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20 Medico-legal questions

Question 5: Disclosure Understanding closecalls

A staff physician assigned a PGY3 surgical resident* to perform a small surgical

procedure. The resident almost performed the procedure on the wrong patient due to aninaccurate patient identification wrist band. The problem was caught in time by chance.

Choose the correct statement that applies:

A) In Canada, a close call must always be discussed with the patient

B) Close calls generally harm patients

C)A patient should receive knowledge of a close call if there is an ongoing

safety risk for that patient

D)An event that does not result in harm is not worth reporting to the

appropriate hospital authority, as prevention is difficult

E)Trainees involved do not need to report adverse events or close calls totheir supervisors

* In Canada, residents are physicians practicing under educational licence andsupervision until the successful completion of their program of studies. Residents aredesignated by Postgraduate Year (PGY) level. The number of years of training varies

for each specialty, ranging from two to six years after medical school.

The answer to this question is: C

Close calls

A close call is an event with the potential for harm that did not result in harm because itdid not reach the patient, owing to timely intervention or good fortune. It is sometimescalled a near miss.

As a general approach, a close call need not be disclosed to a patient, although thereare certain exceptions to this. A patient should receive knowledge of a close call if

there still is an ongoing similar safety risk for that patient, or if the patient is aware ofthe close call and an explanation will allay concern and promote trust. In the casepresented, the inaccurate identification band poses an ongoing risk to the patient.

Close calls are an important opportunity to recognize weaknesses and put systemsafeguards in place to prevent actual adverse events from occurring in the future.

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I

N

D

E

X

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Trainees should discuss adverse events, potential-for-harm, no-harm events and closecalls with their supervising physicians and be encouraged to take part in any

discussions with the patient, as appropriate.

The obligation to report close calls varies across provinces.

In Quebec, the law requires the completion of anincident report for close calls (near misses) in

government-run institutions such as hospitals. Thereport is kept on the patients medical record. Insuch a situation, it is prudent to alert your patient to

the incident, the report and any subsequentpreventative measures put in place. This will lessenthe likelihood of any misunderstanding and mistrust

in the future.

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