ADMIN/NON MEDICINE
MEDICAL ERROR - MISSED DIAGNOSIS/COMPLAINTS
PromptāIncident reportā
ResponseIIMS is NSW specificā¦ Iād probably write āformal incident report - IMS in NSW Healthā
IMS = Incident management system
IMS = Incident management system
PromptWhat is open disclosure
ResponseApology/expression of regret
Factual explanation of what happened
Opportunity for patient to relate their experiences
Discussion of potential consequences
explanation of steps being taken to manage event/prevent recurrence
DOCCUMENT
Factual explanation of what happened
Opportunity for patient to relate their experiences
Discussion of potential consequences
explanation of steps being taken to manage event/prevent recurrence
DOCCUMENT
PromptFactors contributing to delayed diagnosis
ResponseAccess block
Inappropriate triage category
Inappropriate triage screening (Eg: To fast track)
Delay to observations
Ordering investigations without patient assessment
Delay to medical review
Staff fatigue and morale
Inappropriate triage category
Inappropriate triage screening (Eg: To fast track)
Delay to observations
Ordering investigations without patient assessment
Delay to medical review
Staff fatigue and morale
PromptContributors to missed diagnosis
ResponseSystem (think HR stuff)
Inadequate staffing at senior level
Inadequate roster
Process (Think processes on the floor stuff)
XR report delays
No notification of abnormal report
Lack of education/experience of junior medical staff in interpreting CXR
Lack of review of radiology by senior staff
Individual
Lack of understanding/skill/expertise
Poor communication (patient/staff)
Inadequate staffing at senior level
Inadequate roster
Process (Think processes on the floor stuff)
XR report delays
No notification of abnormal report
Lack of education/experience of junior medical staff in interpreting CXR
Lack of review of radiology by senior staff
Individual
Lack of understanding/skill/expertise
Poor communication (patient/staff)
PromptSolutions to minimise missed diagnosis
ResponseSystem
Review adequacy of staff mix + supervision
Senior staff roster to ambulatory care areas
Process
Early imaging reports
Mandatory contact for abnormal reports
Mandate senior review for all patients
GP follow up for all pending reports (Copies forwarded automatically)
Audit of results (Results checking)
Individual
Resident education
Communication skill workshop
Oversight of juniors
Review adequacy of staff mix + supervision
Senior staff roster to ambulatory care areas
Process
Early imaging reports
Mandatory contact for abnormal reports
Mandate senior review for all patients
GP follow up for all pending reports (Copies forwarded automatically)
Audit of results (Results checking)
Individual
Resident education
Communication skill workshop
Oversight of juniors
PromptOutline your approach to management of clinically significant missed imaging findings - Single event (Q was lung lesion on cxr a few months prior)
ResponseEnsure appropriate follow-up of current lesion with referral to Respiratory team for further urgent diagnostic work-up
Documentation of findings of missed diagnosis in the notes
Have a discussion with the patient and family regarding the delay in diagnosis (open disclosure principles) & document discussions with patient and family
Notify ED director
Notify Radiology director
Notify hospital medico-legal department.
Refer this case for review through hospital quality assurance program such as M&M or patient safety committees.
Advise previous treating doctors of missed diagnosis & possible medico-legal implications (At appropriate time etc. not after night shift. Offer support. No blame)
Documentation of findings of missed diagnosis in the notes
Have a discussion with the patient and family regarding the delay in diagnosis (open disclosure principles) & document discussions with patient and family
Notify ED director
Notify Radiology director
Notify hospital medico-legal department.
Refer this case for review through hospital quality assurance program such as M&M or patient safety committees.
Advise previous treating doctors of missed diagnosis & possible medico-legal implications (At appropriate time etc. not after night shift. Offer support. No blame)
PromptMissed diagnosis complaint (Eg: Missed fracture on XR)
ResponseAcknowledge patients complaint and apologise (Ideally within 24h) Reassure patient this will be addressed through hospitals safety and quality system
Explain clinical significance, treat patients medical problem, arrange appropriate follow up (Ironically this is only in about 30% of answers)
Expedite rapid return and assessment
Careful documentation of above
Gather information
Discuss with RMO at an appropriate time (not straight after nights) + debrief +/- management plan
Provide education at departmental teaching to prevent recurrence of error
Staff Education for RMO and staff - M+M etc.
