A 70-year-old man comes to the hospital with acute-onset chest pain. He has stabbing pain and pressure that radiates down his arm and started an hour ago during a bicycle ride. The patient's medical history is significant for generalized anxiety disorder, mild dementia, hyperlipidemia, and metabolic syndrome. Initial electrocardiogram indicates no abnormalities. He is admitted to the hospital for observation, with serial troponins and telemetry monitoring. On hospital day 2, the patient's physician mistakenly orders a dose of valproate for him that was intended for another patient with a seizure disorder. The patient's nurse does not double check the order and administers the medication with the patient's other medications. Later that day, the patient tells the physician of feeling sedated and "mental fogginess" but attributes this to being awakened frequently the night before for vital signs. The patient's daughter feels certain that a good night's sleep will improve her father's symptoms. On realizing the error, the physician's next step should be which of the following?

Question

A 70-year-old man comes to the hospital with acute-onset chest pain.  He has stabbing pain and pressure that radiates down his arm and started an hour ago during a bicycle ride.  The patient's medical history is significant for generalized anxiety disorder, mild dementia, hyperlipidemia, and metabolic syndrome.  Initial electrocardiogram indicates no abnormalities.  He is admitted to the hospital for observation, with serial troponins and telemetry monitoring.  On hospital day 2, the patient's physician mistakenly orders a dose of valproate for him that was intended for another patient with a seizure disorder.  The patient's nurse does not double check the order and administers the medication with the patient's other medications.  Later that day, the patient tells the physician of feeling sedated and "mental fogginess" but attributes this to being awakened frequently the night before for vital signs.  The patient's daughter feels certain that a good night's sleep will improve her father's symptoms.  On realizing the error, the physician's next step should be which of the following?

Quizplus · Accepted Answer

Explanation: Physicians are often reluctant to disclose that a medication error has occurred, particularly when no significant harm has come to the patient. Reasons for this include fear of losing patient trust, legal action, and discipline from the medical board. However, prompt, full disclosure of medical errors has been found to have a neutral to positive effect on patient response to the error as well as the doctor-patient relationship. When an error is discovered, disclosure should be provided in person, in a timely manner that includes an apology for what occurred. Patients should be reassured of efforts to prevent further errors from occurring. (Choice A) Agreeing that the patient's over-sedation is secondary to lack of sleep would be dishonest and misleading. (Choice B) Consulting with hospital risk management would not be appropriate at this time, as it is clear that an error has occurred and no legal action is currently being threatened. The patient and his daughter will likely appreciate a prompt, honest explanation, which may mitigate desire for possible legal action. (Choice D) Transferring care to another physician would be premature as the patient has not expressed an interest in doing so, and this undermines trust in the physician's ability to continue caring for the patient. (Choice E) Waiting to speak with the pharmacy and nursing staff would be appropriate if it is unclear what has occurred or if there is a question about whether the mistake led to an adverse outcome. However, in this case it is clear that the medication error led to the patient's current complaints and the best next step is to provide full disclosure of the event. Educational objective: Medication errors present a significant risk to patient safety. Appropriate management includes prompt disclosure accompanied by an apology and discussion of preventive measures. References: Medication errors: an overview for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/24981217) Patients' and physicians' attitudes regarding the disclosure of medical errors. (http://www.ncbi.nlm.nih.gov/pubmed/12597752) Skills of internal medicine residents in disclosing medical errors: a study using standardized patients. (http://www.ncbi.nlm.nih.gov/pubmed/19940591)

A 70-Year-Old Man Comes to the Hospital with Acute-Onset Chest