CMPA:

Patient safety
 Case: A 48-year-old woman complaining of hearing loss

• Background
A 48-year-old woman presents to her family physician complaining of bilateral hearing loss. On examination, the
physician finds cerumen blocking the external canals of both ears.
The physician recommends ear syringing and proceeds with the procedure. While pressure is applied, the syringe
suddenly breaks apart, causing a rupture of the tympanic membrane.
The physician refers the patient to an otolaryngologist who follows the patient.
The tympanic membrane perforation eventually heals with conservative treatment and there is no permanent
hearing loss.

• Lessons learned
Problems such as this can occur with any equipment that physicians use in their practice. For example, examination
tables may collapse due to poor repairs or from being too old.
Patients have been injured by faulty electrocautery equipment.
Failures in equipment, such as refrigerators for vaccines or sterilizers for surgical equipment, can also cause problems.
 Case: A physician falls asleep

• Background
A staff physician is belligerent and verbally abusive to students and colleagues. The physician sometimes falls
asleep when taking histories from patients.
A concerned colleague complains to the hospital. The Chief of the department conducts an accountability review and
the allegations are confirmed.

• Think about it
How would you handle this situation?

• Outcome
The physician is referred for a medical assessment. The diagnosis is narcolepsy.
A treatment plan is approved, and after several months the physician's health condition is satisfactory and he
returns to work.
1-That is correct
The incident (prescribing another first-generation cephalosporin for a patient with life-threatening allergy to cephalexin
(also a first-generation cephalosporin)) was caught in time and did not reach (touch or enter) the patient.
Patients should be provided information and be encouraged to become knowledgeable about their clinical conditions.
Patients can be active members of the healthcare team.

2-That is incorrect
This term refers to events or incidents that reached (touched or entered) the patient but did not result in harm.

3-That is incorrect
This is not a recognized term but the concept is valid. Patients should be encouraged to voice concerns.

4-That is incorrect
A potential-for-harm event reached or entered the patient.

5-That is incorrect
Possible loss of trust is not a formal patient safety term. However, patients who believe their concerns are not taken
seriously may lose trust in their providers, hospital, or healthcare institution. If concerns have not been explored and
addressed appropriately, subsequent problems in care may increase the risk of a complaint or legal action. Patients who
are made welcome and thanked for raising questions and concerns are more likely to be allies than adversaries.
1- That is incorrect
Physicians' fiduciary duty means they must act in good faith and with loyalty toward the patient and never place their personal interests
ahead of those of their patients.
Claims of a breach of fiduciary duty most often occur when it is alleged the physician has abused the trust within the doctor-patient
relationship by having an inappropriate sexual relationship or committing sexual misconduct.

2-That is incorrect

3-That is correct
In this case there was a claim of negligence based on the failure to meet the standard of care, including the failure to discuss the
complication with the patient.

4-That is incorrect
These claims are brought when it is alleged that the physician has breached an expressed or implied term of the agreement that arises
out of the doctor-patient relationship, usually an allegation that the physician failed to achieve the result "guaranteed." This occurs most
often in the context of cosmetic surgery.
A claim for breach of contract may also be advanced when it is alleged the physician, or someone for whom the physician is responsible in
law, has disclosed confidential information about the patient without proper authorization and in the absence of being required to report the
information by law.

5-That is incorrect
The Supreme Court of Canada has restricted such claims to those non-emergency situations where the physician has carried out surgery
or treatment on the plaintiff without consent, or has gone well beyond or departed from the procedure for which consent was given. Assault
and battery may also be committed where fraud or misrepresentation is used to obtain consent.
These claims are typically restricted to errors where the wrong operation is performed on the patient or the operation is performed on the
wrong patient.
1-That is incorrect
The law does not demand perfection. Medicine is not an exact science. Untoward results may occur even when the
highest degrees of skill and care have been applied.

2-That is incorrect
The weight given to published information depends on the testimony of peer experts as to its credibility, validity,
applicability, and degree of acceptance at the time of the care in question.

3-That is incorrect
The weight given to a clinical practice guideline depends on the testimony of peer experts as to its credibility, validity,
applicability, and degree of acceptance at the time of the care in question.

4-That is incorrect
The law recognizes that all treatment afforded a patient cannot have a successful outcome. Rather, a plaintiff (patient)
must establish on a balance of probabilities that an alleged breach of duty caused or contributed to the harm
sustained.

5-That is correct
The expert witness advises the court in what constitutes the care and skill that could reasonably be expected of a
healthcare provider with similar training and working in similar circumstances.
The expert does not act as an advocate for any party. The expert should ask whether the result could have happened
to others even when being reasonably careful. In formulating an opinion, it is a luxury to be able to review all the facts
in retrospect. Allowances must be made for hindsight bias.
CMPA :
Teams
 Case: Limited knowledge

• Background
A patient has a central venous pressure (CVP) line post-operatively. The attending surgeon asks a senior resident
to see the patient and remove the line.
A medical student in clinical clerkship goes along, and when the resident is delayed outside the room, the student
decides to help the patient move from a chair to the bed.

• Outcome
The CVP line is in the way so the clerk disconnects it.
The patient suffers an air embolism and severe stroke. Subsequently she and her family launch a lawsuit naming all
of the healthcare providers involved, including the student.

• Lessons learned
Peer experts determined:
• It was appropriate for the surgeon to delegate the removal of the central line to a senior resident.
• The resident did not delegate this care and so was not responsible for the harm done.
• The student chose to perform the act but did not have the knowledge or skill to do it safely.
• The student was therefore responsible for the harm to the patient.
 Case: An obstetrical team
• Background
A 36-year-old mother is admitted in active labour. The attending obstetrician ruptures her membranes, assesses the fetal heart
tracing as normal, and asks to be notified when the patient is ready to deliver.
The case room is very busy and the head nurse assigns a young, recently graduated nurse to monitor the patient — despite the junior
nurse's pleas that she is uncomfortable monitoring fetal heart tracings.
Immediately on arriving at the patient's bedside, the junior nurse notes the fetal heart tracing shows marked decelerations. As she has
been taught, the junior nurse turns the patient on her side and administers oxygen, however, the tracing continues to show marked
decelerations.
Two hours later the head nurse remembers to check up on the junior nurse and her patient. The supervisor immediately requests a
scalp electrode to better assess the fetal heart rate. The obstetrical resident applies the scalp electrode, diagnoses severe fetal
distress and arranges for an immediate C-section.
The crash section occurs within 20 minutes, however the child is born with a severe anoxic brain injury.
• Outcome
The child and family launch a lawsuit naming everyone on the obstetrical team, alleging that the failure to react to the abnormal tracing
lead to the delay in delivering their child and ultimately caused the brain damage.
The hospital alleges the physicians should have verified that the nurses were monitoring the fetus.
• Think about it
Should the physicians have been supervising the nurses?
Did the nursing supervisor appropriately delegate to the junior nurse?
Did the nursing supervisor adequately supervise the junior nurse?
• Lessons learned
The judge concluded the following:
 Each member of the obstetrical team had a defined role. It is essential that each person's role be carried out within a standard of
care and training appropriate to that role.
 Nurses are professionals who possess special skills and knowledge and have a duty to use their skills in making appropriate
assessments of patients and to communicate those assessments accurately to physicians.
 Limited resources preclude the ability of every provider to double-check the work of other providers.
 An obstetrician in a hospital setting is entitled to rely on staff nurses to monitor and assess a woman in labour and the fetus.
 The head nurse on an obstetrical team has the obligation to supervise other nurses on the team and to ensure that they are
competent to assess patients and to cope with the workload placed on them.
 The head nurse was made aware of the junior nurse's lack of experience.
 The head nurse failed to perform her assigning and supervisory duties in accordance with an appropriate standard of nursing
care.
 Case: New equipment for a team

• Background
An interventional radiologist has considerable experience with the balloon angioplasty technique, but is using a new
catheter for the first time to treat a patient's subclavian steal syndrome.
The new catheter is advanced in the patient's artery, however, the balloon does not readily inflate. Manipulation is
unsuccessful and the physician specifically asks the nurse if she has removed the balloon sheath. She says she has,
but the sheath has fallen on the floor, out of sight.
The patient returns to the hospital months later, with neck pain and headache. Investigations reveal the balloon sheath
lodged in the artery and it is surgically removed. The patient experiences post-operative complications and is left with a
significant scar.
• Think about it
What are some of the risks associated with working with unfamiliar equipment or in unfamiliar environments?
What are some of the barriers to effective team function?
• Lessons learned
There are a number of risks and barriers associated with this case.
I. Lack of orientation in the use of the new equipment.
In this case, the radiologist and nurse did not familiarize themselves with the new catheter.
II. Inadequate information sharing, faulty assumptions, defensiveness.
In this case, the nurse did not indicate she could not find the sheath as she assumed it had fallen under a drape
or onto the floor.
III. Complacency, failure to monitor each other's performance, lack of situational awareness.
In this case, the radiologist accepted assurances the sheath had been removed even though it could not be
found.
 Case: Psychiatric team caring for a suicidal patient

• Background
An 18-year-old student is depressed and has suicidal ideation. He is admitted to a psychiatric facility for treatment
following an examination by the psychiatrist.
The physician prescribes an anti-depressant medication and orders close observation which means the young man
will be seen every 30 minutes. A team comprising a psychologist, nurses, a social worker, and the psychiatrist will be
caring for the patient.
As is often the case, it is extremely busy on the psychiatric ward. The hospital policy states that an "intake conference,"
intended to orient all of the team members to a patient, should occur for each admitted patient, but this does not
happen.
The patient's room is at the end of the corridor, away from the nursing station, so it is difficult for nurses to observe his
behaviour.
The patient refuses to take the oral anti-depressant and generally does not communicate with the team members.
While any member of the team could increase the level of observation to "constant," and although they are all
concerned, none of the team members does so.
The patient's aunt alerts the duty nurse that the patient has told her how he could commit suicide while in the hospital.
She neither records this information in the medical record, nor alerts other members of the team.
• Outcome
The next day the teenage patient crashes through the glass window of his hospital room, runs across the parking lot
and is hit by a car.
He is left paraplegic and requires continuous care.
• Think about it
What are some of the barriers to the effective functioning of the team that might have played a role?
 Case: Psychiatric team caring for a suicidal patient
(continued)

• Legal action
The family launches a lawsuit, naming each member of the team.
The allegations include:
1- incorrect diagnosis
2- failure of the team to hold an intake conference
3- failure to increase the level of observation
4- inadequate strength of the window glass in the facility
• Legal outcome
The psychiatrist was found negligent for having misdiagnosed the severity of the patient's psychiatric condition.
Each member of the team was found negligent for failing to increase the level of observation of the patient.
Each member of the team was held accountable in the failure to hold the intake conference.
The judge was also critical about the lack of documentation in the medical record.
• Lessons learned
This case highlights several issues in healthcare:
1. workload and resource issues: lack of beds close to the nursing station, distractions among the team
2. lack of documentation
3. lack of communication of critical information between team members
4. lack of coordination of care across the team: each team member had the ability to increase the level of
observation of the patient, but no one did
5. inadequate hospital policy: while the policy stipulated an "intake conference" should occur, it did not specify who
was to arrange the conference, and this lack of clarity resulted in no one arranging the meeting
 Case: "This isn't a surgical problem"

• Background
A patient with a past history of Crohn's disease develops abdominal pain. Specialists in medicine, gastroenterology
and surgery assess him. CT scanning is initially reported to be inconclusive. The resident in surgery declares that
"this isn't a surgical problem."
The patient continues to deteriorate, but the first-year resident cannot convince the surgical service to reassess him.
The internist does not respond to the resident's pleas, and also has great difficulty getting the attention of the surgical
service.
• Outcome
Only when the resident becomes more forceful and demanding that a surgeon attend, does the surgeon arrive and it
becomes clear that this is indeed a surgical problem.
The patient subsequently has a stormy post-operative course but survives.
• Lessons learned
The assertiveness by the resident and the internist that the patient needs urgent intervention is an example of
appropriate advocacy on behalf of the patient that should be respected and trigger a suitable response.
1-That is incorrect
This was not the issue in this case. However, if there are resource constraints, healthcare providers are expected to do
the best they can for patients and to act reasonably in such circumstances.

