when things go wrong

22
Mike Purdon, BSc, BA, MDCM, dip ABFP Director, Faculty Development, SMP

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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 Presentation

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Page 1: When Things Go Wrong

Mike Purdon, BSc, BA, MDCM, dip ABFPDirector, Faculty Development, SMP

Page 2: When Things Go Wrong

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

Page 3: When Things Go Wrong

Errors Three cases Frame, then teach Medico-legal aspects

Page 4: When Things Go Wrong

“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

Page 5: When Things Go Wrong
Page 6: When Things Go Wrong
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What is the morbidity?

Technical Normative Knowledge

Individual System

Page 8: When Things Go Wrong

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.

Page 9: When Things Go Wrong
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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

Page 11: When Things Go Wrong

“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”

Page 12: When Things Go Wrong

What is the morbidity?

Technical Normative Knowledge

Individual Systems

Page 13: When Things Go Wrong

Self correcting? Individual actions System actions

Page 14: When Things Go Wrong
Page 15: When Things Go Wrong

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

Page 16: When Things Go Wrong

Debate about antimicrobials in treatment of ABRS/AVRS

Sample of moxifloxicin x 14 days

Page 17: When Things Go Wrong

Patient seen in ER in Mexico with torrential epistaxis

INR 12 Nasal packing, vitamin K

Page 18: When Things Go Wrong

What is the morbidity?

Technical Normative Knowledge

Individual System

Page 19: When Things Go Wrong

Self correcting? Individual actions System actions

Page 20: When Things Go Wrong

Disclosure Apology legislation, 2006 Case 1 Case 2 Case 3

Page 21: When Things Go Wrong

What is the morbidity?

Technical Normative Knowledge

Individual Systems

Page 22: When Things Go Wrong

Errors Three cases Frame then teach Medico-legal aspects