Team management of errors

Dr A is the consultant in charge of a team of junior doctors including a registrar, a medical officer and a houseman. At the outset, Dr A tells the team what is required of them and the standards he expects from all his team members. In the course of managing patients, the registrar Dr C tells Dr A that medical officer B seems unsure of himself and has made a number of minor errors in documentation, ordering tests and medicines. Then one day medical officer Dr B receives blood for transfusion into a patient. He fails to cross check the identification information between the blood and the patient and gives it to the wrong patient. The patient has an acute transfusion reaction and becomes severely ill. Another time, the same Dr B injects an antibiotic into a patient without first checking the patient’s drug allergy history and the patient goes into anaphylactic shock. The second patient’s son launches a complaint against the entire team.

This case was originally designed for a November 2016 CENTRES workshop on the ECEG professional guidelines.