Disclosing a medication error to a family — OSCE

Station brief (8–10 minutes)

A three-year-old was given ten times the intended morphine dose because of a decimal-point slip on a handwritten chart. The child became bradypnoeic, was reversed with naloxone and is now stable. The parents are frightened and are asking what happened. The prescribing registrar is distressed. You are the senior registrar. Conduct the initial open disclosure with the parents, explain how the error was able to happen using a systems framework, and outline steps unit will now take. Address the registrar's wellbeing. Do not invent local statutory wording. ^{[12] [3]}