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168 Clinical Communication Skills in Medicine
systolic function and flattening of the interventricular septum, in keeping with massive
pulmonary embolism. She has been shifted to the intensive care unit and commenced on
high-flow oxygen, intravenous fluid bolus, unfractionated heparin, and inotropes. As she
is too unwell for computed tomographic pulmonary angiography, the decision has been
taken to commence intravenous tissue plasminogen on clinical grounds.
When talking to the husband, you should follow the same approach that is outlined for
the patient with delayed diagnosis of stroke.
DOI: 10.1201/9781003533337-38 169
Torsades de pointes literally means ‘twisting of the points’. It is so named as the
QRS complexes appear twisted around the isoelectric line. Aprolonged QT interval (inter-
val between onset of depolarisation and completion of repolarisation) is a risk factor for
torsades. As the QT interval varies with the heart rate, it is corrected for the heart rate and
reported as QTc. AQTc of >500 ms increases the risk of torsades and ventricular arrythmia.
It can potentially degenerate into ventricular brillation and cause death.
A prolonged QTc is usually caused by drugs (e.g. macrolides, quinolones, chlorpromazine,
tricyclic antidepressants, lithium) or electrolyte disturbances (e.g. hypokalaemia, hypomag-
nesaemia). It may be asymptomatic or present with dizziness and syncope. The treatment of
This 74-year-old woman, with a background history of hypertension, diabetes mellitus, hyper-
lipidaemia, heart failure with reduced ejection fraction, and non-alcoholic fatty liver disease, was
admitted three days ago with a productive cough and breathlessness. She was diagnosed with
community-acquired pneumonia and acute decompensated heart failure. She was commenced on
oxygen by nasal prongs, amoxicillin–clavulanic acid, azithromycin, and furosemide.
She was clinically improving, and her vital parameters remained satisfactory. However, she sud-
denly developed dizziness and palpitations earlier this morning. Her heart rate was 150/minute and
blood pressure 106/78 mmHg at that time. Her 12-lead electrocardiogram showed torsades de
pointes. She was given intravenous magnesium sulphate, following which her symptoms resolved
rapidly, and the rhythm reverted to normal. Her corrected QT (QTc) interval was noted to be
580 ms (normal <440 ms). She was commenced on oral potassium replacement, as her serum
potassium was 3.3 mmol/L (normal 3.5–5 mmol/L). Serum magnesium and troponin were normal.
It was only realised after this event that her QTc on admission was already prolonged at 520 ms,
and azithromycin was erroneously prescribed and given for two days. Azithromycin has now been
discontinued. Her vital parameters are stable at present, but the plan is to shift her to a ward with
continuous cardiac monitoring facility because of the risk of recurrence of torsades.
The patient has asked the medical team to update her daughter. You are the medical registrar. Your
task is to talk to her daughter about the drug error and the next steps.
Case 33
The 74-Year-Old Woman Who
Has Suffered Harm Because of a
Medication Error
170 Clinical Communication Skills in Medicine
torsades is intravenous magnesium sulphate (even in patents with normal serum magnesium),
correction of serum electrolytes, and removal of the offending agent. Some patients may need
isoprenaline or transvenous pacing to accelerate the heart rate. Torsades often terminates
spontaneously, but it frequently recurs if the underlying cause is not corrected. Prognosis is
excellent, and no long-term treatment is required once the QTc interval returns to normal.
Patients often lose trust in their healthcare providers when errors happen, but the manner
in which we respond and the timeliness of the response can have a profound impact on the
likelihood of restoring trust. Patients or relatives usually expect three things from the health-
care provider: (1) a sincere apology (a bad apology is worse than no apology at all), (2) a
clear narration of the events that led to the error, and (3) an outline of the steps that will be
taken to avoid similar errors in the future. Make sure you cover these three issues during your
conversation with her. There may be an offer of a nancial compensation for any harm that
has been done, but there is no need to discuss that at this stage.
• Introduce yourself, and conrm her identity and relationship to the patient. Ask what
she has been told so far.
She says she was told that her mother’s breathing trouble was due to a combination of infec-
tion and excess uid in the lungs. She is aware that she is on antibiotics and a water tablet to
remove the excess uid. She is pleased that she is getting better. She is hoping that she can be
discharged home soon.
• Tell her that her mother has responded well to antibiotics and the diuretic.
‘She has indeed responded well to the treatments. She has no fever, and her pulse, breath-
ing, oxygen level in the blood, and blood pressure are all normal. She must continue
taking the water tablet and complete the antibiotic course.’
• Ask if her mother told her what happened earlier that morning.
