

❖ What is a boundary?

❑ A boundary is an accepted social, physical or psychological space between people. Boundaries create an appropriate
therapeutic distance between physician and patient and clarify their respective roles and expectations. In simplest
terms, boundaries define limits of the therapeutic relationship.

❑ There are two categories of boundary transgressions:

✔ boundary crossings
✔ boundary violations

❑ Boundary crossings are usually benign, such as accepting baked goods from a patient to share with office staff.
Sometimes boundaries are crossed deliberately, such as when a physician holds the hand of a patient who has
reached out for support after receiving unpleasant news.
✔ In other cases, boundaries are crossed due to carelessness, lack of attention, or simple misunderstandings.
✔ For example, a patient may be offended at what you think is a harmless joke, or a more conservative patient who
prefers to be addressed as "Mrs." may be insulted if addressed by her first name or "dear."
 Maintaining appropriate boundaries
❑ It is important to recognize that the lines between appropriate behaviour and boundary crossings are blurry.
✔ When the boundaries of the therapeutic relationship are crossed, caregivers enter a "grey area" in which the
consequences of their action on the patient's well-being may be positive (welcomed supportive
touch), neutral (addressing the patient by first name according to his or her request), or negative (holding the
patient's hand who is uncomfortable and thus increasing her anxiety).
✔ At times it may be helpful to enter a grey area, but in doing so, there is also a greater risk of harm, exploitation, or
other detrimental effects to the patient. [REF]

❑ Boundary violations are harmful or exploitative to the patient. Sexual contact with a patient is always considered
a boundary violation. Some other examples are:
✔ excessive self-disclosure
✔ giving or accepting inappropriate or elaborate gifts
✔ probing for inappropriate or irrelevant personal information
✔ failing to obtain consent for intimate examinations
✔ failing to respect a patient's privacy

❑ Although most boundary transgressions are thought of as intrusive behaviour, the opposite may also hold: the
physician may be under-involved (e.g. formal, cold, distant, dismissive, not empathic). This can also result in harm
and lead to complaints.
 The "slippery slope"

❑ Boundary crossings do not usually cause harm to the patient. However, repeated crossings or progressively
bolder minor violations may become a "slippery slope" resulting in a more serious boundary violation.

❑ A slippery slope can play out in many different ways. Consider the following cases and identify where the
physician or medical trainee is on the slippery slope.

❖ Intimate procedures or examinations

❑ To minimize misunderstandings during intimate procedures or examinations physicians should:

✔ Adequately and clearly explain to patients a procedure or examination, and why it is being performed.
✔ Obtain a patient's informed consent for a specific procedure or examination.
✔ Give patients sufficient privacy to undress (and redress).
✔ Avoid altering or removing a patient's clothing without express consent.
✔ Offer to have a chaperone present during sensitive examinations or procedures.
✔ Document any steps taken to minimize a patient's discomfort with an examination or procedure.
 Case: Inappropriate conduct during an examination

• Background
A family physician is asked to see and examine a young woman as an urgent appointment for counseling regarding an
unwanted pregnancy.
As he is rushed, the physician does not leave the room while the woman is undressing. The office has run out of
drapes so he gives the patient a small hand towel to cover her lower abdomen.
The physician proceeds to do an internal examination without explaining to the patient what he is doing. He does not
have a chaperone and when exiting the room leaves the examination room door open while the patient redresses.
• Outcome
The woman complained to the College, stating she felt traumatized and sexually abused by the experience.
• Think about it
List the poor decisions made by the physician.
How could the physician's behaviour impact the patient?
How would this impact the patient's future relationships with healthcare providers?
• Lessons learned
It is not uncommon for physicians to face allegations that they have violated a boundary while performing intimate
procedures or examinations (for example, gynecological examinations.
 The "slippery slope"

❖ Dual relationships — Professional and social

❑ Physicians may well have patients with whom they socialize or have friendships. In these cases, physicians
should still be conscious of the potential for boundary crossings and, as much as possible, separate their
personal and professional obligations. The closer the relationship is between the physician and the patient, the
greater the risk of a perceived boundary violation.