2-That is incorrect
Although clinical situations exist that warrant ordering constant observation of specific psychiatric patients, it would not
be appropriate or possible to constantly observe every patient.

3-That is correct
Collaborative practice has many benefits for patients, but also reinforces the need for a team to communicate concerns
with each other. The method of communication should match the perceived urgency and seriousness of the clinical
situation.
It is important to take advantage of all the information available. For example, the nursing notes in the medical record
can be a valuable resource.

4-That is incorrect
Research shows suicide is difficult to predict. However, better communication by the healthcare team and the use of
suicide risk assessment tools might have made a difference in this case.

5-That is incorrect
There is a better answer. An existing policy and procedure was in place and was not the issue in this case. However
sometimes policies and procedures may require review and improvement.
1-That is incorrect
A resident will generally be held to a standard of care appropriate to the level of training received, experience, and the situation. The
courts have stated that a medical trainee must not fail to understand one's own inexperience, lack of knowledge, and lack of skill.
Residents who seek guidance and advice in a timely way can reduce medical-legal risk and liability.
The courts have also recognized the attending physician may be indirectly liable for failing to take reasonable steps to ensure that the
resident was properly supervised. In the event of litigation, the supervising physician will be held to a standard of care that could
reasonably be expected of a normal prudent physician in the circumstances.

2-That is incorrect
Given that surgery was significantly delayed in this case, the extent of the infarcted bowel was likely greater. Early intervention by the
senior resident or staff surgeon would likely have been helpful in this case.

3-That is incorrect
Residents may be named in legal actions. In some legal actions, plaintiffs (patients) have stated they did not understand who was
treating them and the roles of each member of the team. When patients feel as if no one is in charge of their care, they may become
frustrated.

4-That is incorrect
Departments usually have policies that outline the expectations for supervision by attending staff physicians. The timing of
assessment by a staff physician will depend on the perceived urgency of the clinical condition.
Some departments or individual staff physicians may establish a set of triggers to help residents know when to contact the attending
physician about clinical matters.

5-That is correct
Despite several years of training, residents may not yet have gained sufficient knowledge or experience to fully address the clinical
needs of some patients. Consequently they depend on more advanced residents and staff physicians for guidance and advice.
Staff physicians or senior residents that delay assisting a resident when contacted, or avoid direct assessment as required, run the
risk that if the clinical condition worsens or becomes critical, the patient and family may perceive that there was insufficient supervision
and the quality of care provided was poor. A court may agree.
1-That is correct
If important information is not shared poor outcomes may result. It appears in this case that the nurses were reluctant
to voice concerns about the changes in FHR with more senior members, especially after being rebuked by the
resident. This probably delayed the recognition of the fetal distress in this case. A provider is expected to act in the
best interests of the patient.

2-That is incorrect
The nurse continued to observe the patient, noting the progress and her concerns in the medical record. In this case,
these concerns were not relayed to the resident after he rebuked the nurse. This may have been a factor leading to the
poor outcome.

3-That is incorrect
Although non-specific, certain FHR rates and patterns are considered predictive of intrapartum fetal hypoxia. However,
the ongoing abnormalities were not shared among team members so these could be appropriately addressed.

4-That is incorrect
The C-section was delayed due to a failure in communication. Once the team identified the requirement for C-section,
this was arranged and accomplished quickly.

5-That is incorrect
Uterine rupture is rare and often catastrophic.
 CMPA :
Communication
 Case: Miscommunication with a mother

 Background
A two-year-old child is brought to his family physician with a fever, cough, and tachypnea. After a careful history
and a thorough physical examination, the physician orders a chest X-ray which confirms pneumonia. The physician,
who is very rushed, prescribes an antibiotic and succinctly informs the mother to follow up in 2 to 3 days .
The mother believes the physician was not listening to her concerns and does not have confidence in his
recommendations. She takes her child to see another physician the same day. The second physician
independently arrives at the same diagnosis and prescribes the same antibiotic.
The child's mother complains to the medical regulatory authority (College) that the first doctor did not listen to her
concerns and, as a result, she was forced to see a second physician.
 Outcome
The College reviewed the medical record created by the first physician and concluded the examination and treatment
were appropriate.
The College reminded the physician that his failure to communicate effectively with the child's mother left her
feeling unsure of the diagnosis and unaware of the rationale for his recommended treatment.
 Case: Impatience with a new patient

 Background
A 33-year-old male with a long history of drug abuse attends an appointment with a new physician. He indicates he
is taking Methadone prescribed by another physician. The patient speaks despairingly about previous physicians he
had consulted and indicates he wishes to stop all his medications immediately.
The physician advises him not to do this due to potential life-threatening withdrawal symptoms. She recommends that
the patient follow up with his previous doctor to determine a plan to discontinue the Methadone.
The patient complains to the College that the physician was rushed, impatient, and lacked appropriate knowledge
about addiction and treatment options.
 Outcome
The physician admitted she was impatient with the patient but also stated she had tried to develop a working
relationship to no avail.
The College dismissed the complaint but reminded the physician of the importance of patience when
communicating with patients.
Case: Cancer patient declines to sign consent form for
surgery

 Background
An overall healthy man with a history of hemorrhoids presents to his family doctor due to streaks of blood in the
stool. An investigation reveals bowel carcinoma. The patient is referred to a surgeon. Following a consent
discussion for partial bowel resection, the patient refuses to sign the consent form.
 Think about it
What should you do if a patient declines to sign a consent form?
 Suggestions
There may be several issues to deal with:
I. Concerns: Despite the explanations of the risks and benefits of the proposed treatment, does the patient
have unanswered questions about the surgery? Further explanations may help.
II. Signing a form: The refusal to sign may be related to apprehension about signing a legal form. An
explanation about the reason for the form may alleviate the patient's concerns.
III. Barriers: If a language barrier exists, a family member may be asked to translate (with the patient's
permission), or a translation service may be used. Consider whether additional supports for those with visual,
hearing, or other impairments are required.
IV. Culture: Try to be sensitive to the cultural background of your patient. Because communication styles vary
across cultures, consider seeking advice from those knowledgeable in a particular culture.
Any discussions with the patient and the patient's decision should be documented in the medical record.
 Case: A demanding and concerned mother

 Background
A woman attends the emergency department with her 18-month-old child, who has a cough. She states at the
outset that she wants a prescription for antibiotics.
The exam reveals a healthy-looking child with an occasional cough, no fever, and an otherwise completely negative
exam. The doctor explains this to the mother, and says that antibiotics are not indicated.
The mother becomes angry and insists that her child needs the antibiotics. Other modalities for treatment are
suggested, but finally the mother says she will sue the doctor and have his medical license revoked. She refuses
further examination or assessment by a colleague and storms out. The doctor writes a note in the medical record.
 Outcome
The College notifies the doctor of a complaint. The College reviews the medical record and the response from the
doctor. It concludes the doctor has given medically sound advice and has treated the patient and the mother politely.
The complaint is considered groundless and is dismissed.
 Case: Sharing health information with family

• Background
A father is scheduled to see you immediately following his 15-year-old daughter's appointment. At her visit, the
daughter requests a prescription for the birth control pill (BCP).
After taking her sexual history, counseling her about sexual health issues and explaining the risks associated with the
BCP, you write out the prescription. During the father's visit, he asks you whether his daughter is sexually
active.
• Think about it
What would you tell him?
• Outcome
The father is not within the circle of care in this case. If a patient is able to provide informed consent for treatment,
the patient should also authorize the release of her confidential health information.
An adolescent's expressed wish should be respected.
 Case: Mandatory reporting of suspected child abuse

• Background
A father brings in his four-year-old child because the child is not weight bearing following a "fall from a swing."
X-rays of both lower extremities reveal a new fracture and other healing fractures. The father denies the child has
ever been injured.
• Think about it
In addition to providing clinical care for the fracture, what is your best next step?
• Outcome
Report your suspicion that the child may be in need of protection to the child protection authorities. The purpose is
protection, not accusation. The authorities will investigate further.
 Case: Threat of harm

• Background
A patient tells you he was fired unfairly. As he talks to you, he becomes more and more agitated, finally declaring "I'm
going to make my boss wish he'd never seen me."
You ask the patient to elaborate and he tells you he's going to make a car bomb and set it off at the workplace
during working hours. He convinces you he knows how to make a bomb and bolts from the office.
• Think about it
What would you do next?
• Suggestions
This would appear to be an imminent, credible risk of serious bodily harm to a recognized group of individuals.
Canadian law permits you to take steps to warn the potential victims (e.g. the plant manager) or the police. Only
the facts relevant to the warning should be divulged. You should seek legal advice on how to proceed if you believe
time permits.
 Case: Treating multiple members in a family

• Background
A young woman is applying for insurance. She asks her family physician to complete the attending physician's
statement, as requested by the insurance company.
In the statement, the physician includes the family history of diabetes, as he knows the patient's mother
suffered from the condition.
The insurance company writes back asking for more information, specifically for the diabetic family member's
relationship to the applicant.
• Think about it
Would providing the information about this patient's mother breach the mother's confidentiality?
• Outcome
If the patient had not revealed the family history of diabetes but the physician was aware of the mother's diabetes only
because the mother was also his patient, he cannot reveal the information to the insurance company without the
mother's consent.
In this case, the family physician was free to release the information to the insurance company because the daughter
had informed him about her mother's condition and he had placed the information in the daughter's file.
• Lessons learned
A significant advantage in family medicine is that the physician is often aware of the medical histories and social
circumstances of each member of a family. However, when releasing an individual patient's health information — with
the consent of the patient — to a third party, the family physician can reveal only information obtained directly
from that patient.
 Case: A misdirected email

• Background
A 55-year-old woman with cough and dyspnea sees her family physician before travelling for business to a remote part of
Canada. The physician orders chest X-rays, and it is agreed that the results will be communicated to the patient by
email.
• Clinical events
The X-rays reveal a moderately-sized pneumothorax of the right lung and suggest the possibility of an underlying
neoplasm. The radiologist dictates an urgent report, which is flagged in the family physician's electronic medical record.
The family physician sends an email describing the X-ray findings and advising the patient to go to the emergency
department.
• Outcome
The email is mistakenly sent to the patient's ex-husband, who sees the message only the following day. He then
informs the patient of her diagnosis and the need for urgent follow-up. Fortunately, the patient is seen prior to her planned
trip and does not experience any harm as a result of the delay.
• Think about it
What are the risks of communicating with patients via email?
Is it appropriate to deliver bad news or a serious diagnosis by email?
• Lessons learned
Establish and document a plan with patients regarding electronic communication. Clarify expectations and discuss
the risks of using emails or text messages with patients, taking into consideration whether the means of
communication to be used is secure. Even if the patient's consent is obtained, the physician is still obligated to protect
the patient's privacy. Physicians should ensure that their office staff are trained on privacy requirements, and that contact
information for patients, including email addresses, is confirmed on a regular basis.
Finally, keep in mind that sensitive or urgent information may be more appropriately communicated in person or
by telephone.
 Case: Think before sharing clinical photos

