Full_Disclosure - Spotlight Case June 2004 The Wrong Shot:...

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Spotlight Case June 2004 The Wrong Shot: Error Disclosure
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2 Source and Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Commentary by: Thomas H. Gallagher, MD, University of Washington; Wendy Levinson, MD, University of Toronto Spotlight Editor: Tracy Minichiello, MD Managing Editor: Erin Hartman, MS
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3 Objectives At the conclusion of this educational activity, participants should be able to: Describe the rationale for disclosing harmful errors to patients Appreciate the features of disclosure considered most important to patients Define the “disclosure gap” Recognize the emotional impact that errors have on health care workers List specific steps that institutions can take to enhance the disclosure of harmful errors to patients
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4 Case: The Wrong Shot A 10-year-old child from India presented to his pediatrician’s office for a school physical. The child had no past medical history; all immunizations were up to date with the exception of Hepatitis B. The physician discussed vaccination with the patient’s father and obtained consent. The nurse drew up the vaccine and the physician administered it. After administration, the physician went to record the lot number and discovered that vaccine for Hepatitis A had been given instead of Hepatitis B.
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5 Frequency of Adverse Drug Events Adverse drug events (ADE) are common in both inpatient and outpatient setting In hospitalized patients up to 6.5% of patients
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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Full_Disclosure - Spotlight Case June 2004 The Wrong Shot:...

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