⮚ Be aware of when a therapeutic boundary is being crossed.

⮚ Bringing your personal life into the relationship with a patient carries the risk of impinging on the quality of medical
care and has potentially serious consequences.

❑ Physicians may be asked to act as a patient's power of attorney. In most cases, physicians should respectfully
decline these requests, especially when another suitable individual is reasonably available to take on the role.
 Case: Investment advice gone awry

• Background
A stockbroker follows up with his cardiologist concerning coronary arterial disease.
While indulging in small talk, the cardiologist asks what stocks are recommended. The broker replies, and after
finishing his afternoon clinic the cardiologist purchases those stocks from a different broker.
On a later visit, the cardiologist tells the patient that he has lost money on those stocks. The broker feels badly, but
also wonders how this would affect the quality of care he would receive.
• Possible patient outcomes
The patient may no longer trust the doctor's medical advice, fearing the cardiologist may give inferior care, "to match
the advice he got."
• Think about it
Can you think of any other outcomes that could harm the patient, physician, or both?
What are some questions you can ask yourself to assess whether boundaries are being blurred in the doctor-patient
relationship?
The patient may go elsewhere, with undesirable delays in treatment.
 Case: Business relationships with patients

• Background
During a routine office visit a family physician becomes aware that an elderly patient has land for sale. He has cared
for the patient for many years and they often discuss business.
The physician enters into a sales agreement with the patient to buy the land. The physician's lawyer drafts a purchase
agreement after having the land surveyed for water and sewage requirements.
Before the sale is finalized the patient changes his mind.
The physician starts a legal action to recover his legal and survey costs. Because of the legal action, the physician
terminates the doctor-patient relationship, prompting the patient to complain to the medical regulatory authority
(College).
• Lessons learned
The College concluded the physician's conduct was unprofessional.
The physician subsequently abandoned the legal action and wrote a letter of apology to the patient.
The College accepted the physician's letter of apology and his commitment not to enter into personal transactions with
patients.
 Case: Should I hire my patient?

• Background
A young female physician is starting her practice after finishing residency and having her first child. She is challenged
by the demands of work and managing her home and family.
During a routine clinic visit a patient tells her that she is a house cleaner and looking for work. The young doctor is
thankful for the fortunate timing and hires her patient. The patient is grateful for the income.
• Think about it
Is it appropriate to hire a patient?
In what ways can this influence the doctor-patient relationship?
Can you identify potential medical-legal risks with this case?
How might hiring your patient lead to a College complaint or legal action against you?
• Lessons learned
Physicians should avoid entering into business deals with patients.
At least one College has noted that these transactions can result in a finding of professional misconduct, and the
finding can be based solely on the power imbalance between the physician and patient.
Patients may feel pressured to enter into a personal transaction with their physician out of fear that refusing might
jeopardize their relationship with the physician or the quality of care they will receive.
 The "slippery slope"

❖ Self-disclosure

❑ It is unacceptable for physicians to discuss their sex life or sexual relationships with patients.
✔ Not only can divulging intimate personal information make patients uncomfortable, it could lead the patient to
misunderstand the nature of the relationship and see it as a friendship rather than purely professional.
 Case: I know what you mean

• Background
A medical student sees a 16-year-old patient for persistent headaches. When the student asks the patient if she is
experiencing a high level of stress in her life, the patient confides that her parents are going through an acrimonious
divorce.
The medical student describes her own experiences with her difficult divorce, saying "It is really difficult for me; my
spouse doesn't understand the rigors of medical training. Some days I don't know if it is all worth it."
• Think about it
Discuss the appropriateness of the medical student's comment.
How might a comment like this make the patient feel?
• Lessons learned
While it may be appropriate in some circumstances to share with your patients limited general information about
yourself (for example, a favorite sports team, the fact that you have a pet), it is generally improper to disclose detailed
personal information or share intimate details about your personal life (e.g. relationship problems).
 The "slippery slope"

❖ Treating family and friends

❑ Most Colleges have policies that prohibit physicians from treating or prescribing medications for family members,
except for minor conditions or in emergencies.
 Case: Who is your doctor?