She says she was going to ask you about it. Her mother told her that she suddenly became
dizzy and felt her heart racing. It only lasted a short while. She felt ne after a medicine was
given through her vein. She asks if it was anything to be concerned about.
Tell her that:
• Her mother developed a cardiac arrhythmia.
‘Yes, she suddenly complained of dizziness this morning and felt her heart racing. The
tracing of her heart at that time showed that her heartbeat was fast and irregular. After
we gave her the appropriate treatment, the heartbeat quickly returned to normal within
a few minutes.
‘An electrical signal passes through the heart muscle to make the heart pump blood.
Aslowing of this signal along the path can cause this kind of an irregular heartbeat. If it
is not treated promptly, it can even stop the heart. Thankfully, she responded well to the
treatment that we administered.’
Medication Error 171
• She has been commenced on oral potassium replacement, as serum levels were found
to be low.
‘Her blood tests done at that time showed that her potassium level was a bit low. Alow
potassium level can cause this kind of irregular heartbeat. The water tablet that she is
taking can cause the potassium level to go down. We are now giving her potassium tab-
lets to replace it.’
After a brief pause, tell her that:
• You would like to tell her about a mistake that contributed to this problem.
‘I would like to tell you about a mistake that we made which may have contributed to
this problem. The tracing of the heart done at the time of admission already showed the
slowing of the electrical signal. We avoid giving certain medications in people with this
kind of slowing. Azithromycin, one of the two antibiotics that we had been giving her to
treat the lung infection, is one of them.
‘We overlooked the slowing of the electrical signal on the tracing and gave this anti-
biotic by mistake. We suspect it further slowed the electrical signal and triggered the
irregular heartbeat. It could have been life-threatening, but thankfully, she responded to
the treatment that we gave her and the heartbeat quickly returned to normal. We are so
sorry that we made this mistake.’
She is taken aback upon hearing this. She asks how long she was given the antibiotic that
triggered the irregular heartbeat.
• Tell her that azithromycin was given for two days and it has now been discontinued.
‘The antibiotic was given once daily for two days – the day before yesterday and yester-
day. The usual course is three days, but we have stopped it now.
‘She can continue taking Augmentin, the other antibiotic. We had to start her on two
different antibiotics as there are some bacteria that do not respond to Augmentin.’
She says this is completely unacceptable. She asks in an angry tone if her mother’s heart will
be permanently damaged because of the antibiotic.
• Tell her that once the QTc interval returns to normal, there are no long-term
consequences.
‘She is at risk of developing the irregular heartbeat again until the slowing of the electri-
cal signal is corrected. We therefore plan to shift her to another ward so that her heart
tracing can be monitored continuously. Once the tracing returns to normal, there are no
long-term consequences. It is not a permanent problem. There won’t be any damage to
the heart because of this.’
She says that while she appreciates you for being honest and admitting the mistake, she is
appalled that the team was so careless. She asks you to name the person who prescribed the
antibiotic.
172 Clinical Communication Skills in Medicine
Tell her that:
• You are unable to single out anyone in particular.
‘I agree that this is not acceptable at all. We sincerely apologise for this oversight. Ido
not wish to offer any excuses for the mistake. We always check the heart tracing before
prescribing this antibiotic, but we somehow failed to do that on this occasion. Iam
unable to single out anyone, however. It was a collective error made by the team. Our
whole team will take responsibility for this mistake.’
• You will be submitting an incident report.
‘We will thoroughly investigate to nd out what went wrong and put in corrective meas-
ures in place so that this mistake is not repeated. We’ll learn from this mistake and make
sure the message is conveyed to the other doctors. Once we complete the investigations,
we’ll let you know what we found and how we will prevent this mistake in the future.’
‘You will, of course, defend your colleague, so there is no point in asking you’, she says. She
continues to talk in an angry tone and wonders if those who made this mistake were qualied
enough to take care of patients. She comments that her mother is not a guinea pig for them
to learn by making a mistake on her. She asks if she can make a complaint.
• Tell her that she can make a complaint and this will not affect the care of her mother.
‘You can indeed make a complaint. I’ll give you the contact details of the patient liaison
service department. Regardless of whether or not you proceed with the complaint, we
will thoroughly investigate the problem to nd out what went wrong. Making a com-
plaint will not affect the care of your mother in any way.’
End the discussion by summarising the main points. Apologise once again, and tell her that
her mother will soon be shifted to another ward so that she can be monitored closely. If all is
well, she should be able to go home in a few days. Tell her that if she has any further queries,
you would be happy to come back and talk to her.
SUMMARY
This scenario tests your skills in talking to a relative about a medication error that led
to patient harm. You will be expected to:
• Provide an update to the daughter on the progress of her mother.
