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

Errors Three cases Frame, then teach Medico-legal aspects

“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

What is the morbidity?

Technical Normative Knowledge

Individual System

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.

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

“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”

What is the morbidity?

Technical Normative Knowledge

Individual Systems

Self correcting? Individual actions System actions

36 year old male Stereotypical facial pain, fevers, headache Travelling to Mexico for honeymoon Wants course of antibiotics

Debate about antimicrobials in treatment of ABRS/AVRS

Sample of moxifloxicin x 14 days

Patient seen in ER in Mexico with torrential epistaxis

INR 12 Nasal packing, vitamin K

What is the morbidity?

Technical Normative Knowledge

Individual System

Self correcting? Individual actions System actions

Disclosure Apology legislation, 2006 Case 1 Case 2 Case 3

What is the morbidity?

Technical Normative Knowledge

Individual Systems

Errors Three cases Frame then teach Medico-legal aspects