when things go wrong
DESCRIPTION
When Things Go Wrong. Mike Purdon, BSc, BA, MDCM, dip ABFP Director, Faculty Development, SMP. Disclosure. I do not have any financial affiliation with any information presented during this session. No products are endorsed during this session. Outline. Errors Three cases - PowerPoint PPT PresentationTRANSCRIPT
When Things Go Wrong
Mike Purdon, BSc, BA, MDCM, dip ABFPDirector, Faculty Development, SMP
I do not have any financial affiliation with any information presented during this session. No products are endorsed during this session
Disclosure
Errors Three cases Frame, then teach Medico-legal aspects
Outline
“A medical error is anything that happens in my office that shouldn’t have happened and I absolutely do not want to happen again”
Rare Institute of Medicine, 1999
Errors
Case 1: Osteoarthritis of the knee
Case 1: osteoarthritis of the knee
What is the morbidity?
Technical Normative Knowledge
Individual System
Frame
Self correcting? Individual actions System actions
◦ …demonstrate an awareness of and responsiveness to the larger context and system of health care and learn to effectively call on system resources to provide care that is of optimal value.
Teaching
30 year old woman, six months post partum Sertraline 50 mg daily “No sex drive” Wonders about medication side effects Resident advises continued use of
medication
Case 2: Post partum patient
“Look, my wife and I had crazy sex until we had a kid. We tried everything at least once.”
“I really haven’t had anything that I would call worthwhile sex with her for two years since our son was born.”
“Keep taking your medication and tell your husband not to be a hound dog”
Case 2: Post partum patient
What is the morbidity?
Technical Normative Knowledge
Individual Systems
Frame
Self correcting? Individual actions System actions
Teaching
36 year old male Stereotypical facial pain, fevers, headache Travelling to Mexico for honeymoon Wants course of antibiotics
Case 3: Acute sinusitis
Debate about antimicrobials in treatment of ABRS/AVRS
Sample of moxifloxicin x 14 days
Acute sinusitis
Patient seen in ER in Mexico with torrential epistaxis
INR 12 Nasal packing, vitamin K
Case 3: Acute sinusitis
What is the morbidity?
Technical Normative Knowledge
Individual System
Frame
Self correcting? Individual actions System actions
Teaching
Disclosure Apology legislation, 2006 Case 1 Case 2 Case 3
Medicolegal Aspects
What is the morbidity?
Technical Normative Knowledge
Individual Systems
Frame
Errors Three cases Frame then teach Medico-legal aspects
Outline