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.
![](https://i0.wp.com/www.endocrine-witch.net/wp-content/uploads/2015/06/sw_aligned.jpg?resize=400%2C297&ssl=1)
![](https://i0.wp.com/www.endocrine-witch.net/wp-content/uploads/2015/06/sw_not_aligned.jpg?resize=400%2C297&ssl=1)
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?