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.
The key points that the candidate needed to cover were:
- Facilitating the initial critical incident debrief of the Registrar and allowing him/her to vent and tell his/her version of events
- Ensuring there is ongoing psychological and emotional support for the Registrar
- Give him/her the option of standing down for the rest of the shift or providing support if he/she chooses to stay
- Arranging a mentor within the department (e.g. SOT)
- Ensuring there is back-up from friends/family at home
- Offering professional counselling
- Open disclosure with family advice on the medico-legal process that will ensue
- Need for comprehensive and accurate documentation in records and factual account for registrar’s own records
- Early contact with medical defence organisation and hospital medico-legal advisors
- Reporting to coroner if/when the patient dies
- The event will be the subject of a Root Cause Analysis by the hospital
- Counselling with regards to future career and training
- Arrange follow-up meeting with mentor and departmental head for next day
A common omission from candidates’ answers was failing to discuss medico legal issues and root cause analysis.
- 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
- Clinician open disclosure
- Commencement of a formal open disclosure process
- Discuss the need to refer to the coroner (if relevant)
- 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).
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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.