Medical Error: Missed Foreign Body

[Plabforum]

Who you are:
You are an FY2 in the A&E.

Who the patient is:
A mother brought in her 2-year-old child, Milan, due to him swallowing a foreign body. You examined the child and did an x-ray; you thought it was normal and sent the child home. Later, the radiologist found that there’s a button (can say, Lego) in the oesophagus.

What you should do:
Talk to mother over the phone, tell her what happened and ask her to bring the child back in again.

Approach

D: Hi, I’m Dr (name) I am calling from the hospital. Are you Milan’s mother?

Use Telephonic approach

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To Telephonic Patient:

1. Greeting Hello, can I speak with John Parker?
2. Introduction I’m Dr [Last name], one of the junior doctor at King’s College Hospital. I understand that we had an appointment with you today.
3. Consent Is this good time to talk?
4. Signpost Before I proceed I want to confirm few things so that I’m sure I’ve the right person.
5. Identification Can you please confirm your age? Can you please confirm the first line of your address?

Assess knowledge

D: I understand that your daughter was here in the hospital because you thought she swallowed a button?
P: Yes, he was playing with his older brother and I was in the kitchen when his older brother called me saying that he swallowed a button, but the doctor told me that the X-ray was fine.

General questions

D: Yes, the doctor you saw was me. Is it OK if I just ask you a few questions about Milan. Is he in front of you right now?
P: Yes.
D: How is he now?
P: He is fine.
D: Is he active and playful?
P: Yes

Questions to check food pipe

D: Is he eating well?
P: Yes.
D: Have you fed him?
P: Yes.
D: Any vomiting?
P: No
D: Has he been to pass stool since you left the hospital?
P: Yes, no problem with that at all.

Questions to check windpipe (assess harm)

D: Is he breathing well?
P: Yes.
D: Any difficulty breathing?
P: Yes,
D: Any drooling saliva?
P: Yes.
D: Any problems that you are concerned about?
P: You are worrying me, why are you asking all of these questions?

Inform about error

Well, when you came to the hospital today and we did the x-ray, I couldn’t see anything unusual on the x-ray and sent you home. However, after our radiologist double checked it, he spotted what appears to be a button in Milan’s food pipe. Unfortunately, it seems I made a mistake in not spotting the button and sent you home.

Apology

D: I’m really sorry that I’ve missed this, please accept my apology,
P: How could you miss it?
D: It’s my mistake and there is no excuse for what happened, that’s why all x rays get reviewed again by the radiologists.
D: I’m really sorry, now, my main concern is making sure Milan is OK. So, please can you bring him back to the hospital?

P: Doctor, is he in danger?
D: Well, no, I don’t believe so, from the information you have given me he sounds fine. The last thing I want is to frighten you, but we need you to bring him back so we can see if the button is still in the food pipe or if it
has moved. Depending on the location of the button we can decide the next course of action.
D: However, a foreign body can get stuck sometimes in the food pipe or it can be poisonous and cause damage to the food pipe.

Management

1. Bring him.
2. Senior.
3. Examine him → General – Physical → Chest – Abdomen.
4. Investigations → Repeat CXR and abdominal X-ray.
5. Management → If the foreign body is stuck, he might need endoscopy to remove it. However if it has passed the food pipe it can come out with his stool.

P: Doctor, I can’t bring him in. (Refusal approach)
D: May I ask you why?

• Address the concern.
  P: I am about to go to work right now.
  D: I totally understand that, but it’s really important that we see Milan again. I can provide you with a letter saying that you needed to come to the hospital for your employer.

Offer her transport if she doesn’t have any way of coming in.

• Risk or ultimate risk?
  D: It might get stuck in his food pipe and this might cause inflammation and other complications
• Benefits.
  D: We will make sure that he is fine and we can follow up with him after.

P: Doctor, how are you going to make sure that you don’t make this mistake again in the future?
D: Well, I totally appreciate your concern:

• I will always go back to my senior before discharging any patient.
• I will enroll myself in some courses to be able to read X-rays better.
• I will report this incident in the incident form.
• There’s also meeting called RCAM where seniors and consultants meet and try to find solutions on how to prevent errors from happening.
• Don’t offer complaint procedure unless she mentions that she wants to complain, then offer PALS.