• Background
A 32-year-old recreational hockey player is diagnosed with a comminuted tibial fracture. He is assessed by a
medical student doing a rotation in the emergency department. She sends a photo of the initial X-ray via text
messaging to her fellow classmates for its teaching value. She fails to notice that the patient's demographic
information is visible on the photo.
• Follow-up
The patient is seen again one week later in the orthopaedics clinic by a different medical student. He incidentally
mentions to the patient that he had already seen his impressive X-ray by text message the previous week.
• Outcome
The patient is very upset that his medical information was shared without his consent and files a complaint against
the first medical student to her school.
The medical student is required to write an essay about the importance of patient privacy and a reprimand is
officially documented in her academic record.
• Think about it
How might sharing a photo of a patient's X-ray, rash, or other clinical findings constitute a breach of confidentiality?
What strategies could the medical student have used to prevent this complaint?
• Lessons learned
Prior to sharing, consider whether the recipient of the shared information is in the circle of care. When sharing
identifiable information outside the circle of care or for purposes other than providing care, it is generally necessary to
obtain patient consent. Not doing so could result in a privacy breach with serious consequences.
When sharing using social media, be mindful that even de-identified medical stories or photos might be identifiable by
others through metadata. If you have any doubts, consider obtaining express consent from the patient.
 Case: A patient brought by the police

• Background
The police bring a man from the airport customs to an emergency department and request that you do the
appropriate examinations to determine if the man is trafficking in cocaine. The police suspect he has swallowed the
drugs in condoms. Your patient does not give consent for the examinations.
• Think about it
As the emergency physician, what is the best next step?
• Suggestions
In this case, the physician should explain the grave risks if a condom containing cocaine ruptures internally. The
patient might then consent to examination.
In these types of circumstances, physicians should be more careful than usual to assure themselves the patient is in
full agreement with what has been suggested, that there has been no coercion (for example, by exaggerating
the risks of consenting or of refusing) and that no one else has imposed their will on the patient.
 Case: A 55-year-old man scheduled for colonoscopy

• Background
A gastroenterologist meets a patient for the first time immediately before a screening colonoscopy. He describes
the list of potential risks for colonoscopy and requests the patient sign the consent form before proceeding.
• Think about it
Is the patient consenting voluntarily?
• Suggestions
Ideally the patient would be provided information about the nature and risks of an investigation as early as possible in
the process. While timing is important when engaging in a consent discussion — especially for an elective procedure
— the practical realities of providing care to all patients in an efficient way may make this difficult.
In this case, the patient has already made the decision to undergo the procedure and has completed the
required preparation. Despite this, the patient is entitled to engage in a full discussion and should not be made to feel
obliged to continue with the investigation.
 Case: A patient with skin cancer

• Background
Mr. Jones, a successful tax accountant, has been diagnosed with an invasive melanoma. His dermatologist wishes to
excise the cancer as soon as possible. Despite being informed of the risks, Mr. Jones insists on delaying the
surgery by four months so he can continue to work during his busiest time of year.
• Think about it
What is the dermatologist's next step?
• Suggestions
Even when faced with an serious operable cancerous lesion and the strong likelihood of a good surgical outcome, a
mentally capable patient may instead choose a less effective treatment than what is recommended, despite a thorough
discussion of the risks and benefits of surgery. This is the patient's right.
Mr. Jones should be told about the consequences of leaving the condition untreated. Although there should be no
coercion (i.e., unduly frightening patients who refuse treatment), the courts now recognize there is an obligation to
inform patients about the potential consequences of refusing treatment.
The dermatologist may wish to advise the patient to discuss with his family about the decision to delay the
surgery. If the patient persists in wanting to delay the surgery, consultation with a colleague for a second opinion
may be helpful.
 Case: A request from a youth
• Background
A 14-year-old girl comes to see you to ask for a prescription for birth control pills. You find her to be very mature
and sensibly wanting protection.
• Think about it
Can this youth consent to treatment or must her parents be involved?
• Outcome
Yes, this youth can consent to treatment. If, in the physician's judgment, the patient is a mature minor the physician
cannot inform the parents without the patient's consent.
 Case: A conflict with the parents of a child

• Background
Ann, who is eight years old, presents with polydipsia, polyuria, polyphagia, and weight loss over the past two months.
You diagnose Type 1 diabetes based on her blood glucose.
Ann requires insulin therapy; however her parents refuse, believing she can be managed with diet and a new
herbal remedy they have read about. What should you do?
• Think about it
What should you do?
• Suggestion
A parent or guardian is required to act in the best interests of the child. If medically necessary treatment is refused, the
doctor is obliged to report the matter to the child protection authorities
 Case: Life-threatening injury requiring immediate
treatment

• Background
While on vacation, a young woman who is hiking in the woods is attacked by a bear. She is brought to the emergency
department unconscious with extensive blood loss. No substitute decision maker is available.
• Think about it
Can you treat her to save her life without her consent?
• Lesson learned
Yes. In an emergency when the patient or substitute decision maker cannot consent the physician may proceed
if there is demonstrable severe suffering or an imminent threat to the life or health of the patient.
 Case: A patient with an inflammatory bowel disease

• Background
Joan is a 57-year-old post-menopausal woman with a known diagnosis of osteoporosis.
• Think about it
Before prescribing a course of steroids as treatment for Crohn's disease, what material and special risks might you
wish to discuss with Joan?
• Suggestions
You will want to discuss the possible common, but generally non- serious, side effects associated with corticosteroid
therapy. As well, you will want to discuss the more serious, but fortunately less common potential side effects, such as
the possibility of avascular necrosis of bone.
Given Joan already has osteoporosis, you will also want to discuss the special risks of bone loss. Be sure to answer
any questions Joan asks.
 Case: A violinist with hand symptoms

• Background
A plastic surgeon is discussing a carpal tunnel release in a 59-year-old violinist.
• Think about it
What risks should be included in the consent discussion?
• Suggestion
The surgeon will want to discuss the material risks of the procedure, as well as the special risks to a violinist.
 Case: A serious condition is discovered

Background
Ms. Smith presents to a plastic surgeon for an augmentation mammoplasty. While operating, Dr. Adam finds a
suspicious mass in the patient's left breast.
Frozen section biopsies confirm her impression of a malignancy. Dr. Adam performs a lumpectomy to save the patient
from having an additional anaesthetic.
Outcome
The patient is upset to discover she has had a lumpectomy without her consent even though the final pathology
confirmed a malignancy.
Lesson learned
Dr. Adam was proceeding in the medical best interests of her patient and the lumpectomy was clearly medically
indicated. However, the courts have repeatedly affirmed that good intentions of a physician cannot be substituted for
the will of the patient.
 Case: Trouble in follow-up of an INR

• Context
A 54-year-old male patient begins a course of anticoagulants prescribed by a consulting cardiologist. She instructs the
patient to see his family physician to manage the International Normalized Ratio (INR).
• Outcome
The patient calls the family physician for an appointment. The receptionist, who is not aware of the importance of the
follow-up, arranges an appointment in three weeks. Unfortunately the patient dies from massive cerebral bleeding prior
to being seen.
• Think about it
How might this patient's outcome have been prevented?
• Lessons learned
To facilitate continuity of care, the health professional responsible for following the patient after discharge should
receive information about any outstanding investigations or any required follow-up testing.
The discharge information should be sufficient to enable ongoing care. In particular, the information should indicate the
provider most responsible for following the patient and for arranging recommended investigations.
 Case: An older woman looking forward to seeing her
granddaughter
• Background
An 85-year-old woman with no significant medical history presents to the emergency department with a two-day
history of fever, cough, and shortness of breath. She is assessed by a medical trainee supervised by a staff physician.
The patient functions well and lives independently. On admission to the ED, her oxygen saturation on room air is a little
low. A chest X-ray shows a dense right lower lobe pneumonia. Based on the overall clinical assessment, it is
recommended that she be admitted to hospital.
She is upset by the "long wait" and adamantly refuses admission because of a much anticipated upcoming visit with
her only granddaughter. She appears fully cognizant of her disease and the risk of being discharged, but she remains
unyielding and asks to sign an "against medical advice" (AMA) form.
• Think about it
What would you do next in this situation?
• Lessons learned
A physician should make reasonable attempts to confirm that the patient understands the potential consequences
of refusing the recommended investigations or treatments. Consider the patient's mental competency. The patient
who appears to understand the nature of the disease and the consequences of accepting or refusing treatment is likely
capable.
This assessment is based on the overall clinical picture. In some situations, obtaining a consultation from another
physician may be helpful in determining the patient's mental competency.
Even if a mentally capable patient refuses treatment, the physician should explain why more observation, investigation,
treatment, and follow-up are recommended. This discussion may help alleviate the patient's concerns or fears.
It may also be helpful to ask if the patient has any other personal concerns, for example, responsibility for the care
of a spouse at home or a pet left unattended. There may be a way to resolve such issues. When possible and with the
patient's permission, it is generally useful to include family members in the discussion. Depending on the
apparent seriousness of the clinical condition and available resources, it may be helpful to ask another physician to
see the patient to reinforce the need for the recommended investigations or treatments.
The physician should advise the patient signing the AMA form of any necessary follow-up. Discharge instructions
should still be provided. The patient should be made to feel welcome to return and seek re-evaluation.
 Case: Fracture leads to paraplegia

• Background
An emergency physician identifies a compression fracture of the ninth thoracic vertebra (T9) on the X-ray of a middle-aged
patient who had fallen two weeks prior.
The patient has a known alcohol addiction, a history of ankylosing spondylitis, and cervical spine fracture. Despite the correct
diagnosis, the emergency physician fails to document his assessment or X-ray interpretation in the patient record prior
to admission.
The next day, the radiologist reports the mild loss of T9 vertebral body height, either acute or chronic, and recommends further
investigation. However, he fails to document the 2 mm shift or report the fracture as unstable. The family physician does not see
the X-ray and the report is not available for several days. He also fails to investigate the patient's back pain.
When the patient becomes confused and starts thrashing about the bed, the family physician prescribes chemical and physical
restraints for suspected alcohol withdrawal.
The following day, the nurse notes a fever, increased abdominal distension and urinary incontinence, which she documents in the
nurses' notes. However, she reports only the fever to the family physician, and the family physician does not read the nurses'
notes.
The next morning, signs of paraplegia are evident. A CT myelogram reveals a posterior process fracture of T9 with fragment shift
and large epidural hematoma resulting in cord compression. The patient undergoes spinal surgery, but he remains paraplegic.
• Think about it
What information should have been shared between team members?
• Lessons learned
The emergency physician should have advised the family physician verbally or in writing of his interpretation of the X-ray of the
T9 compression fracture.
The radiologist should have noted the 2 mm vertebral shift and reported the T9 fracture as unstable.
The family physician should have read the nurses' notes.
The nurse should have documented the patient's neurological symptoms in the patient record, and communicated all of the
patient's symptoms to the family physician, not just the fever.
 Case: A developing infection

