11/13/24, 8\:19 PM Guide | Medical error

Medical error

Table of contents
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Introduction

Learning to explain a medical error is a valuable skill in clinical practice. Given the nature of the healthcare environment, you
may encounter these situations in placements or when you start work. It may also appear in OSCEs.
For this guide, we will use the SPIKES framework as an example of how to explain a medical error to a patient or relative. The
SPIKES framework was developed for breaking bad news. However, it can be applied to a variety of clinical
situations, including explaining mistakes and errors.

Medical errors

A medical error is a mistake made in the context of healthcare and may include several situations\:
Where direct patient harm has occurred (e.g. prescribing and administering a medication a patient has a known allergy to)
Where harm may occur in the future as a result of an error (e.g. an incident leading to foetal ischaemia, where problems
due to hypoxic injury may not become apparent for years)
Where harm may have occurred but was prevented (e.g. a patient being prescribed a medication they have a known
allergy to, but it is not administered as sta
When an error occurs, the patient should receive an apology, be told what the error was, and any actions that will be taken
to prevent the same scenario from occurring again.
Saying sorry
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According to guidance from the General Medical Council and NHS Resolution, apologising to a patient is not an
admission of legal liability.

Why is this important?

Medical errors are common. The NHS National Reporting and Learning System (NRLS) received over 2 million patient safety
incident reports from April 2021 to March 2022, and while the majority of cases reported no harm, around 30% resulted in some
form of harm to patients.
2
Medical providers all have a duty of candour to be open and honest during a patient's care. In the context of a medical error,
we have a duty to report it and inform the patient.
The duty of candour can be split into two types - statutory (currently only in England and Scotland) and professional. The
professional duty of candour is regulated by speciGeneral Medical Council (GMC) and the Nursing and
Midwifery Council (NMC). The statutory duty of candour is regulated by the Care Quality Commission (CQC) in England and the
Care Inspectorate in Scotland.
3
Both are very similar, but the statutory duty also includes additional requirements for "noti
- these must
be speci2013 Francis inquiry,
which found serious failings in transparency at the Mid Sta
3

Clinical communication\: general tips

Prepare for the consultation by choosing an appropriate environment (see the ‘setting’ section below) and performing
su

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself including your full name and role.
Check you have the correct patient and con
Explain the purpose of the interview (e.g.
y o u r o p e r a t i o n .
” ).
“ I h a v e b e e n a s k e d t o s p e a k t o y o u a b o u t t h e r e c e n t b l o o d t r a n s f u s i o n y o u h a d a f t e r
If you are seeing the patient instead of their usual doctor – apologise for the change and explain that you are stepping in for
whatever reason.
Gain consent to discuss the topic with the patient and explain that the discussion will be con

Active listening

Display active listening skills throughout the consultation\:
Maintain an appropriate level of eye contact throughout
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair)
Nod to acknowledge what the patient is saying where appropriate
Avoid interrupting the patient throughout the consultation

Establish rapport

Try to establish a rapport with your patient\:
Ask how they are, o
Empathise with any emotion they display/verbalise and acknowledge the di
experiencing (watch them carefully)
Listen and respond to the things the patient says
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Structuring the consultation

SPIKES is an e

Setting

It’s important to explain the error in an appropriate setting\:
The discussion should occur in a comfortable, quiet, and private room. Although this is not always possible, make sure you
have at least some privacy and that the patient and family have somewhere to sit. Bad news should never be broken
standing in a corridor!
Make sure to have some tissues available
Ensure both you and the patient/relative are sitting down
Arrange the chairs if necessary (e.g. at approximately 45-degree angles to each other), avoiding physical barriers between
you and the patient (e.g. a desk)
Ensure you have uninterrupted time during the meeting (turn o

Perception

Begin by discussing the sequence of events leading up to this point and how the patient is feeling generally.
Explore the patient's ideas about the situation and what they already know. In the video demonstration, the patient required a
blood transfusion following knee surgery. In this example, the doctor asks things like\:
" D o y o u u n d e r s t a n d w h y y o u h a d t h e
b l e e d ?" and " H a s a n y o n e s p o k e n t o y o u a b o u t w h y y o u h a d t h e b l e e d ?"
. These can also serve as a warning shot to the patient.

Invitation

Check if the patient wants to discuss the issue with you today – in an OSCE setting the answer will always be yes, however, on
the wards, be aware that some patients may want to wait until family are present.
Explore if they have any speci
them. In this case, you should provide reassurance where appropriate\:
" J u s t t o r e a s s u r e y o u t h e r e i s n' t a n o t h e r d i a gn o s i s a n d
y o u a r e r e c o v e r i n g w e l l , b u t I' m g o i n g t o e x p l a i n a b i t m o r e a b o u t w h a t h a p p e n e d a n d w h y w e t h i n k y o u h a d t h e b l e e d"
.

