An attending physician realizes they accidentally prescribed a ten-fold overdose of an anticoagulant, which a nurse has just administered to the patient. Arrange the following steps in the most appropriate chronological order for managing this medical error according to professional and ethical guidelines.
- 1Examine the patient immediately and administer any necessary medical treatments or reversal agents.
- 2Disclose the error clearly and honestly to the patient and their family.
- 3File an internal incident report with the hospital's patient safety department.
- 4Participate in a multidisciplinary root cause analysis to evaluate the prescribing system.
Answer
The correct sequence is: (1) Examine and stabilize the patient, (2) Disclose the error to the patient, (3) File an internal incident report, and (4) Participate in a root cause analysis.
When a medical error occurs, the standard professional protocol dictates a clear sequence of priorities. The absolute first priority is patient safety, requiring immediate clinical assessment and intervention. Once the patient is stabilized, the physician must uphold the ethical principle of autonomy and honesty by promptly disclosing the error to the patient. Following clinical and ethical duties, the physician fulfills their institutional responsibility by filing an incident report. Finally, the physician participates in a root cause analysis, which is a long-term, systemic approach to preventing similar errors in the future.
Step-by-Step Solution
Key Concept
Management of Medical Errors