• Make a disclosure about the medication error, and sincerely apologise for the
oversight.
• Clearly explain what went wrong and how she is being managed.
• Reassure her that there won’t be any long-term consequences to the heart.
Medication Error 173
• Tell her that the whole team will take responsibility for the error. Do not single out
anyone.
• Tell her that an incident report will be submitted, and measures will be put in place
so that this error is not repeated.
• Tell her that if she makes a complaint, it will not affect the care of her mother.
Variations of this scenario may include errors with other medications such as insulin
(e.g. administering the wrong preparation or dosage, resulting in hypoglycaemia), anti-
biotics (e.g. overlooking an allergy), and anticoagulants (e.g. prescribing the incorrect
dose, resulting in bleeding).
174 DOI: 10.1201/9781003533337-39
This 78-year-old man, with a background history of Alzheimer’s dementia, stroke, and hyperten-
sion, was admitted four days ago with increasing confusion. He was diagnosed with pneumonia
and commenced on antibiotics. As he was deemed to be at increased risk of falls, appropriate
precautions were taken, which included raising the bed rails, having a call light at the bedside, and
placing his possessions within his reach. He was improving clinically, and his mental state slowly
seemed to be reaching his baseline.
He unfortunately fell off his bed a short while ago. At the time when he fell, one of the two
nurses in his bay was attending to another patient, and the other nurse had just gone to pick
something up from the nursing counter. He probably tried to climb over the bed rail, but it was
not clear why he did that. He did not seem restless or agitated when he was last seen by the
nurses about 15 minutes before he fell. After he fell, he was seen by the junior doctor straighta-
way. There was a 5 cm laceration over the forehead and some bruising around the right eye. An
urgent computed tomography (CT) scan of the brain was arranged, which showed a small sub-
dural haematoma on the right side. There was no skull fracture. The laceration was sutured, and
aspirin was withheld. He was discussed with the neurosurgeon, who did not feel that operative
intervention was indicated. He suggested monitoring his Glasgow Coma Scale (GCS) and repeat-
ing the CT scan if there was a drop in his GCS. His vital parameters and GCS (14/15, which is his
baseline) have been stable since the fall.
His daughter has just arrived on the ward. She has not seen her father yet, as he has been taken
down to the eye clinic. You are the medical registrar. Your task is to let her know that her father
fell in the ward and discuss the next steps.
Case 34
The 78-Year-Old Man Who Fell Off His
Bed in the Ward
• Introduce yourself, and conrm her identity and relationship to the patient.
She wonders why you have come to speak to her now, as another doctor from the team
updated her this morning over the phone and told her that her father was responding well
to the treatment.
Inpatient Fall 175
• Tell her what happened.
‘Your father is indeed responding well to the antibiotics. Iam here to talk to you about some-
thing else. Iam very sorry, but this is going to be difcult. [Pause.] Ashort while ago, your
father fell off the bed and hit his head.’
She starts screaming and says this is completely unacceptable. She asks how he is and why
he is not on his bed.
• Tell her how he is at present and how he was managed after the fall.
‘He is stable at present. He is no more confused than usual. The rest of his parameters,
including pulse, blood pressure, breathing, and oxygen level in the blood, are all normal. He
developed a bruise around his right eye, so we have sent him to the eye clinic to get his eyes
checked. He sustained a cut on his forehead, which we have sutured. It was about 5 centi-
metres long.
‘We did an urgent scan of his head, and it showed a small collection of blood around
his brain on the right side. There was no fracture of any of his skull bones.’
‘Blood around his brain!’ she exclaims. She asks if he is going to be OK and what you are
going to do about the bleeding in the brain.
Tell her that:
• The neurosurgeon did not feel that operative intervention was necessary.
‘We consulted the brain surgeon. He did not feel that an operation was necessary to
remove the blood clot. We’ve stopped the aspirin, the blood-thinning tablet that he was
taking, as it can make the bleeding worse. If he remains stable, we’ll restart the aspirin at
a later date, after consulting the brain surgeon.’
• You will continue to monitor him closely.
‘We will continue to monitor him closely. If he becomes less conscious or more confused,
we’ll repeat the brain scan to check if the blood clot around the brain is increasing in size.
We are hoping that he will remain stable and the blood clot will dissolve soon.’
She continues to talk in an angry tone. She asks how he could have fallen when so many
of you were around. She feels that he must have fallen because the staff on the oor were
irresponsible.
• Tell her that appropriate precautions were taken to prevent him from falling.
