A 57-year-old woman is admitted to the hospital for intravenous antibiotic therapy for lower extremity cellulitis. During her stay, a physician writes a handwritten order for '8 U regular insulin' to manage a mild hyperglycemic episode. The covering nurse misreads the 'U' as a zero and inadvertently administers 80 units of regular insulin. Thirty minutes later, the patient becomes profoundly diaphoretic and confused. Point-of-care glucose testing reveals a blood glucose level of 38 mg/dL. The hospital immediately initiates its standardized patient safety and error response protocol.
Arrange the following actions in the most appropriate chronological sequence according to best practices in medical error management and disclosure.
- 1Administer intravenous dextrose to rapidly correct the patient's symptomatic hypoglycemia.
- 2Document the objective clinical findings in the medical record and file an internal safety incident report.
- 3Hold an initial conversation with the patient and her family to explain what is currently known and express empathy.
- 4Convene a multidisciplinary committee to perform a root cause analysis of the medication prescribing and administration process.
- 5Conduct a follow-up meeting with the patient to share the formal investigation findings and outline the new system safeguards.
Cevap
The correct sequence of actions following a medical error is: 1) attend to the patient's immediate medical needs, 2) report the incident internally and document facts, 3) follow this with an initial empathetic disclosure to the patient, 4) conduct a formal root cause analysis, and 5) hold a follow-up meeting with the patient to discuss system improvements.
The standard response to a medical error follows a structured chronological sequence to ensure safety, transparency, and system improvement. The immediate priority is always the clinical stabilization of the patient (e.g., administering dextrose). Once stable, the objective clinical facts must be documented in the medical record, and an internal incident report must be filed to alert risk management. Promptly thereafter, an initial disclosure is made to the patient to acknowledge the event, express empathy, and outline next steps without speculating on blame. Following this, a multidisciplinary team conducts a root cause analysis to identify latent system failures, such as the use of forbidden abbreviations (the letter 'U'). Finally, a follow-up disclosure meeting is held to share these findings and the subsequent system improvements with the patient, providing transparency and closure.
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Anahtar Kavram
Structured Medical Error Response and Disclosure