Making Mistakes and Incident Reports

You are an FY2 doctor on your 4-month cardiology rotation. You are coming to the end of a long day shift on the ward. One of your patients is a diabetic suffering from heart failure. As listed on the drug chart, you give him his evening dose of insulin, but you forget to record this on the drug chart. You hand over to the night team. During the night shift the patient receives another insulin dose as the night staff thought this had not been done. The following day your patient complains to you that he had a terrible night. He explains how he sweated profusely, felt dizzy and endured headaches, all of which are signs of hypoglycemia. You realize your error when you look at the drug chart. You tell your consultant, who advises that you should fill out an incident report.

• What should you tell this patient?
• Are NHS trusts under any obligations to be open and honest when mistakes are made?
• What is the purpose of an incident report?
• What happens to the form once it has been completed?

Apply Theory (Specific Professional Healthcare Competencies + Clinical Medical Ethical Principles) to Practice in order to provide Optimal Patient-Centered Care (OPCC)

Clinical Ethics and Law, Second edition. Carolyn Johnston, Penelope Bradbury, Series editor: Janice Ryme