• Background
Following an uneventful lung removal and post-operative course, the thoracic surgeon writes an order that the
patient could be discharged the following morning. The patient's temperature spikes late that evening.
The on-call general surgery resident, who is covering for thoracic surgery, orders bloodwork and a chest X-ray. As
the white blood cell count (WBC) is elevated, he documents in the patient record that he suspects an infection, but he
does not inform the thoracic surgeon.
The next morning, the thoracic surgeon and team visit the patient. The nurse reports that the patient had a fever the
previous evening, but he now appears to be fine. She does not mention the elevated WBC and the order for a chest X-
ray. The thoracic surgeon also does not personally review the patient's chart. Unaware of the on-call resident's
concerns the previous evening, the patient is discharged as planned.
• Outcome
Five days later, the patient dies of a lung infection.
• Lessons learned
There were three communication breakdowns by different members of the healthcare team.
The on-call resident did not advise the thoracic surgeon that he suspected a post-operative infection based on the
patient's elevated WBC.
The nurse reported some — but not all — of the relevant information about the patient to the thoracic surgeon.
The thoracic surgeon did not read the patient's chart before discharging the patient.
Had any of these communication breakdowns been avoided, the lung infection would likely have been diagnosed and
treated.
 Case: A new-born with tachypnea

• Background
A newborn, who was delivered at term 24 hours prior, develops tachypnea. The treating family physician consults a
pediatrician by telephone.
The pediatrician recommends starting IV gentamicin and ampicillin while awaiting blood culture results. He
recommends the gentamicin be given in divided doses 12 hours apart (q12h) for a total daily dosage of 5 mg/kg/day.
However, the family physician misunderstands the pediatrician's instructions and prescribes the total daily
dose q12h.
• Outcome
The newborn receives three doses before the dose is corrected. There are no gentamicin-related ototoxic or
nephrotoxic complications.
• Think about it
How could the family physician have avoided misinterpreting the gentamicin dosage?
• Lessons learned
If the family physician had used a simple readback approach to verify the gentamicin instructions, the pediatrician
would have noticed the mistake.
Case: Elaine Bromiley – "Can't intubate, can't ventilate"

• Background
Elaine Bromiley was a 37-year-old healthy woman with chronic sinusitis, admitted to hospital for septoplasty.
After induction, the anaesthetist could not place a laryngeal mask. Based on the reasonable assumption that this resulted from
light anaesthesia, the anaesthetist administered an additional small dose of anaesthetic. The laryngeal mask could still not be
placed, and bag and mask ventilation remained inadequate. Further muscle relaxant was given but the larynx could not be
visualized, and endotracheal intubation failed. Nevertheless three highly experienced consultants persisted in several more
attempts to secure the airway by intubation for about 20 minutes. The pO2 was at or less than 40% during much of this time.
At the outset the operating room nurses informed the consultants that surgical equipment was available. A surgical airway was
not attempted. It was decided the patient should be allowed to "wake up naturally" and she was transferred to the recovery unit.
Ms.
• Think about it
The many physicians and nurses involved in this case were all considered to be technically competent professionals. Failure to
intubate is a recognized inherent risk of anaesthesia. Guidelines for "can't intubate, can't ventilate" exist for this recognized
emergency in anaesthesia.
So what went wrong?
• Lessons learned
An investigation of Ms. Bromiley's care concluded the following:
 Loss of situational awareness - The consultants, focusing on intubation, lost sight of the overall clinical condition of the
patient.
 Leadership - An overall leader was required to facilitate communication and decision-making.
 Cognition dispositions - The team, particularly the consultants, anchored on endotracheal intubation as a solution in this
stressful situation and did not consider the guideline protocol.
 Failure to communicate assertively- Some of the nurses recognized the situation that was unfolding and made surgical
airway equipment available. The operating room culture and hierarchies interfered with the nurses' voicing their warnings.
They did not know how to speak up effectively.
 Case: A 16-year-old male with leukemia

• Background
During the last cycle of chemotherapy, the patient's oncologist is running behind schedule and asks a junior
resident to administer three chemotherapeutic agents to the patient. The pharmacy had sent all three preloaded
syringes in the same medication pouch.
The resident has had little orientation to the oncology service and asks the supervising oncologist to clarify his
instructions. Instead, he is chided for not knowing how to do this.
• Think about it
What is the best next step for this resident?
 Case: Questioning another clinician's assessment

• Background
A 27-year-old health economist and active rower presents in the emergency department complaining of sudden
headaches, weakness in his right arm and leg, slurred speech, nausea, vomiting, and mild aphasia.
A three-vessel arteriogram is ordered, and the staff interventional radiologist reads the films as normal. The radiology
resident (who has been on this rotation for only two weeks) also reviews them, and notes that the left carotid artery
looks narrower than the right. When the resident mentions her observation to the staff radiologist, he replies "that's
how the left carotid artery appears in young people." The resident feels that some further review is probably indicated,
but is not confident enough to pursue it further with a staff physician.
• Outcome
Several days later, the patient is readmitted after developing partial paralysis. A repeat arteriogram reveals a left
internal carotid artery dissection with emboli involving the middle cerebral and anterior cerebral arteries. Irreversible
brain damage has occurred.

• Think about it
How might the resident's concerns been asserted more effectively?
 Case: A question about dosage

• Background
As a resident you are speaking with the senior resident supervisor regarding an inpatient. The senior resident gives a
verbal order for warfarin which you believe is double the appropriate dose for this patient.
• Think about it
Using graded assertiveness, how might you discuss your concerns with the senior resident?
• Suggestions
Level 1: That's higher than the dose I was expecting.
Level 2: Perhaps we should check the dose?
Level 3: Is there a reason for the higher dose in this patient?
Level 4: Dr. Jones, the dose you ordered is too high for this patient.
Your choice of level would depend on the urgency of the situation and on the response to lower levels.
 Case: The Josie King story

• Background
Josie King was an 18-month-old child who climbed into a hot bath and suffered extensive body burns. She was
admitted to a pediatric ICU at Johns Hopkins Children's Center in Baltimore. She stabilized and was transferred to an
intermediate-care floor. She died there after a sequence of miscommunications.
Her mother had repeatedly voiced concerns about her daughter's steady deterioration and was repeatedly reassured
by the residents and nurses that all was well. "In my case, no one was listening to me when I tried to tell the doctors
and nurses that Josie didn't look right to me."
• Outcome
Josie acquired a catheter infection, her fluid status was not recognized and managed, and she became dehydrated.
Narcotics that had been ordered stopped were still administered. She had a cardiac arrest and could not be
resuscitated. Subsequently the Josie King Patient Safety Program was launched at the Johns Hopkins Children's
Center.
 Case: Handover failure

• Background
Mark is a 22-year-old who has a neck injury sustained in a snowboarding accident. Although he is neurologically intact,
Mark is diagnosed with a C6 fracture and a C6/C7 subluxation with 3.5 mm anterolisthesis.
• Operative course
The staff neurosurgeon performs a C6/C7 fusion, inserting pedicle screws to stabilize the spine.
He asks the resident to order a follow-up CT scan of the cervical spine on day 3 post-op.
• Post-operative
The CT scan is performed on day 3. The radiologist notes in her report that the pedicle screws are not positioned correctly
and appear to be transecting the vertebral arteries. There is no direct communication of these findings to the neurosurgical
team.
• Handover
The same day the neurosurgery resident transfers care of all his patients to the weekend on-call resident. He mentions
that Mark has had a CT scan of his cervical spine and could probably be discharged the following day. The on-call resident
assumes that his colleague has reviewed the CT scan. He discharges the patient the next day.
• Clinical outcome
Two days later Mark is rushed back to hospital after developing right-sided hemiparesis, diplopia, and ataxia. An angiogram
reveals that one of the screws had injured a vertebral artery, resulting in a stroke.
Mark is left paralyzed on the right side and can no longer walk independently.
• Think about it
How could the handover between the residents have been done differently?
How might communication between the staff neurosurgeon, the radiologist, the residents and the patient have been better?
• Lessons learned
Effective communication between healthcare providers is essential during handovers.
Providing insufficient information, lack of interactive questioning, and lack of time can contribute to ineffective handovers.
Roles and responsibilities should be clarified when handing over responsibility for a patient.
 Case: Rushed handover

• Background
Melissa, a first-year medical resident doing a rotation in cardiology, is on call for the evening. Her senior resident wants to leave for
journal club and rushes through the handover on the phone. He tells her about Mr. C, a patient with chest pain who has had blood
work, including serial cardiac markers, and a chest x-ray. He tells her that Mr. C can probably be discharged if his work-up is
normal.
• Clinical events
Eight hours later, Melissa is reviewing Mr. C's bloodwork, which is normal. She is suddenly notified about an unstable patient and
quickly discharges Mr. C so that she can take care of the patient's hypotension. She assumes that her senior resident had
reviewed Mr. C's chest x-ray, which in fact shows a new right lung mass.
• Outcome
Unfortunately, there is no follow-up of the chest x-ray finding. Mr. C presents to his family doctor 2 years later with hemoptysis, at
which time he is diagnosed with an inoperable lung cancer. He is told that he could have been effectively treated if his previous
chest x-ray had been acted upon 2 years earlier.
• Think about it
What were some of the barriers in this case that contributed to an ineffective handover?
What strategies could Melissa and the senior resident have used during the handover to prevent this adverse outcome?
• Lessons learned
Handovers are high risk situations
Allow appropriate time for a safe and complete handover of care. Limit the number of interruptions and distractions.

Interactive questioning
Face-to-face exchanges allow for interactive questioning. Be aware of hierarchies that may impede effective communication.

Standardized content
The handover should include a retrospective and prospective view of the patient, along with a recommended plan and clear
responsibilities for pending tasks.
 Case: Using SBAR
• Situation
"Mrs. White in room 231 is stable and has been admitted with a possible ectopic pregnancy."
• Background
"She is a 28-year-old gravida 1 who is 8 weeks pregnant. She presented at 2 p.m. with a 2-day history of vaginal
spotting and left-sided abdominal pain. She has gone through 2 pads today. Her vital signs are normal, and her
abdomen is soft with mild tenderness in the left lower quadrant. On pelvic exam, the os is closed, and the patient
has mild left adnexal tenderness with no mass. Her haemoglobin is 120 and her bHCG is 2032. She is Rh-
positive."
• Assessment
"She may have an ectopic pregnancy or a threatened abortion."
• Recommendation
"She will be having an ultrasound in 1 hour. You need to review the results with the radiologist and then call Dr.
Green. If the patient's pain increases or her BP drops below 100 you need to assess her and call Dr. Green right
away. You also need to be careful. Her sister is here but she doesn't want her sister to know that she is pregnant.
Resident: "Got it. I will review the ultrasound in 1 hour and call Dr. Green, unless the patient becomes unstable
while waiting. She doesn't want her sister to know she is pregnant."
Lessons learned
The use of this or other structured communication tools can help to organize and simplify intra- and inter-professional
discussion about patient care, and has the potential to improve the clarity of communications and patient safety.
Note also the effective use of readback — the receiving person repeats back important information during a handover,
which can improve everyone's understanding.
 Case: Failure to perform readback

• Background
John is a first-year paediatric resident who receives a handover from his colleague Jenna. She tells him about a young
child who has had several seizures treated with benzodiazepine. She advises him that if the child has another seizure,
he is to administer intravenous phenytoin at 15 mg/kg at a rate of 1 mg/kg/minute.
• Clinical outcome
John believes she has told him the dose is 50 mg/kg and orders this when the child has another seizure. The child
becomes phenytoin toxic after receiving more than 3 times the usual dose.
• Lessons learned
Readbacks can be helpful in preventing misunderstanding of information during handovers. A readback may be
especially useful for confirming:
1. to-do (action) items
2. medication orders and dosing
3. critical lab results
4. equipment settings
 Case: Involving the family

