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#HealthXPH: To Err is Human; To Forgive, Divine

I’ve been doing virtual ward rounds on Zoom with medical students since last month. Many of them have expressed being overwhelmed, knowing that they have so much to learn. Repeatedly, I have told them – Watch what your residents order. See if it makes sense to you. If it doesn’t, ask. We talked about medical errors and I showed them the Swiss cheese model. It says that a patient comes to harm only when holes in the layers of defense line up.

Medical students are important members of the ward team. They can help make sure that the holes don’t line up! Some anecdotes I have shared on rounds recently –

An intubated cachectic woman with disseminated tuberculosis, gives birth to a premature baby in the ward. The medical clerk was the only one to have noted that the last menstrual period was 4 months ago. The service had not thought of doing a pregnancy test. A patient with a gangrenous left foot is admitted to the wards. Only the intern wrote a physical exam of the right foot, which also had a small wound. Everyone had been looking only at the left foot. Left to fester, that wound if undetected, could have caused problems later.

Six years ago, I wrote #HealthXPH: To Err is Human. I guess it’s time to talk about medical errors again at the #HealthXPH tweet chat. Rehashing the questions from that old tweet chat, let’s talk about the following tonight 4 Dec, 9 pm Manila time.

T1 How can healthcare professionals prevent medical errors?

T2. How can patients prevent medical errors?

T3. How should healthcare professionals disclose medical errors to patients?

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