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communication and hand-offs may have contributed to the error. In
this case, you'd want to investigate the fire alarm protocol and the
administration of drugs in addition to the pharmacy error.
Talking to the family
After a medication error, communication with the family is also
important. Disclosure of a medical error is not easy, but it is, without
a doubt, the right thing to do. Patients and families want to know
what happened and once they get past the initial shock, will have
many questions. You want to give families an honest explanation with
a sincere expression of empathy.
To make open communication with the patient and family more effi-
cient, ensure you have a designated point person who is tasked with
keeping the family updated. In the case above, the hospital's chief
medical officer continued to stay in contact with and provide updates
to the family as the investigation went on.
Whoever communicates with the family should be careful to provide
the known facts and avoid speculating or placing blame before com-
pleting an investigation. In this case, the hospital correctly waited
until it confirmed the medication error before informing the family. It
is okay to say, "We don't have all the answers right now, but we will
be conducting a thorough investigation."
Staff suffer, too
There are other considerations besides the family following a fatal
medication error. After this incident, 3 hospital employees were
placed on administrative leave and provided with counseling.
Experience tells us that healthcare workers are crushed when they're
involved in a medical error, especially when it results in a significant
M E D I C A L M A L P R A C T I C E
