Scenario 1 In-Flight Emergency Disclosure-Physician
1 week ago: Mrs. Jones has been your patient for the past 5 years. She has a PMHx of HTN. She had not been to clinic for the past 1.5 years. She presents today for follow up from a short hospitalization for hypertensive emergency in the setting of running out of her BP meds at home last week. The hospital she was seen at is not in the system in which you practice, and you cannot see their EMR other than the faxed dc summary forwarded to you. On d/c from her hospitalization you note that they started Mrs. Jones on metoprolol 100 mg SA and increased her lisinopril from 10 mgà20 mg. During your visit you find that Mrs. Jones’ BP is still elevated in the 160-170s/80’s both in your office and from her log at home. You decide that lisinopril/metoprolol combination she was discharged from the hospital on is likely not enough and she would benefit from being on Carvedilol instead of metoprolol for better BP reduction. You write her for a new script of Carvedilol 25 mg BID.
Today: Mrs. Jones re-presents today for follow up from an in-flight emergency. She reports that after seeing you last week she went to visit her grandchildren in Denver. During the flight she become disoriented, lightheaded and felt very poorly. They were forced to land the plan emergently. She was told by the doctors who took care of her that her heart rate and blood pressure were dangerously low. She is concerned it was due to the medications you prescribed her during his last visit since this all happened the day that she started taking the new doses you gave her. You review your last note from 1 week ago noting the addition of Coreg 25 mg BID you wrote for her. With a sinking feeling you suddenly realize that because Metoprolol was never prescribed by you, and thus not in your EMR, you had forgotten to tell Mrs. Jones to stop taking the metoprolol. You suddenly realize it was possible she was taking both metoprolol and carvedilol at the same time and that this medication error might be the cause of her in-flight emergency.
Situation: Discuss with the patient the medications she was taking after your most recent clinic appointment. Disclose to the patient the error you committed using the disclosure framework.
How to Disclose:
Inform the patient an adverse event occurred.
Describe what happened.
Stick to the facts, do not speculate
Use easy to understand language
Review implications for the patient.
Now
Future
Apologize and acknowledge responsibility.
Update on planned actions.
Plan to close the loop.