Medical Error: X-ray Mix Up: Chest infection

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Where you are:
You are an FY2 doctor in an outpatient medical unit.

Who your patient is:
A 55-year old James Austin who has come for follow up.

Other information you have about the patient:
Mr Austin had presented to the hospital 6 week ago with a cough. He had a chest x-ray done and was treated with antibiotics for a diagnosis of pneumonia based on a chest X-ray findings. He was then discharged after 2 days.

However, when the department got the radiology report of Mr Austin Chest X-ray it was reported as normal.

It was then found out that the patient was treated based on another patient’s chest X-ray.

What you must do:
Talk to patient explain the medical error and address his concerns

Greet and Paraphrase

I understand you are here for a follow up…

History

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Date Gathering

Current & Previous visit: The Four Questions

When were you admitted?
1.Symptoms: What symptoms did you had?
2.Investigations: What sort of tests did they do?
3.Diagnosis: What did they tell you was wrong?
4.Treatment: What sort of treatment did they offer?
Did you improve?

DD: feel cold, shiver, chest pain, cough, sputum, fever

Tell the error

1. Warn: Thank you for answering my questions. I am glad you’re feeling well, unfortunately, I’m here to tell you about something that went wrong regarding your treatment
2. Narrate: As we understand, initially (history) …Your Xray was reported as normal then we thoroughly checked.
3. Tell the error: Unfortunately, I am sorry to tell you that you were given tx based on someone else’s x-ray and you didn’t have infection at that time.
4. Pt angry - AVE

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A acknowledge - See it, Say it: I can see that you’re upset.
V validate- Anyone in your position would feel the same.
E empathy- We should have been more careful I sincerely apologise.

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Management

What will be done next for the ERROR? The Five Steps

1. Incident reporting:

Please accept our sincere apology, the hospital will take this sort of incidences very seriously, this will be reported as a significant error, this is a documented event.

2. Investigate:

When an error is reported as a significant, it’ll automatically lead to investigation. The senior people will carry out the investigation and conduct RCAM - Root Cause Analysis Meeting: It’s a part of investigation.

3. Action will be taken:

According to the investigation results we’ll take a necessary action. How do you take action? We’ll take necessary action according to our policy and protocol. We will be open and transparent in terms of finding out what happened and the actions taken, the person responsible will be put forward. Are you able to follow?

4. Offer seniors:

We are expecting a senior person from the department will come and speak to you, in the meantime I’ll also have a talk to my senior about the discussion we had.

5. Patient Advice and Liaison Service (PALS):

If you wish to make a formal complaint, you have the full right to do so. I can get in touch with PALS, they can help you put forward your complain further. Is there anything else you would like to ask at this point? you must offer PLAS: your duty to let them know you have the right to complain. Offer PALS automatically even if patient is satisfied- do not mater patient is asking or not.

What will be done next for the PATIENT?

Extra points:

• We will look into the investigation and find out the root cause what went wrong in that way
• We can prevent similar incidents in the future from taking place
• We will spread the news and raise awareness about this error
• We will try to change the way we operate.

P: Will I develop any long-term complications?
D: It is highly unlikely that you may develop long-term complications, a single course of abx doesn’t have that much of an impact.

P: What happened to the other patient?
D: I am not sure but when someone is left without treatment the hospital will contact them immediately and offer treatment. We’ll find out what happened to the other patient and let you know. Will that be okay?

D: The only thing we need to worry about is Antibiotic resistance. It means that Antibiotic may not work in future. It happens in individual who take AB more frequently.

[Abhishek]

Thats helpful i wished i have found this previously anyway Thank you adminstrator