• Background
Mr. Greg undergoes the evacuation of a subdural hematoma. The family is present during the handover when the
team mentions that Mr. Greg would need a repeat CT scan the next day.
Unfortunately the requisition is misplaced and does not reach the diagnostic imaging department.
Two days later, the family realizes that the CT scan had not been performed, and brings this to the team's attention.
This prevents a further delay in the test being performed.
• Lessons learned
Keeping the patient or family informed of the planned investigations, treatment and follow-up plans is important for
good communication and may add an extra safety measure to limit the likelihood of some aspect of care being
overlooked.
Case: A 38-year-old man with gastrointestinal bleeding

• Background
A patient with a significant upper gastrointestinal bleed was admitted to a community hospital under the care of Dr.
A.
A peptic ulcer was suspected.
The patient's condition worsened and Dr. A transferred him to the tertiary care hospital, where Dr. B performed a
gastroscopy. Dr B made a preliminary diagnosis of a Dieulafoy-type lesion a rare condition involving bleeding from a
larger than usual artery in the gastric submucosa. The exact origin of the bleeding is often difficult to locate and treat.
Dr. B was off call for the weekend, and the care of the patient was transferred to Dr. C, a senior surgeon on-call.
However, Dr. B did not inform Dr. C of the diagnosis or the treatment plan. Dr B knew the patient needed to be
monitored closely and at the first sign of re-bleeding an immediate endoscopy needed to be performed to locate and
repair the Dieulafoy's lesion. There was no note of this written in the medical record.
Over the weekend, the patient again began vomiting blood, and his condition suddenly deteriorated. Unfortunately the
patient suffered a cardiac arrest while being re-investigated and could not be resuscitated.
The family commenced a legal action against many physicians, including the Doctors A, B, and C.
• Legal outcomes
Dr. C (on-call surgeon) was dismissed from the action prior to trial.
At the trial, the action against Dr. A was dismissed; however, the court found against Dr. B (receiving surgeon at the
tertiary centre).
The family was awarded compensation, paid by the CMPA on behalf of Dr. B.
Case: A 38-year-old man with gastrointestinal bleeding

In his decision the judge noted, given the diagnosis, the high risk to the patient and the nature of the treatment plan,
careful monitoring of the patient and appropriate intervention was likely to be required. It was therefore incumbent on
Dr. B to take all reasonable steps necessary to ensure the patient's history was communicated to Dr. C and the
treatment plan was followed.
If Dr. B had carefully explained to Dr. C in detail the history and precarious nature of the patient's condition and the
significant danger attendant upon re-bleed, it would be highly unlikely that Dr. C would not have alerted his staff to the
real nature of the patient's problem, the close monitoring that would be necessary and the urgent steps to be taken in
the event of further bleeding.
In his reasons, the judge stated that by these omissions, Dr. B had not met the reasonable standard of care of a
prudent physician. Moreover, he stated Dr. B owed the patient a duty to ensure he would be safe during Dr. B's
absence and failure to do so was not only an omission but also a failure to discharge a fundamental duty of care to his
patient.
• Lessons learned
This case highlights the importance of communication when handing over care to another physician. Consider the
following when handing over care:
Have you thoroughly explained your patient's condition (including any rare diagnosis) and anticipated treatment plan to
the physician to whom you are transferring care?
Are you satisfied the physician to whom you are transferring care has the required expertise to manage the patient's
condition?
 Case: Uninformative referral

• Background
A patient arrives at a dermatologist's office with a consultation letter. The dermatologist determines that the patient
has been treated with prescription creams and ointments (names unknown) and has had blood work (type and results,
unknown).
The patient is taking "tiny white pills" for the skin condition.
Examination reveals an erythematous ulcerated nodule on the patient's left calf. The patient also has a generalized
macular erythema which may be an allergic reaction to the medication, an id reaction to the infection, or it may be
unrelated.
• Outcome
The dermatologist's office needed to contact the family physician's office to determine the blood work results and the
nature of the previous prescriptions. Fortunately, this information was readily available.
• Think about it
How might the poor referral note have contributed to a poor outcome for the patient?
• Lessons learned
The consultant dermatologist uses the referral information to judge the urgency for the required appointment. This
request had insufficient information to be able to judge when to arrange the appointment.
Without information regarding previous investigations and treatments the consulting physician must arrange to speak
to the referring physician. Both physicians must interrupt their busy offices to transfer the information.
 Case: A 50-year-old male with headache

• Background
A school teacher, with a history of headaches and hypertension, presents with severe right-sided frontal headache.
His family physician performs a thorough physical examination and notes a "sluggish right pupil" and "possible right ptosis."
There are no physical findings.
The physician promptly refers the patient to a specialist with a note stating "headache - rule out pathology," but omits
information about the eye findings. The specialist, concerned about the possibility of an intracranial lesion, is unable to reach
the family physician by phone, however, he dictates and mails a consultation letter that same day. The patient is told to see his
doctor as soon as possible.
In the following days, the patient experiences more severe headache associated with vomiting. A leaking aneurysm of the
Circle of Willis is then identified. Following its clipping the patient dies due to diffuse cerebral vasospasm. A legal action begins,
naming all the physicians involved.
• Think about it
What might have improved the communication between the physicians?
• Outcome
The judge criticized a number of care issues in this case, including the failure of the family physician and specialist to
communicate effectively.
From the judgment: "Failing to include relevant clinical information in a referral amounts to negligence as a matter of law."
• Lessons learned
Share what you know:
relevant history and physical findings
results of relevant investigations
actions taken to date
treatments and effects
other consultations and conclusions
 Case: Lack of follow-up after colonoscopy

• Background
A family physician refers a 52-year-old male to an endoscopist for investigation of an iron deficiency anemia and occult blood in
the stools. A colonoscopy is performed. Visualization is achieved only to the level of the mid-transverse colon and the procedure is
terminated due to patient discomfort. The patient is advised to follow up with the endoscopist, but no appointment is given.
Three weeks later, the endoscopist dictates a note stating his intention to arrange a barium enema to ensure there is no bleeding
from the right side of the colon. The patient does not attend the follow-up as he had not received the appointment for the barium
enema and he believes the endoscopist wanted the test done prior to seeing him.
The endoscopist presumes the patient had opted to follow up with the family physician and makes no further enquiries.
During an unrelated visit with his family physician six weeks later, the patient mentions that no date had been set for a follow-up with
the consultant endoscopist. The doctor records the inadequacy of the colonoscopy and the recommendation for a barium enema, but
assumes ordering it would be the responsibility of the consultant.
Seven months after the colonoscopy, the patient returns to his doctor complaining of cramping abdominal pain, and is referred to a
general surgeon. A repeat colonoscopy reveals an obstructing and bleeding mass of the right colon; biopsy confirms
adenocarcinoma. The patient undergoes a right hemicolectomy for a locally invasive cancer. After a course of chemotherapy, the
patient develops a major depression requiring psychiatric care.
The patient starts a legal action alleging the seven-month delay in the diagnosis allowed the cancer to progress and metastasize to
the lymph nodes.
• Outcome
Experts were not supportive of the care given by either the family physician or the endoscopist:
Endoscopist expert: "...with the referral and subsequent follow-up to the incomplete colonoscopy, the onus of responsibility specific
to investigations, including the barium enema, was the primary and direct responsibility of the consultant."
Family physician expert: "...the family physician owed a duty of responsibility, given the time frame of the test not being done, to
ensure that this test had been requisitioned or to direct the patient to contact the consultant. Failure to pursue either option falls
below the standard of care."
Lacking expert support, a settlement was paid to the patient by the CMPA on behalf of both member physicians.
 Case: Hidden information
• Background
A patient suffering from headache is sent for a CT scan to rule out an intracranial lesion. The report's conclusion
specifically states there is no intracranial lesion.
Presence of a vague density in the right eye is mentioned in the body of the report.
The physician successfully treats the patient's migraine headaches. She later develops visual problems and the "vague
density" is found to be a retinoblastoma.
• Think about it
What might have prevented the delay in the diagnosis of the retinoblastoma?
• Lessons learned
To prevent a similar occurrence:
- The physician should read and act on the entire report.
- Potentially significant but incidental findings could be noted in the conclusions of the report.
- The physician should orally communicate critical results that require follow-up.
 Case: Action not documented

• Background
A junior resident on a gynecology rotation assists at an abdominal hysterectomy. The staff surgeon points out the
anatomical landmarks and the steps being taken to define and protect the ureters.
Following the procedure the student is told to dictate the operative report. The resident dictates a standard operative
report using a template and does not mention the care taken to identify and protect the ureters.
• Think about it
How might this approach to record keeping compromise the patient and the physicians in the future?
• Outcome
The patient developed a post-op ureteral obstruction and later sued. When experts reviewed the operative report they
found no reference to the steps taken to protect the ureters and they inferred that no such steps had been taken.
Based on the documentation, surgical peer experts had difficulty supporting the surgeon.
• Lessons learned
Even if good care has been given, incomplete documentation can give the opposite impression.
Templates may help in record keeping but should not preclude a comprehensive note specific to the individual patient.
 Case: Delay in documentation

• Background
A patient is discharged from hospital. The discharge summary is not completed before the patient is re-admitted under
the same physician. This second admission is prolonged and complicated by several intercurrent illnesses and events,
ending in death.
When the physician completes the discharge summaries for both events, laboratory findings from the second
admission are included in the summary for the first.
• Think about it
How might this discharge summary compromise the physician?
• Outcome
At a subsequent mortality review, there was an inference of delay in responding to these results, with delayed
diagnosis and treatment.
Only after detailed review of both admissions was the true sequence of events established.
• Lessons learned
Delay in documentation can result in uncertainty about what actions have already been taken, with potential negative
consequences for both patients and providers.
 Case: A lost test report

• Background
A woman booked for tubal ligation (TL) has a pre-op exam at the hospital. A PAP test is done.
A week later she is admitted and the TL is performed uneventfully. The PAP test report is not included in the chart.
The patient does not see the doctor again and when the health authority closes the hospital all records, including lab
tests, are put into storage.
• Outcome
A year later the patient is found to have cervical cancer. The original PAP test report is located. It shows severe
dysplasia. The patient dies 18 months later.
• Think about it
What system processes might prevent this from happening again?
• Lesson learned
An effective tracking system in the physician's office would have identified that the PAP test result had not been
received. This would have alerted the physician to follow up the result. He would then have contacted the patient for
further care.
 Case: An important arrhythmia

• Background
An emergency physician diagnoses a concussion on a teenager who fell and struck her head after fainting. The
paramedics note a rapid dysrythmia that resolved. The emergency physician notes a borderline abnormal QT
segment on the electrocardiogram (ECG). He forwards a copy to the pediatric cardiologist for a second opinion.
The cardiologist highlights the abnormality and documents a possible long QT syndrome on the ECG report. There
is no direct communication between the two physicians.
The cardiologist intends to send the report back to the emergency physician. However, it is inadvertently sent to an
uninvolved physician with the same surname but different initials. The patient's family physician also does not receive
the cardiologist's report.
A year later, the patient suffers a fatal Torsades de pointes arrhythmia.
• Lessons learned
This case highlights several communication failures:
i. There was no direct communication between the emergency physician and cardiologist.
ii. The cardiologist did not phone or fax the emergency physician to advise him about the potentially serious ECG
abnormality and arrange for follow up.
iii. The ECG report was inadvertently forwarded to an uninvolved physician, who did not redirect it to the appropriate
physician.
iv. When the emergency physician did not receive the ECG report, he did not follow up with the cardiologist.
v. The family physician did not receive the ECG report.
1-That is incorrect
Particular patterns of injuries should raise your suspicions about potential child abuse. Physicians in all provinces and
territories have a mandatory legal duty to report their suspicion of child abuse.