• Background
You are asked to see the wife of a physician colleague in the emergency department. She has fallen and has a
suspected fracture.
When obtaining the patient's history, she tells you she has been taking a large number of sedatives and anxiolytics
prescribed for chronic stress-related symptoms by her physician husband.
• Think about it
Should the husband be prescribing for his wife?
Why is it inappropriate to prescribe for family and friends?
Are there any circumstances when it might be appropriate to prescribe for family and friends?
• Lessons learned
Section 20 of the CMA Code of Ethics states: "Limit treatment of yourself or members of your immediate family to
minor or emergency services and only when another physician is not readily available; there should be no fee for such
treatment."
 The "slippery slope"

❖ Gifts

❑ After receiving care, it is not unusual for patients or their family members to thank physicians by giving gifts. While
such a gesture is often benign, it can become a boundary violation — depending on the circumstances and the
nature of the gifts.

❑ If gift-giving is part of a pattern of behaviour that suggests the patient is looking for more than just a professional
relationship with the physician, the physician should consider talking with the patient. The physician should
explain that it is inappropriate to accept gifts for medical services, or to form a personal relationship with patients.

❑ When a patient offers a gift of significant value or gives multiple gifts (of any value), the physician should explain,
sensitively, why the gifts cannot be accepted. These discussions should be documented in the patient's medical
record.
 Case: The box of chocolates

• Background
A patient has been receiving care for several months following a motor vehicle collision. Her attending physician tells
her she will soon be ready to return to work.
At her next visit she brings a large box of chocolates for the staff, and a bottle of expensive single-malt Scotch for the
doctor "to thank them for all the care."
The doctor examines her and says he thinks she is ready to return to work, but the patient asks him to renew her
disability "just for another month."
• Think about it
How should the doctor respond to his patient?
• Suggestions
The doctor had already come to a conclusion based on his medical judgment. The patient was asking for something
the facts didn't support.
In accepting the gift, he may have signaled a willingness to accede to her wishes. To do so would be a breach of the
doctor's integrity and the trust placed in him by the disability insurer and her employer.
 Case: Gift-bearing patient

• Background
A resident is monitoring an elderly man after a bowel resection for colon cancer. The patient's admitting history
indicates that his wife recently died and his grown children live far away. After his last visit he comments on how good
a job the resident did, adding how much the resident reminds him of his daughter.
One day the patient brings a box of cookies and a bouquet of flowers to thank the resident for taking care of him in
hospital. The patient is doing well until a week later, when he develops a superficial wound infection and he visits the
clinic without an appointment on a very busy day.
The patient catches the resident's eye, asks if she enjoyed the gifts, and could the resident see him for just a minute.
The resident decides to quickly see him when an exam room opens up.
• Think about it
What boundaries were crossed?
How could this conversation and the resident's response impact the other patients who might have overheard?
How could the resident respond to the patient to let him know that jumping the queue is inappropriate?
• Suggestions
Medical students can easily find themselves dealing with boundary issues. In the excitement of clinical work, benign
crossings may seem inconsequential or even go unnoticed, but may ultimately result in a difficult situation.
The medical student in this case was caught on a slippery slope, which began with accepting the patient's gifts.
Although the initial boundary crossing was benign, she then crossed a second boundary in giving him preferential
treatment by seeing him ahead of others on a very busy day.
 The "slippery slope"

❖ Romantic relationships

❑ Romantic and sexual relationships between physicians and current patients are inappropriate and therefore
forbidden.