Feedback to patient regarding outcome/process changes
May need to seek medicolegal advise if patient pursuing this
Explain clinical significance, treat patients medical problem, arrange appropriate follow up (Ironically this is only in about 30% of answers)
Expedite rapid return and assessment
- Return to ED
- Senior review on arrival
- Provide necessary care to patient
Careful documentation of above
Gather information
- - Systems, staff, processes
- complexity, business of shift, degree of supervision, degree of understanding of condition, radiology reporting systems
Discuss with RMO at an appropriate time (not straight after nights) + debrief +/- management plan
Provide education at departmental teaching to prevent recurrence of error
Staff Education for RMO and staff - M+M etc.
Feedback to patient regarding outcome/process changes
May need to seek medicolegal advise if patient pursuing this
PromptAspects of the case you would investigate in a missed diagnosis
ResponseAssessment (history & examination) - accurate, vital signs performed/stable diagnosis/differentials -was ectopic considered/pregnancy excluded
Investigations - was b-HCG performed/ results checked & documented Consult/referrals - discussion with senior ED doctor, O&G prior to discharge
Disposition / follow up instructions given to patient
Be specific. "BHCG" rather than "investigations done"
Need to include information likely to be in clinical notes.
Staffing, workload are part of the incident investigation, but are not usually included in clinical record.
Investigations - was b-HCG performed/ results checked & documented Consult/referrals - discussion with senior ED doctor, O&G prior to discharge
Disposition / follow up instructions given to patient
Be specific. "BHCG" rather than "investigations done"
Need to include information likely to be in clinical notes.
Staffing, workload are part of the incident investigation, but are not usually included in clinical record.
PromptDiscussion with JMO who missed diagnosis
ResponseExplore wellbeing of JMO - home stressors/situation. Assess how they are coping with increased responsibility
Outline expectations - Punctuality, early notification if sick for night shift
Offer support if required - Struggling with increased responsibility may require supervision/no night shifts
Explain missed diagnosis - offer reassurance, unlikely to be long term harm to patient, commonly missed even by experienced clinicians
Explore and address contributing factors to missed diagnosis - patient/system factors, Clinician factors
Outline expectations - Punctuality, early notification if sick for night shift
Offer support if required - Struggling with increased responsibility may require supervision/no night shifts
Explain missed diagnosis - offer reassurance, unlikely to be long term harm to patient, commonly missed even by experienced clinicians
Explore and address contributing factors to missed diagnosis - patient/system factors, Clinician factors
PromptManagement of patient compliant against junior reg
ResponseSpeak to patient - apolgise, elaborate, reassure that you will investigate and follow up with them
Speak to reg - inform of patients complaint, give opportunity to explain/apologise
Document complaint in notes, IIMS/Risk management (Formalise process)
Inform regās seniors (if from other team their consultant) + ED director
Complete complaint process, investigate, take actions
Speak to reg - inform of patients complaint, give opportunity to explain/apologise
Document complaint in notes, IIMS/Risk management (Formalise process)
Inform regās seniors (if from other team their consultant) + ED director
Complete complaint process, investigate, take actions
PromptWhat are the most common medication related incidents
ResponseWrong dose, frequency or strength
Omission of medication
Wrong quantity
The wrong patient
Omission of medication
Wrong quantity
The wrong patient
PromptDefine Root Cause Analysis ā RCA
ResponseRoot cause analysis (RCA) is a structured method used to review an incident in order to identify the healthcare systems issues that contributed to patient harm.
Clinical excellence commission NSW
Clinical excellence commission NSW
PromptHow would you investigate an incident using RCA
Steps you could take to investigate delays to care
Basically āSomeone died. How would you look into itā
Steps you could take to investigate delays to care
Basically āSomeone died. How would you look into itā
ResponseIdentify the incident and decide to investigate
Select people for the investigation team
Gather information
Construct a timeline
Identify factors that caused or contributed to the incident
Link factors to the outcome (contributory factors)
Make recommendations
Half answers, half clinical excellence commision
Select people for the investigation team
Gather information
Construct a timeline
Identify factors that caused or contributed to the incident
Link factors to the outcome (contributory factors)
Make recommendations
Half answers, half clinical excellence commision
Documentation! notify patient of outcome!