2-That is correct
Every Canadian province and territory has legislation requiring physicians to report children who may be in need of
protection, including instances of suspected child abuse, to the appropriate child welfare authorities. Failure to report
constitutes an offence.
Physicians are protected against legal action for making the required report, if the report was not made maliciously or
without reasonable cause.

3-That is incorrect
However, an evaluation by social workers may be only part of the solution.

4-That is incorrect
Such medical conditions are rare. Depending on the clinical findings, it may be necessary to rule these out.

5-That is incorrect
Physicians in all provinces and territories have a mandatory legal duty to report their suspicion of child abuse.
1-That is incorrect
The legal framework for obtaining informed consent from a patient for a given operation, procedure, or treatment was established by the
Supreme Court of Canada in the case of Reibl v. Hughes. The "reasonable physician" standard was replaced by the "reasonable patient"
standard.

2-That is correct
Consider what a reasonable patient in the patient's position would have expected to hear before consenting:
• the nature of the problem
• the proposed treatment and the chances of success
• any significant risks
• any special risks particular to the situation of the patient
• significant alternative therapies available
• the consequences of no treatment
Try to set realistic expectations for the patient and family. A meaningful dialogue helps establish trust, and this is helpful later if things do
not go as planned.
Consider the impact of an adverse clinical outcome on the patient's ability to work or to the patient's lifestyle. Remember that a
physician's general demeanor and tone influences what the patient hears and remembers.

3-That is incorrect
Generally speaking, the more frequent the risk, the greater the obligation to discuss it beforehand. In addition, even uncommon risks of
great potential seriousness should be disclosed. The Supreme Court of Canada has indicated that even if a risk is "a mere possibility" but
if it carries serious consequences such as paralysis or death, it should be regarded as material discussed with the patient.

4-That is incorrect
To make an informed decision, the significant risks of a procedure also need to be discussed. Invasive procedures (even minimally
invasive ones) may have significant risks.
5-That is incorrect
The informed consent process is more than a signature on a form. It is about building a relationship with the patient
and establishing expectations. Invite patients to participate in the decision-making process. The explanation given by
the physician — the dialogue between physician and patient about the proposed treatment — is the all important
element of the consent process.
The consent form is simply evidentiary, written confirmation that explanations were given and the patient agreed to
what was proposed.
1-That is incorrect

2-That is incorrect

3-That is correct
An emergency situation (severe suffering or an imminent threat to life or health of the patient) is an important exception
to the general rule that consent must always be obtained before treatment.
In an emergency, when the patient (or substitute decision maker) is unable to consent, a physician has the duty to do
what is immediately necessary without consent. Treatments should be limited to those necessary to prevent prolonged
suffering or to deal with the imminent threats to life, limb, or health.

4-That is incorrect
However, if the patient is unable to communicate in emergency situations, the patient's known wishes must be
respected. Therefore, before proceeding and if the clinical condition allows, the physician will want to be satisfied that
no advance directives exist or other indications that the patient does not want the proposed treatment.
As soon as the patient is able to make decisions and regains the ability to provide consent, a proper and "informed"
consent must then be obtained from the patient for additional treatment.

5-That is incorrect
In an emergency when the patient (or substitute decision maker) is unable to consent, a physician should not delay in
doing what is immediately necessary. Consultation to help deal clinically with the management of a patient may be
appropriate or prudent.
1-That is incorrect
Confirm that the wife is the SDM. The SDM has the right to participate in decisions on withholding or withdrawing life-
sustaining treatment. However, the SDM must act in compliance with any prior expressed wishes of the patient, or in
the absence of any expression of will, in accordance with the best interests of the patient.

2-That is incorrect
Obtaining advice on prognosis or help with treatment, particularly from providers that know the patient, may be
helpful in some cases.

3-That is incorrect
Physicians should act in the best interests of the patient. There is no obligation to provide treatment that is futile. In
some circumstances consensus on how to proceed may not be reached with an SDM or family, and it is necessary to
apply to a court (or an administrative body) for directions.

4-That is correct
Confirm that the wife is the SDM. Clarify with the SDM the medical condition, prognosis, and patient's wishes, and
then provide your recommendations on how to proceed.
The best interests of the patient are paramount when making end-of-life decisions.
The patient may have an advance directive (sometimes referred to as a living will), with explicit instructions relating
to consent or refusal of treatment in specified circumstances. End-of-life decisions should be documented in the
patient's medical record.

5-That is incorrect
Obtaining information and advice, particularly from those who know the patient, may be helpful in some cases.
1-That is incorrect
Obtaining information and advice, particularly from those who know the patient, may be helpful in some cases.

2-That is incorrect
A detailed explanation of the pathophysiology is likely excessive, however, some explanation of the disease using
terms the patient will comprehend is required.

3-That is incorrect

4-That is incorrect

5-That is correct
When being discharged, patients should be advised how to recognize:
• the symptoms and signs indicating complications may be developing
• the urgency of the response required
• where best to seek medical attention
1-That is incorrect
Consent to treatment may be implied or it may be specifically expressed either orally or in writing.
Consent may be implied in many circumstances either by the words or the behaviour of the patient or by the
circumstances under which treatment is given.
Expressed consent in written form should be obtained for surgical operations and invasive investigative
procedures.

2-That is correct
Material and special risks are discussed. Material risks include risks that occur frequently as well as those that are
very serious, such as death or permanent disability.
A patient's special circumstances might require discussion of potential but normally uncommon risks of the
investigation or treatment.

3- That is incorrect

4-That is incorrect
Information resources should be seen as an adjunct and not a substitute to consent discussions. For relatively
standardized treatments and investigative or therapeutic procedures, background information about what is being
proposed may be provided in the form of, for example, information sheets, brochures, or electronic resources.
These should invite questions about the treatment and indicate there will be an opportunity for further discussion
after the resource has been reviewed.
Often, consent explanations must be tailored to the particular circumstances of the individual patient.

5- That is incorrect
 1- That is incorrect
Generally, a capable minor would need to consent to the involvement of parents in healthcare decisions. If a parent is
present, and depending on the nature of the presenting complaint, it may be important to ask to speak with the minor
alone so sexual activity and other sensitive issues can be addressed.
In some situations and depending on the nature of the medical condition and the complexity of any proposed
treatment, it is often prudent to stress the importance of involving the parents, and to obtain permission to do so.

2- That is incorrect
An individual is considered to have the necessary capacity to give valid consent if the person is able to understand the
nature and anticipated effect of a proposed medical treatment and alternatives, and to understand the consequences
of refusing treatment.
In addition, in Québec the consent of the parent or guardian or the court is necessary for those under 14 years of age.

3- That is incorrect

4- That is correct

5- That is incorrect
Generally, a capable minor would need to consent to the involvement of parents in healthcare decisions. If a parent is
present, and depending on the nature of the presenting complaint, it may be important to ask to speak with the minor
alone so sexual activity and other sensitive issues can be addressed.
In some situations, and depending on the nature of the medical condition and the complexity of any proposed
treatment, it is often prudent to stress the importance of involving the parents, and to obtain permission to do so.
1- That is correct
Patients should be informed about the participation of medical trainees in their care. Some patients might refuse. This
is the patient's prerogative.
When delegating, the supervising physician must decide on the appropriate level of supervision under the
circumstances, given the training level and experience of the trainee.
Trainees should recognize their limitations and not hesitate to voice any concerns about performing a task unfamiliar to
them, or to ask the appropriate questions to clarify what is expected.

2- That is incorrect

3- That is incorrect

4- That is incorrect

5- That is incorrect
1- That is incorrect
There should be no attempt to obtain a blood sample for the police in these situations without the patient's consent or
a warrant issued by a Justice of the Peace. However, there can be clinical reasons to measure the serum ethanol
level.

2- That is incorrect

3- That is incorrect

4- That is incorrect

5- That is correct
In general, there is no legal duty to respond to inquiries made by the police. To comply with the requirements of
confidentiality, physicians should respond to police inquiries such as these by respectfully reminding police that
physicians must keep patient information confidential. There should be no attempt to obtain a blood sample for the
police in these situations without the patient's consent or a warrant issued by a Justice of the Peace. However, there
can be clinical reasons to measure the serum ethanol level.
For routine police inquiries, physicians should respectfully request the police obtain a search warrant to see the
patient's medical record.
1- That is incorrect
Important test findings and interpretations should be included in the medical record The ECG findings alone do not fully explain the
rationale for a physician's decision making but are a component of a sound decision.

2- That is correct
Costochondritis is a more common diagnosis in a younger patient who appears well. MI in this age group is very unusual. It is
difficult to justify admitting all patients with chest pain with a low probability of CAD for observation and further investigation. The
patient's initial denial of cocaine use meant clinical suspicion was lowered and the decision to discharge was reasonable.

The defense is always aided by good documentation. In this case the following helped confirm that the initial assessment was done
well:
• important historical information including any risk factors
• the overall appearance of the patient and important physical findings
• the tenderness of the chest wall and the reproduction of pain, although in retrospect these findings likely misled the physician
• as appropriate, the differential diagnosis including any serious clinical conditions that have been considered. A brief statement
in some cases on why a particular condition was not pursued or was ruled out will help explain clinical reasoning and
judgments.
• important test findings (e.g. the ECG interpretation)
• documented discharge instructions. On the initial visit, this patient was provided information on symptoms and signs specific to
chest pain that should prompt reassessment. It is helpful to state and document if the diagnosis or clinical situation is uncertain
so the patient has the proper expectations.

3- That is incorrect
The lack of a family history of CAD supports the rationale for the decision to discharge the patient. However, it is a component of the
rationale for decision making and not the best answer.

4- That is incorrect
We are not told whether the patient is distressed in this case. However, it is generally wise to consider serious or potentially life
threatening diagnoses and determine whether it is appropriate to investigate further.

5- That is incorrect
While documentation of advice given to patients is important, this is not the best answer for this case.
1- That is correct
The lung nodule was a secondary finding and not related to the main clinical reason for ordering the investigation; this is likely why it
was lost during follow-up. The patient was not made aware of the abnormality.
Canadian courts expect the ordering physicians to appropriately follow up on the results of investigative tests, unless other
arrangements are made. National clinical practice guidelines also suggest communication of critical or unexpected findings between
radiologists and ordering physicians.

2- That is incorrect
It is not practical to keep patients in hospital for further investigation if this can be accomplished safely in the ambulatory setting.

3- That is incorrect
The patient was made aware of the aspirated foreign body but not the incidental finding of the lung nodule. Although communication
of the finding and its importance would have made the necessary follow-up more likely to happen, there is a better answer for this
case.
Try again

4- That is incorrect
There is a better answer in this case. However, documentation in a consultation report, in a progress note or in a patient's problem
list of an important finding and who has agreed to follow up could potentially avoid what happened in this case.
Documentation of when and how findings have been communicated can also help identify where systems of care have broken down
so these can be fixed.
Documentation can help defend a claim of negligence (professional civil liability in Québec) to show that what was done was
appropriate and reasonable in the circumstances.

5- That is incorrect
Mandatory follow up of all discharged patients is not practical. The hospital in this case reviewed the systems and processes for the
follow-up of test reports and identified a number of failures. Several improvements were proposed, including the introduction of a
"tickler system" to prompt the notification of reminders to patients for follow up.
1- That is incorrect
A review of the patient's past medical records is helpful in most cases. The records in this case might have reinforced the
nurses' opinions of a malingering patient exhibiting drug seeking behaviour, and misled the physician.