❑ The more vulnerable the patient, the greater the power imbalance between patient and doctor. It is even more
important to observe boundaries with patients suffering from emotional or mental illnesses or with chronic
diseases.
 Case: A dinner date

• Background
A young, unmarried male physician has just begun practice and is new to the region. One of his first patients has
recently separated, and they go on a dinner date.
Later, the patient's separated spouse learns of this and lodges a complaint with the College.
• Think about it
When personal and professional boundaries are blurred, how might the physician's ability to objectively assess and
advise the patient be affected?
Would you consider the patient to be vulnerable, considering that she had recently separated from her spouse?
Do you think the patient would have made the same decision (to go on a date with her physician) if she was not
working through issues in her marriage?
How might a practice in a rural or isolated setting (e.g. when a physician provides care to an entire community) pose a
challenge for maintaining professional boundaries?
• Lessons learned
Consider the slippery slope from this dinner date to sexual relations. A sexual relationship — of any type — between a
physician and patient constitutes sexual abuse. Consent by the patient is not a defence to an allegation of sexual
abuse.
 Case: Patient attracted to the therapist

• Background
A patient with multiple stressors and no local support system is seen in the emergency department. Psychotherapy is
recommended and takes place over the coming months.
The patient wants to develop a social relationship with Dr. A, which is refused. After consultation, the patient's care is
transferred to another psychiatrist (Dr. B), who is the same sex as the patient. However, the patient continues to send
gifts and ask for dates with Dr. A, who feels harassed and threatens to take legal action.
The patient continues to demand a social relationship with Dr. A, and finally sues Dr. A, claiming "countertransference"
(referring to the physician's emotional involvement in the therapeutic interaction).
• Outcome
The court found that Dr. A had diagnosed and treated the patient properly and the boundaries had been observed by
Dr. A, despite the patient's attempts to cross them.
Transferring the patient to another provider was appropriate in this circumstance.
 Preventing boundary issues
❑ An important aspect of prevention is recognizing which situations may cross a boundary. Because trivial
boundary crossings may lead to more serious boundary violations such as sexual contact, it is important to be
aware of non-sexual boundary issues. Here are some strategies to consider:

⮚ Give clear, timely explanations of:

• the reason for taking a history or doing an examination
• the nature of the examination

⮚ Ensure that sexual histories are:

• relevant to the clinical situation
• performed in a sensitive manner

⮚ Ensure touching will not be misinterpreted.

⮚ Use a chaperone during intimate exams.

⮚ Respect the patient's right to privacy:

• provide appropriate draping
• leave the room when the patient changes clothes

⮚ Look for early signs of emotional involvement (yours and your patient's).

⮚ See patients only in medically appropriate settings.

⮚ Be cautious of social contact outside the office or hospital.

⮚ Be knowledgeable about gender, cultural, and ethnic sensitivities.

⮚ Be alert to possible misunderstandings.

⮚ Ask yourself what a neutral outsider would say if observing your conduct.
 Preventing boundary issues

❑ Medical students should consider speaking with a supervisor or mentor if involved in an actual or potential
boundary issue.

✔ While students cannot be the subject of complaints to a medical regulatory authority (College), boundary
crossings and violations by students can be reported to their educational institution or hospital, and may be
disciplined for inappropriate behaviour.
❖ Developing your digital presence

❑ You're more than just you. How does being a physician influence your social media presence? Society expects
that physicians will adhere to the highest standards of professionalism. As a result, what you post on social
media, whether in your personal or professional capacity, may lead to unintended consequences for you and
others.

❖ "Intentional" versus "unintentional" online identities

❑ You are responsible for what you personally post ("intentional" online identity). While you cannot completely
control what information is posted by others about you ("unintentional" online identity), you can regularly monitor
your online presence. Creating separate personal and professional social media identities may allow you to
redirect users to your public professional profile. You should consider asking friends to refrain from tagging you in
media (e.g. photos) that may be perceived as unprofessional .
 Developing your digital presence

❖ Pseudonyms/Aliases

❑ Some authors suggest that one way that medical professionals can protect themselves while using social media
is to post using a nickname or using a pseudonymous email address. While this may help you to minimize the
availability of your personal information on social media, it does not give you full license to post unprofessional
content. The possibility of subsequently being identified as the author always exists.

