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When Things Go Wrong

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

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When Things Go Wrong

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  1. When Things Go Wrong Mike Purdon, BSc, BA, MDCM, dip ABFP Director, Faculty Development, SMP

  2. Disclosure • I do not have any financial affiliation with any information presented during this session. No products are endorsed during this session

  3. Outline • Errors • Three cases • Frame, then teach • Medico-legal aspects

  4. Errors • “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

  5. Case 1: Osteoarthritis of the knee

  6. Case 1: osteoarthritis of the knee

  7. Frame • What is the morbidity? • Technical • Normative • Knowledge • Individual • System

  8. Teaching • 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.

  9. Case 2: Post partum patient • 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

  10. 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”

  11. Frame • What is the morbidity? • Technical • Normative • Knowledge • Individual • Systems

  12. Teaching • Self correcting? • Individual actions • System actions

  13. Case 3: Acute sinusitis • 36 year old male • Stereotypical facial pain, fevers, headache • Travelling to Mexico for honeymoon • Wants course of antibiotics

  14. Acute sinusitis • Debate about antimicrobials in treatment of ABRS/AVRS • Sample of moxifloxicin x 14 days

  15. Case 3: Acute sinusitis • Patient seen in ER in Mexico with torrential epistaxis • INR 12 • Nasal packing, vitamin K

  16. Frame • What is the morbidity? • Technical • Normative • Knowledge • Individual • System

  17. Teaching • Self correcting? • Individual actions • System actions

  18. Medicolegal Aspects • Disclosure • Apology legislation, 2006 • Case 1 • Case 2 • Case 3

  19. Frame • What is the morbidity? • Technical • Normative • Knowledge • Individual • Systems

  20. Outline • Errors • Three cases • Frame then teach • Medico-legal aspects

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