2- That is correct
The physician kept an open mind and did not permit cognitive biases such as bandwagon effect (diagnostic momentum) or
attribution effect from deterring her from searching for other pathology.

3- That is incorrect
In this case the physical examination of the abdomen was exceptionally difficult and could not be relied upon given the
patient's distress.

4- That is incorrect
Although the radiologist interpretation of the images was an important component of the successful diagnosis, there is a
better answer for this case.

5- That is incorrect
In this case the patient's name on a list of patients with drug seeking behaviour kept in the emergency department would
have compromised the physician's objectivity. Physicians are advised to remain alert to their obligation to protect patient
confidentiality when considering the creation of lists of patients attending the emergency department for any specific
reason.
 CMPA:
Managing risks
 Case: A 58-year-old man with back pain

• Background
An obese Caucasian male, with a history of hypertension and smoking, complains of severe lower back pain that has lasted four
days.
The back pain is accompanied by occasional vomiting and radiates intermittently to both lower quadrants of the abdomen. The
increased severity of back pain had awoken him on the morning he sees his doctor.
Vital signs are normal except for a mild elevation of the systolic blood pressure. Dr. A assesses the patient at 0500 hours and
finds no significant physical abnormalities. Femoral pulses are strong and symmetrical. A flat plate X-ray of the abdomen is read
and later confirmed as normal. A complete blood count (CBC) is normal.
• Background continued
The preliminary diagnosis by Dr. A is musculoskeletal back pain. Narcotic analgesics are administered.
At shift change the patient's care is transferred to Dr. B, who reviews the patient and agrees with the previous diagnostic
impression of mechanical back pain.
Dr. B subsequently discharges the patient with a prescription for analgesics and the instruction to find a family doctor for follow-up
care.
• Outcome
Two days later, the patient is found dead at home.
An autopsy reveals a ruptured abdominal aortic aneurysm (AAA) with 3,000 cc of blood in the retroperitoneal space.
The patient's family threatens a legal action against Dr. B, alleging failure to diagnose the condition and failure to provide
adequate discharge instructions.
• Think about it
What can we learn from this case?
• Lessons learned
Leaking AAA may mimic renal colic, mechanical back pain, and diverticulitis/gastroenteritis .
In particular, AAA might be considered in the differential diagnosis of an older patient with symptoms suggestive of renal colic.
 Case: A 58-year-old man with back pain (continued)

Severe radiating pain is a common symptom. Syncope and vomiting may also be associated with AAA.
A patient with persistent symptoms may warrant a new evaluation. As appropriate, alternative diagnoses including the
"worst case" possibility should be considered.
Patients with pain require analgesia. Even if appropriate doses of narcotics control the patient's pain, it may still be
prudent to review the patient to determine if the diagnosis is being masked by the analgesia. When appropriate doses
of narcotics fail to control pain, the patient's diagnosis should be reassessed.
In appropriate clinical circumstances, the medical record should indicate that the diagnosis with the worst prognosis, in
this case AAA, was considered and was pursued if reasonable to do so.
The rationale for not investigating should also be clearly documented.
 Case: No news is good news
• Background
A 55-year-old woman has a screening mammogram as a component of her annual health exam. The radiologist
dictates the report as "lesion in left upper quadrant suspicious for malignancy, recommend needle biopsy."
The report is transcribed but not sent to the referring physician.
The patient assumes no news is good news and does not follow up.
The radiologist assumes the report has been sent to the family physician.
• Outcome
One year later the patient presents to her family physician with a palpable breast lump.
Investigation, including biopsy confirms an invasive carcinoma with lymph node involvement.
• Think about it
How might this delay in diagnosis have been prevented?
Who do you think might be accountable for the follow-up of the mammogram?
• Lessons learned
The courts have ruled that when ordering a test the physician must be satisfied there are systems in place, both
in the office and the laboratory/facility, to reasonably ensure the results of the test are received in a timely
manner. In this case, both the family physician and the diagnostic imaging centre have responsibility for following up
on the mammogram.
The more serious the implications of an abnormal result, the more promptly the result should be delivered to the
referring physician. The protocol or system must also provide for appropriate steps to be taken to report the results to
the patient and to arrange necessary follow up.
 Case: Failed follow-up of a biopsy

• Background
A family medicine resident excises and sends to pathology an irritated nevus on the thigh of a 27-year-old teacher
in the ambulatory care clinic.
No follow-up appointment is arranged as the resident is not worried about the diagnosis.
• Outcome
One year later the patient returns to the clinic because he has developed a black spot in the scar of the previous
biopsy.
The supervising physician discovers the previous biopsy report, filed at the back of the patient's medical record,
indicating a malignant melanoma and recommending a wide excision.
• Think about it
Could this happen to one of your hospital patients?
When dictating the patient's discharge summary do you confirm that all investigation reports have returned, been
reviewed and acted upon?
• Lessons learned
Lab and diagnostic imaging tests are of no value if they are not performed, reported, received, read, and acted
upon.
Is there an effective tracking system in place in your practice or facility to review diagnostic tests in a timely fashion?
 Case: Radiology department chief seeks advice

• Background
The chief of a hospital radiology lab calls the CMPA for advice regarding the handling of critically abnormal
investigations which have been ordered by walk-in clinic physicians who are not available to receive the
results, particularly outside regular office hours.
There is no mechanism in place in these walk-in clinics for urgent matters to be reported to a responsible physician.
The problem is further compounded by the fact that patient contact information is often inaccurate on requisitions.
• Think about it
What advice would you give to the chief of radiology?
Do you think urgent critical results may need to be communicated directly to the patient by the radiologist in this
circumstance?
• Suggestions
CMPA advice is based on court decisions:
While the report to patients is usually the duty of the ordering physician, the laboratory or facility may be expected
to take necessary steps to notify patients in cases of emergency when the ordering physician is not available.
Reasonable efforts should be made to contact the patients. It is recommended that the chief discuss with hospital
authorities the need for revised procedures to ensure that patient contact information is accurate.
The chief of radiology also plans to contact the clinics to discuss the issue and find a suitable solution.
 Case: Failure to follow up a patient following an MRI

• Background
A 47-year-old businessman, with a recently diagnosed large liver mass, is referred to a gastroenterologist.
Physical examination is unremarkable. The gastroenterologist informs the patient the mass is probably a
hemangioma and does not generally require any particular treatment.
Nevertheless, the physician sends the patient for an MRI and blood work, instructing the patient to return when he
has completed the tests.
• Outcome
The gastroenterologist does not contact the patient as he is certain the patient will follow up, having been
instructed to do so.
Nine months later the patient is diagnosed with pancreatic cancer and liver metastasis.
• Think about it
How might this delay in diagnosis have been prevented?
• Lessons learned
The more serious the abnormality and possible consequences on the patient's health, the more urgent it is for the
physician who is aware of the result to take action.
It may be appropriate to directly contact the ordering/referring physician if a critical or unexpected result is found.
Physicians ordering investigations have a duty to communicate the results to the patient and to make reasonable
efforts to ensure appropriate follow-up is arranged.
If applicable, provide information to the consultant from whom you sought advice.
Provide the information to the referring physician. (In this case the gastroenterologist failed to contact the patient).
As a student, notify your supervisor of abnormal test results.
 Case: An investigation for anemia

• Background
A family physician refers a 52-year-old male to an endoscopist for investigation of an iron deficiency anemia and
occult blood in the stools. A colonoscopy is performed, however, the procedure is terminated due to patient
discomfort. Visualization is achieved only to the level of the mid-transverse colon.
The patient is advised to follow up with the endoscopist, but no appointment is given.
Three weeks later, the endoscopist dictates a consultation note stating "a barium enema will need to be arranged to
rule out a lesion in the right colon."
The patient does not receive the appointment for the barium enema and does not follow up with the endoscopist. He
believes the endoscopist wanted the test done prior to seeing him.
• Think about it
How could this delay in diagnosis have been prevented?
• Outcome
Experts who were subsequently asked to comment on this case were not supportive of the care given by either the
family physician or the endoscopist:
Endoscopist expert: "...with the referral and subsequent to the incomplete colonoscopy, the onus of responsibility
specific to investigations, including the barium enema, was the primary and direct responsibility of the consultant."
Family physician expert: "...the (family physician) owed a duty of responsibility, given the time frame of the test not
being done, to ensure that this test had been requisitioned or to direct the patient to contact the consultant. Failure to
pursue either option falls below the standard of care."
The legal action was settled on behalf of both the family physician and the endoscopist.
 Case: Post-delivery care of a young woman

• Background
A young woman in her first pregnancy has initially progressed well in labour, but she is failing to progress in the second stage.
The patient has been pushing for nearly three hours when the obstetrician on call arrives. He has never met this young woman
before. As the patient is tired, he recommends delivering the baby by forceps.
Forceps delivery of the head is followed by shoulder dystocia, which the surgeon is able to successfully manage.
Inspection of the perineum and vagina reveals a fourth degree tear. The delivering obstetrician repairs this using a standard
procedure, and then transfers the patient back to her attending obstetrician for postnatal management.
Neither physician discusses the tear with the patient.
The tear does not heal well and the patient needs further surgery.
• Outcome
The new mother complained to the medical regulatory authority (College) about the on-call physician, citing the following concerns:
She would have insisted on a caesarean section if she had known the forceps could cause a recto-vaginal tear.
Postpartum care was unsatisfactory.
No one told her about the serious nature of the tear, or its possible long-term consequences.
The College had no criticism concerning the first two complaints relating to the physician's care. However, it did have concerns
about the lack of communication with the patient.
The College stated that "best practice" would have been for the doctor to make sure, before the patient was discharged,
that she was made aware of the circumstances of the tear and repair, as well as the potential complications that might
arise.
The College pointed out that "patients are entitled to be informed of all aspects of their healthcare," including a right to know about
complications that have occurred.
• Lessons learned
When a complication occurs, it is important to decide who should discuss it with the patient, and when.
Usually this is the most responsible physician, but when more than one physician is involved, good communication between the
physicians helps ensure the patient receives both good care and adequate information.
 Case: Check the nurse's notes

• Background
A young pregnant woman develops acute gallbladder symptoms. When the symptoms do not respond to conservative
measures a surgeon is consulted.
Together the surgeon and obstetrician decide to induce labour as early as possible and to follow with definitive gallbladder
surgery. However, a spontaneous delivery occurs and is managed by a nurse before the physician can arrive. The
obstetrician delivers the placenta and notes a mucosal tear, which he believes does not need to be treated.
A study the next day confirms cholelithiasis, and two days post-partum a laparoscopic cholecystectomy is carried out. The
patient tolerates that procedure well, but several weeks later complains of passing stool through the vagina.
The patient ultimately requires repair of a recto-vaginal fistula by a colorectal surgeon. She sues both physicians, alleging
failure to recognize and treat the fistula in a timely fashion.
• Outcome
The nurses' notes for the day following delivery showed the patient had complained to the nurses of passing gas through the
vagina.
The obstetrician stated it was not his habit to read nurses' notes and he did not do so on this occasion. The surgeon who
performed the cholecystectomy also stated he did not read nurses' notes.
The patient said she clearly recalled speaking to the obstetrician about her symptoms.
Experts stated that late repair is typically more complicated than an early repair, often requires revision, and causes more pain
and difficulty. Had either of the doctors read the nurses' notes, it is likely the diagnosis would have been made and the repair
would have taken place earlier. Instead the patient suffered prolonged discomfort and embarrassment before undergoing a
difficult repair.
The experts could not support the standard of care provided, and a settlement was paid on behalf of the obstetrician.
• Lessons learned
Nurses' notes often contain valuable information that can help physicians in the management of patients.
The physician who performs an assessment or procedure may be found responsible for an adverse outcome, even if care is
transferred to another physician.
Communication among members of the care team facilitates safe and effective patient care.
 Case: Post-op discharge instructions