❖ Social Media Do's

1. Use it as a platform to share valuable information and resources
2. Maintain separate personal and professional identities
3. Update your privacy settings regularly
4. Manage digital distraction when you are providing clinical care

❖ Social Media Don'ts

1) Violate/breach patient privacy
2) Provide personalized medical advice
3) Abuse/denigrate colleagues, patients, or organizations
4) Post without thinking of the consequences
 Case: Using your smartphone in the workplace

• Background
Angela, a first-year resident on call for orthopaedic surgery, is paged to the ward to assess an elderly female patient
with fever after hip replacement surgery. The patient is not seen for several hours, and by the time Angela sees her,
the patient is hypotensive and requires admission to the intensive care unit (ICU).
• Hospital complaint
The family launches a complaint at the hospital that their mother was not seen promptly. In their complaint letter, they
mention seeing Angela on the ward at several points earlier that evening talking animatedly and texting on her phone,
seemingly oblivious to her on-call responsibilities.
• Outcome
Angela is required to meet with the postgraduate program director and to write a personal reflection about how her
digital distraction could have resulted in a more serious patient outcome. The hospital considers whether it should
develop a policy to guide smartphone usage by its employees.
• Think about it
How often do you access texts, emails, or social media during the day? Could the frequency of your smartphone
usage cause you to be distracted from your responsibilities?
 Case: Blogging about patients

• Background
Gerard, an emergency physician working in a small town, posts on his secure personal Facebook page about a
particularly difficult day at work. In his post, he mentions how he is aggravated by "worthless drug-seekers" who are
the "scourge of society," displacing the needs of patients with "real concerns."
• College complaint
Gerard receives a notice of complaint from his provincial regulatory authority (College), which was made by the relative
of a patient he saw in the emergency department on the day of his Facebook post. The relative indicated the post had
been forwarded to him by a friend, a family physician who is one of Gerard's Facebook contacts.
• Outcome
The complaints committee is concerned about Gerard's unprofessional comments and the impact on the profession.
Gerard receives a verbal caution and is required by the College to attend a one-day course on professionalism.
• Think about it
Does your post breach any privacy or professional obligations? Does what you post reflect what you would say in
person to patients or others? Are you likely to feel the same way tomorrow, after your post has been viewed by others?
❖ Respect for colleagues

❑ When other healthcare workers do not perform optimally, it is appropriate to take steps to improve their
performance. However, this should be done with empathy and courtesy, not with anger or disrespect.
 Case: A colleague's unprofessional behaviour

The Canadian Medical Association (CMA) Code of Ethics states that physicians are ethically obligated to report "to the
appropriate authority any unprofessional conduct by colleagues."
• Background
A fourth-year medical student is completing her internal medicine rotation. She has become close friends with one of
the first-year residents and frequently attends the same social events.
The student notices that the resident often drinks excessively. She has discussed this with her friend, recommending
that she seek assistance from her family physician.
One evening, the student is on-call with the resident and smells alcohol on the resident's breath. She becomes
concerned about the patients' safety as she believes the resident's performance is compromised.
• Think about it
What factors should the student consider when deciding whether to report the resident?
Answer: The risk of harm to patients.
What should the clerk do in this situation?
Answer: Immediately seek help from a supervisor to assess the resident's competency to continue.
What reporting responsibilities do treating physicians have when concerned about physician patients?
Answer: Determine if the resident should stop practising until she can be referred to the provincial physician health
program for assessment and treatment if necessary.
Contact the CMPA for advice on reporting requirements to the College.
• Lessons learned
While reporting a physician colleague or physician patient can be difficult and upsetting, it is important to understand
your reporting obligations in these types of circumstances.
1- That is incorrect

2- That is incorrect

3- That is incorrect

4-That is correct
The CMA Code of Ethics states: "Limit treatment of yourself or members of your immediate family to minor or
emergency services and only when another physician is not readily available; there should be no fee for such
treatment."

