A few weeks ago, I overheard one of the interns worrying about accidentally prescribing a medication and giving to patient the wrong dose frequency. The error was picked up by another resident who is on the cardiology consult service as the medication was felt by the cardiology team to be contributing to the patients presenting issue (symptomatic bradycardia).
I will admit that at the time I was only concerned with reassuring the resident that he would not lose his residency spot due to this error, as the patient was still alive. When the resident was consoled I forgot about this issue. Until attending this conference.
You guys made a very good point that if we do not report errors, we lose the opportunity to learn. Because when I disclosed this error with my workmates, who also attended this conference this weekend, we developed some questions which we lost the opportunity… Continue reading
One of the questions that kept coming to my mind as I watched the Lewis Blackman story, was why didn’t anyone second guess their diagnosis. As medical professionals we have a tendency to form anchoring biases which restrict us to specific diagnoses but I felt frustrated watching the film because Lewis’ signs and symptoms did not match the diagnoses he had been given. We should all be open to reassessing our patients and refining diagnoses in order to not make another catastrophic mistake such as this. I remember in medical school, in Barbados, our attendings would insist that we had a list of possible diagnoses for all of our patients just to ensure that we considered all likely alternative diagnoses. From that list, we would exclude unlikely diagnoses until we found the one that fit. Something like that would have saved Lewis.
One of the many useful things I learnt… Continue reading