Compromising patient safety: Lessons learnt from some critical incidents

摘要

During my professional career as a clinician for nearly five decades, I have come across several instances where I felt that my role as a clinician has been a failure. I consider these instances as critical incidents that have molded my clinical practice and hopefully made me a better clinician. In this paper, I will discuss about few of those situations, narrating the experience that I lived through, highlighting where I think I went wrong and how best we clinicians should perform under such circumstances. I have divided the paper into lapses in history taking, lack of completeness in physical examination, premature closure in making a diagnosis and inadequacies in treatment, and each of these will be illustrated using a real-life scenario that I have lived through. As clinicians, we should strive for zero error, but we human beings are imperfect and often have room for improvement in the ways we act and react. In your clinical practice, irrespective of whether you experience critical incidents or not, it is always better to reflect how you could have treated each patient you have seen, better and make your practice more reflective rather than thinking in a stereotyped manner.