An elderly patient with type 2 diabetes experiences a severe hypoglycemic seizure on the medical ward after a nurse inadvertently programs an intravenous insulin pump to deliver ten times the intended hourly rate. The patient requires emergency administration of dextrose. Arrange the following actions regarding the management, disclosure, and investigation of this medical error in the most appropriate chronological sequence.
- 1Administer intravenous dextrose to correct the hypoglycemia and stabilize the patient.
- 2Remove the involved infusion pump from service and secure it to preserve evidence.
- 3Disclose the occurrence of the error to the patient and provide a sincere apology.
- 4Convene a multidisciplinary team to perform a root cause analysis of the event.
- 5Share the final investigation findings and newly implemented safety policies with the patient.
Answer
The correct sequence prioritizes immediate clinical stabilization, followed by securing evidence, providing initial patient disclosure, conducting a systemic investigation, and finally communicating the long-term preventive outcomes.
Following a severe medical error, the immediate priority is always patient stabilization and harm mitigation. Once the patient is safe, the involved equipment must be sequestered to preserve objective evidence and prevent subsequent harm. With the patient stable and initial facts gathered, the physician must promptly disclose the error to the patient and offer a sincere apology, rather than waiting for a complete systemic review. Subsequently, a formal, multidisciplinary root cause analysis is conducted to map the event and address underlying systemic flaws. Finally, the loop is closed by sharing these findings and the implemented process changes with the patient.
Step-by-Step Solution
Key Concept
Medical Error Management and Disclosure Sequence