Paeds Cases · professional-practice-and-evidence
Open disclosure after a medication error — OSCE
OSCE on staged open disclosure after a tenfold medication error, addressing acknowledgement, apology, language access and follow-up.
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Target exams
MRCPCH ClinicalRACP DCERCPSC Pediatrics
Prompt
Parents of a 3-year-old, with limited English, are at the bedside after the child received a tenfold opioid dose from a decimal-point error overnight; the child was given naloxone and is now stable; nothing has yet been said to the family.
Station brief (8–10 minutes)
Conduct the initial open-disclosure conversation with the parents after the tenfold medication error. The child is stable. Acknowledge what happened, apologise, give the known facts, arrange appropriate follow-up, and ensure language access. Do not invent jurisdiction-specific statutory wording or local tribunal procedure. [1] [4]
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References5Show ledgerHide ledger
- [1]Iedema RA The National Open Disclosure Pilot: evaluation of a policy implementation initiative. The Medical journal of Australia, 2008.PMID 18393742
- [2]Iedema R Patients' and family members' experiences of open disclosure following adverse events. International journal for quality in health care, 2008.PMID 18801752
- [4]Jacob H Openness and honesty when things go wrong: the professional duty of candour (GMC guideline). Archives of disease in childhood. Education and practice edition, 2016.PMID 27002114
- [5]Inkster T Duty of candour and communication during an infection control incident in a paediatric ward of a Scottish hospital. Journal of medical ethics, 2022.PMID 33593873
- [14]New L Second-Victim Phenomenon. Nursing clinics of North America, 2024.PMID 38272580