Treating family members, even episodically, is problematic because:

it is difficult to be objective
care often becomes fragmented (for example, between you and the patient's family doctor)
maintaining confidentiality of information is difficult
medical record keeping is usually inadequate
Some Colleges consider family members to include people with whom the physician has close personal or emotional
involvement, such as friends. To minimize the risk of a boundary violation, physicians who are asked to treat a friend
should consider whether their personal relationship might affect their ability to provide quality care. If so, the physician
should generally decline to treat the person and refer the individual to another physician. The physician should clearly
document these discussions.
The College for each province/territory can provide more information about treating family members.

5- That is incorrect
1- That is correct
Romantic relationships between physicians and patients are boundary violations and are forbidden. The penalties are
serious.
Patients need objective advice about their healthcare. Clinical advice and care may be less objective if personal and
professional boundaries are blurred.
More information about professional obligations and expectations may be found on the College website for each
province/territory.

2- That is incorrect

3- That is incorrect
Colleges are mandated to review all complaints received and investigate those of potential significance. The potential
consequences of complaints coming from an individual who is not a patient are identical to those stemming from a
patient: dismissal (of the complaint), counselling, a written or verbal caution, or referral to a committee such as a
discipline committee or a physician wellness program.
A review of CMPA files identified College cases involving complaints from non-patients. Of these, nearly half were
complaints made by physicians about other physicians. Most others were from pharmacists, nurses, physiotherapists,
social workers, office staff, hospital employees, worker compensation agencies, law enforcement personnel, and
members of the public.

4- That is incorrect

5- That is incorrect
1- That is incorrect
In this case such questions are helpful in contributing to the development of a diagnosis. Posing such questions
prematurely in an interview without sufficient foundation and without explanation for why they are asked may result in a
patient questioning their necessity and the motives of the physician.

2- That is incorrect
Colleges typically suggest that physicians offer to have a chaperone present during sensitive examinations or
procedures. Although a good answer, there is a better answer for this case.

3- That is incorrect
Physicians are responsible for ensuring that professionalism and appropriate boundaries are maintained with patients
at all times.
Whatever the gender of the patient or physician, in order to minimize misunderstandings in these situations physicians
should adequately and clearly explain to patients the procedure or examination, and why it is being performed.

4- That is correct
Misunderstandings commonly occur if no explanation is provided to a patient prior to relevant questions about sexual
history or before physical examinations of the breast, genitals or rectum. It is best to explain the reasons for such
questions or examinations so that the patient will recognize these are necessary and part of good clinical care.
It is not uncommon for physicians to face allegations that they have violated a boundary when performing intimate
procedures or examinations. Patients may be uncomfortable with, or afraid of, these procedures or examinations. To
minimize misunderstandings in these situations, physicians should adequately and clearly explain the procedure or
examination, and why it is being performed. As well, physicians should obtain the patient's informed consent for the
specific procedure or examination.
Many Colleges encourage physicians to give the patient sufficient privacy to undress (and re-dress) and to avoid
altering or removing a patient's clothing without first obtaining express consent.
5- That is incorrect
Without receiving an explanation, a patient may have not understand the reasons for questions or intimate
examinations. Respectful communication is an essential element of the doctor-patient relationship. Certain types or
styles of communication with patients are likely to be unappreciated. These include addressing patients in an
inappropriate or too familiar way, asking inappropriate personal questions not related to the patients' concerns, and
using offensive or vulgar language.
While physicians can be relaxed and cordial with patients, it is important to keep a work-related distance. In the doctor-
patient relationship, patients depend on and trust their physician. Consequently, physicians must ensure they are
professional and maintain appropriate boundaries with patients at all times