Scenario 2 IV Iron Anaphylaxis Disclosure-Physician
1 week ago: Mr. Bob has a PMHx of CKD4 2/2 poorly controlled DM2, HFrEF 2/2 ischemia, CAD and anemia who presents to your renal clinic today for routine follow up. He has been your patient for the past 2 years and his renal function has slowly worsened to his current CKD4 w/creatinine around 3.7 at baseline. He is nearing needing iHD, with frequent admissions for CHF exacerbations due to his failing kidneys and difficult volume management. He is a very complex patient and you have much to discuss about his renal health and how that interacts with his CHF. You also have to discuss fistula placement. As the visit wraps up you pop open the EMR and remember that his hemoglobin has been hanging out between 7-8 and realize he would benefit from some iron given his anemia and CHF. He already takes so many pills and has compliance issues making PO iron less than ideal. You tell Mr. Bob that you would like to give him a dose of IV iron next week to bring his blood counts back up. He agrees and you ask your nurse coordinator to schedule the appointment. You then rush to your next patient as Mr. Bob’s visit already has you running behind.
Today: You get a call from a hospitalist saying that Mr. Bob was admitted to the hospital 2 days ago after experiencing anaphylaxis in infusion clinic to IV iron. He had just received his test dose (5mL) when he immediately became SOB, diaphoretic and tachypneic. His nurse and some very helpful Hematology residents who were in clinic nearby immediately started appropriate treatment with IM epinephrine. Despite their excellent care, Mr. Bob went into PEA arrest and required 2 minutes of CPR before obtaining ROSC. You immediately recognize that you did not discuss risks/benefits of IV iron with the patient when he was last in clinic because you were so busy and he had so many other medical issues to discuss. The hospitalist says that the patient is stable and transferring to the medicine ward. You immediately tell the hospitalist that you will come in and do an error disclosure with the patient and his wife this afternoon.
Situation: Discuss with the patient and his wife what happened in infusion clinic. The risk of anaphylaxis to IV iron is exceedingly rare less than 30 per 1,000,000. Disclose to the patient the error you committed by not providing a risks/benefits discussion before the administration of IV iron. (Of note, there is no required informed consent for IV iron so you did not break any hospital policy). Use 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.