‘It appears that he tried to climb over the bed rail before he fell off the bed and landed
on the oor. We took appropriate precautions to prevent him from falling. We raised his
bed rails, placed his possessions within his reach, and gave him a call light to use if he
wanted anything.
176 Clinical Communication Skills in Medicine
‘He was responding well to the antibiotic, and his mental state was improving. He did
not seem restless or agitated when he was seen by our nurse about 15 minutes before he
fell, so it is not clear why he tried to climb over the bed rail. There were two nurses in his
bay, but one was attending to another patient at that time and the other had just left the
bay to pick something from the nursing counter. He was therefore unfortunately briey
out of sight of both the nurses.’
She asks why you did not consider tying him to the bed, as he was at higher risk of falling.
Restraints should be used only if the individual is a threat to himself or others. The
least-restrictive option should be chosen and used for the shortest possible time, as the use
of restraints is not without risks. Patients who are restrained are at risk of worsening con-
fusion or agitation, deep vein thrombosis, pressure ulcers, and deconditioning, so frequent
re-evaluations are necessary.
Before tying a patient, it is preferable to rst try less-restrictive forms of restraining, like using
bed rails, 1:1 nursing, using a table tray in a geriatric chair, or chemical tranquilisation.
• Tell her that physical restraint is only used as a last resort.
‘We only do that in people who are agitated or restless and when we feel that they are
at risk of harming themselves or others. Even in people who are agitated, we use it as a
last-resort option and for the shortest possible time because it can sometimes make them
more confused or agitated. Keeping them immobilised can also increase the risk of blood
clots or bedsores.
‘Your father never displayed aggressive behaviour at any time, and his mental state was
much better compared to how it was at the time of admission. Raising the side rail was
also a form of restraint, and we least expected him to climb over it.’
She asks how he will be monitored, as it may not be so easy to spot a small change in the
mental state or conscious level in a man like him who is already a bit confused.
• Tell her that you will be monitoring his GCS.
‘We will be monitoring him using a measure called the Glasgow Coma Scale. We’ll regu-
larly check his eyes, speech, and the movement of his limbs and give him a score ranging
from 3 to 15. Right now, he is able to open his eyes on his own and move all his four
limbs when we ask him to do so, but he is not completely aware of his surroundings, so
we have given him a score of 14 out of 15. This was his baseline score even before he was
admitted to the hospital.
‘If he is only able to open his eyes when we call him or apply some pressure on his
body, or if he is not able to open his eyes at all, then the score for his eyes will be lowered
accordingly. We have a similar grading system for how well he speaks or moves his limbs.
If the overall score falls by two or more points, we’ll repeat the brain scan to check if the
blood clot is increasing in size. If the repeat scan shows that the blood clot is increasing
in size, we’ll inform the brain surgeon.’
She says she will be raising a complaint and seeking nancial compensation for the harm that
the hospital has caused.
Inpatient Fall 177
This scenario tests your skills in informing the daughter about an adverse event that
her father has suffered. You will be expected to:
• Inform the daughter that her father fell from his bed, and sincerely apologise for
what happened.
• Outline the steps that were taken soon after he fell and how you will continue to
monitor him.
• Explain what precautions were taken to prevent him from falling, without sounding
too defensive.
• Explain why he was not restrained.
• Tell her that she is free to make a complaint and this will not affect the care of her
father.
• Tell her that an incident report will be submitted, and any gaps that are found will be
addressed.
A variation of this case is disclosing a procedural complication to the daughter of an
elderly man. He was admitted to the acute medical unit a little earlier with upper gas-
trointestinal bleeding. The decision was made to insert a central line through his right
internal jugular vein, as he was haemodynamically unstable and peripheral venous access
was difficult. There was no time to do the procedure under ultrasound guidance. You
Tell her that:
• She is free to complain. It will not affect her father’s medical care.
‘I am sorry that this is adding to your distress. I’ll pass you the contact details of the
patient liaison service ofce, to whom you can provide your feedback. Iwould like to
assure you that making a complaint will not, in any way, affect how we care for your
father.’
• You will submit an incident report to ensure that any gaps are addressed.
‘We take the necessary steps to prevent people at high risk from falling, but unfortu-
nately, this cannot be completely prevented. I’ll submit an incident report, which will lead
to a thorough investigation to look into what happened. We’ll then be able to share more
details of what went wrong. If we nd any gaps, we’ll certainly learn from them and put
in measures in place to ensure that they are not repeated.’
If she has no further questions, end the conversation by telling her that her father should be
back in the ward soon. You will continue to monitor him closely and inform the neurosur-
geons promptly if there are any signs of deterioration. Tell her that the team will continue to
update her on his progress.
SUMMARY
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