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Medical error Case Study
The document is a case study on a medical error involving a patient who received an overdose of insulin, leading to severe hypoglycemia. It outlines steps to take after a medical error, including immediate actions, documentation protocols, communication with affected parties, and investigation strategies to prevent recurrence. The study emphasizes the importance of fostering a patient safety culture and the need for transparency and accountability in medical practice.
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Medical error Case Study
- 1. Medical Error Case Study Editedby Abdalla Ibrahim Accreditation Specialist Healthcare Surveyor Original Lecture by Dr. Samir Omar, Health Care Quality Advisor Adopted with permission on December 2014
- 2. Objectives Learn step-by-stepwhat to do when medical error occurs and how to report it Learn how to identify root cause of a medical error and how to prevent its recurrence Motivate your colleagues to foster a patient safety culture
- 3. The Story On Sundaymorning, Mr. XX had attended my clinic due to marked polyuria. His RBS was 28.8 mmol/L, otherwise he was completely normal.
- 4. The Story I’ve prescribedN. saline 1.5 L , IV, over 2 hours and 5.0 u of regular insulin by direct IV push / 30 minutes, until his RBS is 9.0 mmol/l.
- 5. The Story I’vebeen called to give the IV injection, Which was easily done.
- 6. The Story Twentyminutes later, my patient was very much apprehensive, sweating and started shivering. His RBS was 0.8 mmol/l.
- 7. The Story My nursehad told me that I’ve pushed 50.0 u of regular insulin in the IV line.
- 8.
- 9. What Happened? OnSunday 5/12/2014, at 9:12 am, In the treatment room, I had injected Mr. XX a doe of 50.0 u of regular insulin intravenously, Which resulted in severe hypoglycemia. 1- Identify
- 10. What is yourimmediate action? I did the followings immediately: • Stop N. Saline • Start 5% glucose 1.0 liter, IV • Give 50 ml of 50% glucose IV / 30 min until RBS is 9.0 mmol/l • Call Ambulance and transfer to A/E and… 2- Immediate Action
- 11.
- 12. Who else cannotify? Doctor other than the offender. A Nurse who witnessed the incident Any other attendant, even a visitor
- 13. In order notto forget the facts!!! Document only the facts of what occurred and treatment given Do Not document: ◦ Blame ◦ Subjective feelings or thoughts ◦ Opinions • Refer to organization “Incident Report” Form 4- Document
- 14.
- 15. 9.00 Pt. Attend 9:15 RBS 28.8 9:20 prescribe 9:25 Nurse prepare 9:30 Dr. Pushed insulin 9:45 Pt. reaction 9:46 RBS 0.8mmol 9:47 Glucose infusion 10:15 RBS 5.4 mmol 10:16 Transfer To SMC • 9:00 am,Mr. XX had attended my clinic complaining of giddiness. • 9:15 am, his RBS was tested (28.8 mmol/l). • 9:20 am, I prescribed Regular insulin 5.0 u, iv/30 minutes, until RBS is 9.0 mmol/l and N. Saline 1.5 l/2 hours. Time line analysis
- 16. 9.00 Pt. Attend 9:15 RBS 28.8 9:20 prescribe 9:25 Nurse prepare 9:30 Dr. Pushed insulin 9:45 Pt. reaction 9:46 RBS 0.8mmol 9:47 Glucose infusion 10:15 RBS 5.4 mmol 10:16 Transfer To SMC • 9:25, nurseYY prepared 50.0 u of regular insulin and kept them in kidney shaped basin at patient’s side table. • 9:30 am I’ve arrived at the patient side to push the dose in the IV line. • 9:45 am, I was informed that my patient is sweaty and very nervous and shivering. Time line analysis
- 17. • 9:45 am,his RBS retested, found 0.8 mmol/l. • 9:47 am, 1.0 L of 5% glucose was IV given, 50 ml of 50% glucose iv/30 min until RBS is 9.0 mmol. • 10:15 am, patient was referred to A/E. his last RBS was 5.4 mmol/l. 9.00 Pt. Attend 9:15 RBS 28.8 9:20 prescribe 9:25 Nurse prepare 9:30 Dr. Pushed insulin 9:45 Pt. reaction 9:46 RBS 0.8mmol 9:47 Glucose infusion 10:15 RBS 5.4 mmol 10:16 Transfer To SMC Time line analysis
- 18. How to admityour medical errors? 5- Disclosure
- 19. 1. Open communicationwith patient and family 2. Talk in privacy 3. Keep telephone closed, prevent distraction 4. Let a colleague attend the discussion 5. No blames 6. Don't be defensive Disclosure Technique 5- Disclosure
- 20. Disclosure Technique Describe whathappened in facts, not opinion Tell consequences of the event Tell steps being taken to manage the event Tell steps being taken to prevent recurrence Express your sorrow and regret
- 21. Which is better!! Burrythe whole thing Disclose the event
- 22. Why disclosure Literatureshows that after an unanticipated outcome, the patient and family want to know honestly: What happened? How it happens? How hospital will prevent future events?