Knowledge

Ensure you deliver the information in sizeable chunks, and regularly check the patient’s understanding.
Explain the error using simple language\:
“ O n e o f t h e d r u g s y o u w e r e p r e s c r i b e d , t h e a n t i c o a gu l a n t , w h i c h i s t h e b l o o d t h i n n e r ,
w a s m i s t a k e n l y p r e s c r i b e d a t a h i g h e r d o s e t h a n y o u n e e d e d . A n d t h a t m i gh t h a v e c a u s e d o r c o n t r i b u t e d t o y o u r b l e e d"
.
Allow a large pause if necessary, so the patient can digest what you have told them.
After explaining the error, it is important to apologise for what went wrong\:
" I' m r e a l l y s o r r y t h a t t h i s h a p p e n e d"
. It is wise to wait
for the patient to re-initiate the conversation. Make sure your tone is respectful, at a slow pace, and clear.
You can o
h a v e h a p p e n e d ?"
.
" D o y o u w a n t m e t o e x p l a i n w h a t m i g h t
Explain the circumstances of the mistake slowly and clearly. Use the correct language. There should not be any ambiguity,
and avoid using euphemisms or medical jargon. Deliver information in chunks, pausing between each piece of information.
" T h i s d r u g s h o u l d h a v e b e e n p r e s c r i b e d a s a l o w d o s e f o r y o u t o p r e v e n t b l o o d c l o t s f r o m h a p p e n i n g b e c a u s e y o u' r e l e s s
m o b i l e a f t e r s u r g e r y . W e a l s o u s e t h e d r u g a t a h i g h e r d o s e t o t r e a t b l o o d c l o t s , a n d y o u w e r e m i s t a k e n l y p r e s c r i b e d t h e h i gh e r
d o s e"
.

Emotions and empathy

Recognise and respond to emotions with acceptance, empathy and concern. Demonstrate an empathic approach
throughout the consultation.
It is natural for a patient to have an emotional reaction and they may become angry. It is important to recognise this, and you
may note some of the following behaviours when a patient is angry\:
Loud speech or shouting
Swearing/verbal abuse
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Aggressive posturing
Standing up and not wanting to sit down
Pacing up and down
Shaking/
Change in eye contact
If you recognise that the patient is angry then you can adjust your communication style to try and defuse as much of the
anger as possible or to try and prevent the situation from escalating.
You can read the full guide on dealing with angry patients and relatives, but some general tips are\:
Provide the patient with time to process the information and express their feelings
Try to keep a calm tone
Speak slowly and clearly
Adopt a professional yet relaxed posture
Acknowledge the patient's anger and concerns
Try to understand why they are angry
Respond with empathy

Strategy and summary

Explain the next steps to the patient clearly and reassure the patient that the situation has been, or will be reviewed and is
being taken seriously.
" S o y o u' l l c o n t i n u e y o u r r e h a b , I' v e p e r s o n a l l y d o u b l e-c h e c k e d y o u r m e d i c a t i o n s t o m a k e s u r e a l l o f y o u r p r e s c r i p t i o n s a r e
c o r r e c t . W e' v e d i s c u s s e d t h i s a s a t e a m b e c a u s e w e w a n t t o p r e v e n t t h i s f r o m h a p p e n i n g a ga i n , a n d I' v e s u b m i t t e d a f o r m a l
i n c i d e n t r e p o r t a s w e l l"
.
Provide the patient with details of how to make a formal complaint\:
c o m p l a i n t t o t h e l i a i s o n s e r v i c e"
.
" I u n d e r s t a n d , I' l l g e t y o u a f o r m s o y o u c a n m a k e a f o r m a l
Allow them to ask any questions they may have. They may feel that they need time to process the information given, and it
may be appropriate to o

After the consultation

Dispose of PPE appropriately and wash your hands.
Be aware that explaining a medical error can be emotionally challenging for you as a healthcare professional, particularly if it
was a mistake that you made or the patient became very angry.
Think through your own thoughts, and re

References

1. MDU Notes. Learning from Medical Errors. Available from\: [LINK]
2. NHS England. NRLS national patient safety incident reports\: commentary. October 2022. Available from\: [LINK]
3. Care Quality Commission. The duty of candour\: guidance for providers. Available from\: [LINK]
4. The MDU. Breaking bad news. Available from\: [LINK]
Source\: geekymedics.com
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