Harm during care

Activity summary

This text case portrays an emergency procedure that is delegated to a medical student and results in an injury to the patient. The facilitation questions and suggestions to faculty focus on helping learners to understand the origins of harm to patients and when a physician should disclose a patient safety incident (accident in Québec).

Considerations discussed in this exercise also apply in Québec where a Regulation allows medical students and residents to carry out reserved acts assigned to them under the supervision of a physician.

Case scenario

A 51-year-old previously healthy female presents to the emergency department after the sudden onset of palpitations 6 hours previously. She is not experiencing chest pain or shortness of breath. Her vital signs on admission include an irregular pulse of 160, blood pressure 160/90, respiratory rate 16, and oxygen saturation 99% on room air. Physical examination is normal. An ECG is done, which demonstrates atrial fibrillation. 

The emergency physician meets with the patient and discusses the nature and risks of atrial fibrillation, as well as the risks and benefits of various treatment options. The patient chooses to proceed with electrical cardioversion. The physician explains that slight erythema of the chest in the areas of electrical shock may occur despite the use of protective pads. 

After administering appropriate sedation prior to the procedure, the physician asks a nurse to apply gel pads to the chest and charge the defibrillator’s paddles. He delegates the cardioversion to a fourth-year medical student, who the physician is fairly confident can perform the procedure by herself. The physician is then called away to briefly assess another patient with an urgent clinical issue. When the physician returns, the medical student has just successfully cardioverted the patient to sinus rhythm, but the physician notices the gel pads were never applied to the patient’s chest. 

When the patient wakes up, full thickness burns are noted where the paddles had been placed.

Facilitation questions

1. Is what happened in this case the result of the natural progression of a medical condition or the result of healthcare delivery?
2. Is the burn in this case likely a consequence of a system failure, of issues in provider performance, or both?
3. What information should be communicated to the patient with regards to the incident?
4. What should the medical student's role ideally be in a disclosure discussion with the patient?
5. How does provider error differ from the exercise of clinical judgment? Give examples.
6. What are the attending physician’s general responsibilities with regards to the supervision of trainees and the delegation of medical procedures?
7. What are the trainee’s responsibilities when being delegated a medical procedure?
8. What should typically be discussed with the patient in advance with regards to delegation of a medical procedure to a trainee?

Suggestions to faculty

This text case can also be used to consider the CMPA Good practices, "Physician-team: Delegation and supervision of trainees" and "Physician-patient: Disclosure of patient safety incidents". For example, discuss with learners whether the delegation and supervision of the medical student were appropriate, as well as the elements of a disclosure discussion.

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.