- 23. Why disclosure Weare our patient’s advocates Rebuilds trust Keep good Doctor-Patient relationship
- 24. Reporting: Do we havea policy for clinical incidents? Follow you own Reporting Policy and process Use your own Reporting Form 6- Reporting
- 25. What do youexpect next? To determine sequence of events that led to consequence To take corrective action & recommendations To prevent recurrence of the incident 7- Investigate
- 26. Who can investigate? InvestigationTeam Employee ‘s supervisor Safety officer Safety committee representative Employee involved
- 27.
- 28. How to investigate? CaseReview Root Cause Analysis 5 Way Chart In response to adverse event THREE possible ways of investigations are found:
- 29. Case Review • Todecide if the medical care offered is of accepted standards? • If not, the offender physician may be subjected to certain supports. • To recommend corrective measures such as education and training
- 30. System Nurse Patient had receivedover dose of insulin No written P&P Environment Dim light Poor maintenance PatientDoctor Pt did not speak up Pt unaware of speak up initiative Miss interpret dose Dim light Poor maintenance Did not check/recheck dose No written P&P Used illegal format Unaware of legal format Did not check dose before inj No written P&P Root Cause Analysis and fish bone graph Exhausted Overworking Hours
- 31. Patient received insulin over dose Doctor Dr. Used illegible numberform. Dr. Unaware of eligible format No DPP for prescrip writing Dr. did not check dose before inj. No DPP for drug admin Nurse Mis-interpret dose Dim light Poor light maitenance Nurse did not use check- recheck method No DPP for drug admin Environment Dim light Poor light maintenance System No DPP for drug admin. Patient Pt. did not speak up Pt. unaware of speak up initiative 5 whys? chart
- 32. What are thepossible mistakes done? * Used unusual number format (5.0) * Did not recheck the 7 Rs before pushing medicine * Misinterpret prescription * Did not obey 7 Rs before giving injection * Did not speak up before pushing injection.
- 33. What are thepossible mistakes done? The 7 Rights
- 34. Poor maintenance of lighting inthe treatment room. What are the Root Causes of the event Unaware of (Do NOT DO LIST). Physician Unaware of the Speak Up Initiative Patients • No written policy & procedure of drug administration • Overworking Hours for nurses System Environment
- 35. Recommendations 1. Educate doctorson DO Not DO List. 2. Educate patients about Speak Up Initiatives. 3. Provide a written policy and procedure for drug administration. 4. Improve maintenance in the treatment room. 5. Never to blame or judge liability 8- Change
- 36.
- 37. What about theError maker!
- 38. Error maker!! How doeshe feel?? • Shame • Afraid of punishment • Isolated • Worthless • His opinion and advice are not required
- 39. How do werespond to error maker? TRUST: • Treatment in just • Respect • Understanding and compassion • Supportive care • Transparency and opportunity to contribute
- 40. • Talk tosome one for: • Reaffirmation of their professional competency • Validation in their decision making ability. • Reassurance of self worth. What does he need?
- 41. • Learning /changing. •Involving in other issues • Physical activity/distraction • Seeking support e.g. counselling What does She/he need?
- 42.