Case examples of student involvement in prevention of medical error
| No | Description of event | Contributing factors or problems | Role of medical student | Lessons learned |
|---|---|---|---|---|
| OR, operating room; DNR, do not resuscitate; MAR, medication administration record. | ||||
| 1 | Non-sterile prepped limb noticed before incision | Poor team communication Assumptions of OR staff responsibilities OR culture and hierarchy limiting communication Daily variation of OR team members | Observations of procedures and deviations from the norm prompted the student to question the omission of sterile technique | Don’t assume anything; keep a suspect eye when things do not look correct Err on the side of caution, err in favor of the patient Don’t be afraid to speak up, even if you are wrong Learn proper sterile techniques |
| 2 | Drugs ordered but not administered | Drug order system requires transcription from hand written order to computer based MAR No formal practice of confirming that ordered drugs are administered | Drug administration was not confirmed | Students are in a position to follow the practice of checking orders are carried out and medications administered |
| 3 | DNR order not followed | No system for alerting DNR orders to team Student hesitant to communicate knowledge of DNR order | Communicated DNR order to team | Students encouraged to communicate with team members when there are questions about proper procedures |
| 4 | Infection exposure | Language barrier Emergency setting Complete history not taken | Student initiated translator consult Obtained history suggestive of tuberculosis Initiated respiratory precautions | Effective communication is vital in patient safety When language barriers arise, translators must be used to ensure safe patient care |