Rodgers D, Rodríguez-Bauzá DE, Silva-Rodríguez ME

Language: Spanish
References: 21
Page: 140-146
PDF size: 203.85 Kb.

ABSTRACT

Medication error is a major cause of patient morbidity and mortality, but it can be a confusing and under-appreciated concept. Medication error is a major cause of patient morbidity and mortality, but it can be a confusing and under-appreciated concept. In practice, a comprehensive system that assesses damage, root cause, and psychological aspects of errors is beneficial in modifying communication and helping to prevent future errors. In this 1.5-hour simulation scenario, a 65-year-old male patient “X” with history of Parkinson’s disease, advanced dementia and type 2 diabetes mellitus presented to the Emergency Department with progressive worsening in his general condition, nausea and vomiting of food content, fever, confusion and aggressiveness accompanied by his daughter who is his legal representative and caregiver. He is admitted with a diagnosis on admission: diabetic ketoacidosis, complicated acute pyelonephritis, and septic shock, being transferred to the Intensive Care Unit, with the immediate action of the medical team, hemodynamic stability, fluid replacement, correction of acidosis and electrolyte disorders are archived, starting also broad spectrum antibiotic treatment. During the 5th day of hospital stay, resident “A” inadvertently prescribed laxatives for patient “X” thinking he was writing the order for patient “Y”. This error results in moderate dehydration after several episodes of diarrhea, requiring adjustments in fluid replacement. Because this patient’s altered mental state and advanced dementia prevent the patient from understanding of what occurred, it is more appropriate for the medical team to disclose the error to his daughter. The objectives are to develop skills for medical errors disclosure in a safe simulated environment, using Buckman’s protocol for communication of medical errors. This clinical simulation case allows participants a useful framework for understanding and analyzing ethical conflicts, inspiring them to make thoughtful ethical clinical decisions and have tools to deal with these events.

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