A junior  trainee  in  distress  has asked to speak to you regarding a medical error they have made that has resulted in a life-threatening adverse outcome for the patient.

Outline the key points of the initial discussion with the trainee.
 

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College answer

The key points that the candidate needed to cover were:

  1. Facilitating the initial critical incident debrief of the Registrar and allowing him/her to vent and tell his/her version of events
  1. Ensuring there is ongoing psychological and emotional support for the Registrar
    1. Give him/her the option of standing down for the rest of the  shift  or  providing support if he/she chooses to stay
    2. Arranging a mentor within the department (e.g. SOT)
    3. Ensuring there is back-up from friends/family at home
    4. Offering professional counselling
  1. Providing
    1. Open disclosure with family advice on the medico-legal process that will ensue
    2. Need for comprehensive and accurate documentation in records and factual account for registrar’s own records
    3. Early contact with medical defence organisation and hospital medico-legal advisors
    4. Reporting to coroner if/when the patient dies
    5. The event will be the subject of a Root Cause Analysis by the hospital
  1. Counselling with regards to future career and training
  1. Arrange follow-up meeting with mentor and departmental head for next day
 

Examiners Comments:

A common omission from candidates’ answers was failing to discuss medico legal issues and root cause analysis.

Discussion

  • Ensure the critical incident is being managed appropriately from a medical standpoint
    • Commit staff to ensure the patient is safe 
    • Ensure appropriate steps are being taken to ameliorate the risk from the critical incident (for example,  where a line has been accidentally inserted into a carotid artery causing a stoke - ensure that the vascular surgical team, neurology team and neurosurgical team have been consulted and have offered their opinions).
    • Delegate clinical duties so as to focus yourself on the debriefing session
  • Critical incident debrief (management of the traumatised trainee)
    • Debrief session
    • Organise time off work for the trainee, if appropriate
    • Involve an impartial mentor
    • Ensure that there are support people available from the extraclinical environment (friends, family)
    • Make an offer of professional counselling
    • Give advice regarding open disclosure process and medicolegal risk
  • Management of the affected patient and family
  • Management of the organisation
    • Factual and detailed documentation
    • Inform the clinical governance administrators
    • Inform the hospital medicolegal team
    • Inform the director of the department
    • Inform own medicolegal indemnity and defence organisation - as you were supposed to be supervising that trainee, and may even be responsible for the training program locally (if you happen to be the SOT).

References

CICM: GUIDELINES FOR ASSISTING TRAINEES WITH DIFFICULTIES (T-13), 2010

Mitchell, Jeffrey T. "Stress. The history, status and future of critical incident stress debriefings." JEMS: a journal of emergency medical services 13.11 (1988): 46-7.

Mitchell, Jeffrey T., and George S. Everly Jr. "Critical Incident Stress Debriefing (CISD) and the Prevention of Work-Related Traumatic Stress among High Risk occupational Groups.Psychotraumatology: Key papers and core concepts in post-traumatic stress (1994): 267.

Bledsoe, Bryan E. "C RITICAL I NCIDENT S TRESS M ANAGEMENT (CISM): B ENEFIT OR R ISK FOR E MERGENCY S ERVICES?."Prehospital Emergency Care 7.2 (2003): 272-279.

Harris, Morag B., Mustafa Baloğlu, and James R. Stacks. "Mental health of trauma-exposed firefighters and critical incident stress debriefing.Journal of Loss &Trauma 7.3 (2002): 223-238.

Laurent, Alexandra, et al. "Error in intensive care: psychological repercussions and defense mechanisms among health professionals." Critical care medicine 42.11 (2014): 2370-2378.