• Background
A 62-year-old man undergoes an uneventful arthroscopy and meniscectomy of his left knee.
On discharge from the day surgery the patient receives written instructions to attend the hospital emergency
department if he has any trouble with his leg. The orthopaedic surgeon also verbally instructs the patient to call his
clinic office if he has any problems.
Three days later, the patient calls the clinic and notifies the receptionist of swelling of the knee and shortness of breath.
The receptionist reassures the patient and suggests applying ice and elevating the leg.
The next day the patient dies from a massive pulmonary embolus.
• Outcome
In the subsequent legal action, the patient's wife alleged the receptionist provided inadequate recommendations, and
the reassurances had discouraged the patient from seeking additional medical care.
The trial judge dismissed the action against the orthopaedic surgeon, but the decision was reversed on appeal.
The Appeal Court believed the surgeon had a duty to inform the patient about the risk of pulmonary embolism. The
judgment noted that an uninformed patient would not be able to establish a link between a minor procedure on the
knee and breathing difficulties.
The plaintiff was awarded compensation.
• Lessons learned
In this case, the Appeal Court stated that post-operative information given to patients is part of the physician's duty to
follow up.
 Briefing case: Patient information confirmed

• Background
An elderly nursing home resident with Alzheimer's disease falls and fractures her hip. Surgery is scheduled for later that day.
Consent for the procedure cannot be obtained as no family members are present, and the contact telephone number is incorrect.
The emergency department (ED) nurse is aware the consent has not been signed, but she does not advise the orthopaedic
surgeon.
On arrival in the operating room (OR), the nurse reviews the pre-operative checklist. She inserts a check mark in the box beside
"OR consent," even though no signed consent exists.
The surgeon does not personally verify the consent form before induction of anaesthesia.
• Outcome
Post-operatively, a family member complains that the family had not been advised of the planned procedure and no consent
for surgery had been obtained.
• Think about it
What steps should the team members have taken to confirm that consent for surgery was obtained?
• Suggestions
The ED nurse should have advised the orthopaedic surgeon that there was no signed consent.
The OR nurse should have verified that consent for surgery existed before checking off the "OR consent" box on the pre-
operative checklist.
The orthopaedic surgeon should have verified the consent for surgery when reviewing the patient's clinical documentation before
induction of anesthesia.
The OR team should have verbally confirmed the consent for surgery during the briefing phase.

• Lessons learned
Although other healthcare professionals may play a role in patient consent, the obligation to obtain informed consent generally
rests with the physician who is to carry out the treatment or investigative procedure. [REF]
In situations where the patient is not capable of giving his or her own consent, the consent discussion must take place with the
substitute decision-maker (for mentally incapacitated patients) or a parent or guardian (for minor patients). [REF]
 Briefing case: Antibiotic prophylaxis
• Background
A general surgeon performs an appendectomy on an obese, diabetic patient. No antibiotics are prescribed before
the surgery.
The patient's appendix ruptures intra-operatively.
Despite the administration of antibiotics for three days following surgery, the patient develops serious complications
including intra-abdominal abscess, sepsis, and multi-system failure.
The patient is left with permanent physical disabilities.
• Outcome
The patient initiated and won a legal action.
The court concluded that the general surgeon's failure to prescribe pre-operative antibiotics prior to removal of
an inflamed appendix breached the standard of care.
• Lessons learned
Had a surgical safety checklist been used, the OR team may have recognized during the briefing stage that
antibiotics had not been administered.
 Time-out case: Surgeon, anaesthesiologist, and nurse
verbally confirm

• Background
Prior to right ankle surgery, an orthopaedic surgeon discusses the procedure with a patient and marks the site of surgery
with a felt-tipped marker.
On the patient's arrival in the OR, the surgeon stands on the left side of the OR table. Without checking the marked site, she
places a roll under the patient's left hip.
Following the surgeon's lead, the OR nurses help apply the tourniquet and then prep the left leg with antiseptic solution. The
OR team does not verbally confirm the site of surgery.
Shortly after the skin incision on the left ankle, the anaesthesiologist advises the surgeon that she is operating on the wrong
side. The surgeon promptly sutures the incision and proceeds to perform the intended surgery on the right ankle.
When the patient wakes up, the surgeon informs the patient about what happened.
No related long-term consequences result.
• Think about it
What steps should the OR team members have taken to confirm the site of surgery before skin incision?
• Suggestions
The orthopaedic surgeon should have visually checked the marked site before positioning the patient's hip.
The nurse should have personally checked the marked site before prepping the skin.
The OR team should have verbally confirmed the site during the time-out stage.
• Lessons learned
Surgeons have a shared obligation to ensure they operate on the correct site, side, and level, and perform the intended
procedure on the correct patient.
It is helpful to review the medical record and patient before the surgery and mark the correct surgical area.
Marking the site is particularly important for procedures that involve laterality (i.e. left versus right or medical versus lateral),
multiple structures, or multiple levels (i.e. digit, skin lesion, or vertebra).
Debriefing case: Nurse reviews with team: instrument,
sponge, needle counts
Background
A gynecologist performs an emergency laparotomy when bleeding difficulties are encountered during lysis of uterine
adhesions.
Multiple sponges are placed into and removed from the abdominal cavity to control the bleeding, which stops with the application
of pressure to the bleeding site
During the sponge count, the nurse reports that one sponge is missing. The gynecologist locates and removes the missing sponge
and closes the wound.
Two days later, the patient develops a fever and abdominal distention. A CT scan reveals five sponges in the abdomen, which are
then surgically removed.
Outcome
An intra-operative abdominal X-ray prior to wound closure confirms there are no further sponges in the abdomen
Experts were of the opinion that the retained laparotomy sponges adversely affected the patient's pre-existing fertility problem.
Think about it
What else might the gynecologist have done when the nurse reported a missing sponge during the surgical count of the
emergency laparotomy?
Suggestions
Steps the gynecologist could have done include:
 perform a manual sweep of the abdomen to ensure no additional sponges remained
 consider performing an abdominal X-ray prior to wound closure, particularly due to the emergent nature of the laparotomy
 Factors that increase the risk of retention of a foreign body include:
 obesity
 emergency procedures
 unplanned changes to the procedure
 surgeries involving multiple openings or multiple stages
 poor visualization of the surgical site
Awareness of these risk factors should alert the OR team to the increased possibility of retention of a foreign body.
Lessons learned
Hospitals have policies and procedures that outline the items that need to be counted, the required documentation, and measures
to be taken in the event of a discrepancy.
 Debriefing case: Nurse reviews with team: Important
intra-operative events

• Background
A general surgeon encounters technical difficulties with an automatic EEA stapler during a low anterior resection with
primary colorectal anastomosis.
Unaware that one of the stapler parts, the anvil, had been retained in the bowel, the surgeon manually sutures the
anastomosis. The OR nurse reports the sponge and instrument counts as being correct.
The anvil later migrates, causing total disruption of the anastomosis.
• Outcome
The foreign body is subsequently removed surgically.
Subsequent colorectal anastomosis is unsuccessful, and the patient is left with two stomas.
Experts believed the anvil was a contributing factor in the disruption of the anastomosis.
• Think about it
What safety measures could the OR team have taken before the patient left the OR to to ensure the anvil was not left in
the colon?
• Suggestions
As the person who placed the anvil into the proximal colon, it was the shared responsibility of the general surgeon to
ensure it was not forgotten prior to manually suturing the anastomosis.
The OR nurse should have inspected the stapler and informed the general surgeon before the end of the procedure that
part of the instrument was missing. This safety step is particularly important as the EEA stapler has several detachable
parts.
• Lessons learned
All surgical instruments should be accounted for and inspected for completeness, particularly if the instrument breaks, is
disassembled during the procedure or has the potential to detach.
When an instrument does not functioning properly, it should be removed from use until it is repaired or replaced.
 Case: Sound-alike or look-alike medication
names
• Background
A 67-year-old patient with a history of a mood disorder, mild dementia and intermittent alcohol abuse complains of
depression and insomnia. The psychiatrist changes her antidepressant to clomipramine at bedtime.
The patient's symptoms improve, so the psychiatrist advises her to continue the same medication. After approximately
six months of treatment, the patient is hospitalized due to generalized muscular rigidity, a fine tremor, difficulty moving,
and confusion.
The psychiatrist reviews the patient's actual medications at that time and notes that the pharmacist has been
dispensing chlorpromazine instead of clomipramine. The patient's symptoms gradually improve with no long-term
effects after stopping the chlorpromazine.
• Think about it
To prevent this dispensing error, how should the psychiatrist have written out the medication prescription?
• Lessons learned
Experts commented that the prescription was illegible.
Experts suggested this adverse event (accident in Québec) might have been avoided if the psychiatrist had written
legibly and considered writing both the generic and brand names: clomipramine (Anafranil), chlorpromazine (Largactil).
The pharmacist should have considered contacting the psychiatrist for clarification.
 Case: Resident unaware of patient's anticoagulated
status at admission

• Background
An elderly long-term care facility patient on warfarin falls and sustains a large head laceration, but does not lose
consciousness. Facility staff provide a list of the patient's current medications to the paramedic who, in turn, gives the
list to the emergency department (ED) triage nurse.
Although the nurse notes in the ED medical record all of the patient's medications, including warfarin, she does not
verbally communicate this information to other ED personnel. The ED resident does not review the patient's list of
home medications, so he is unaware of the patient's anticoagulated status.
After examining the patient and suturing the laceration, the ED resident discharges the patient back to the long-term
care facility.
• Outcome
No imaging is ordered because the ED resident believes there is no clinical indication for it.
The patient subsequently dies of an undiagnosed subdural hemorrhage
• Think about it
What do you think contributed to this adverse event (accident in Québec)?
• Lessons learned
A better patient outcome might have resulted if the triage nurse had notified the ED resident and other ED personnel of
the patient's anticoagulation medication.
If the ED resident had reviewed the patient's list of home medications in the ED record, he would have noted the
patient was on warfarin and might have ordered further diagnostic investigations (e.g. International Normalized Ratio
[INR] level, head CT scan).
 Case: No leading zero or decimal point for a
medication

• Background
A resident diagnoses gastroesophageal reflux following her assessment of a six-month-old infant.
Based on the weight and length of the baby, the resident determines the correct dose of Maxeran® (metoclopramide)
is 0.2 mg PO QID before feeds. However, she fails to write a leading zero and a decimal point before the number "2"
on the prescription.
• Outcome
The pharmacist dispenses the "2 mg" dose as per the prescription. After receiving six doses of 2 mg, the infant
develops a dystonic reaction, which requires hospitalization.
• Think about it
How could the resident have prevented this prescription error?
• Suggestions
The resident should have carefully double-checked the prescription before giving it to the parent. Had he performed
this simple safety check, he probably would have realized the decimal point was missing from the intended dose.
Regular use of a leading zero may have prompted him to notice the decimal point was missing on the prescription.
• Lessons learned
Writing medication orders and prescriptions requires your full attention.
Every medication order and prescription should be legible.
When the intended dose has a decimal point, be especially careful to insert the decimal point clearly.
Use a leading zero before a decimal point for doses that are less than one, (e.g. 0.2 mg).
Never use a trailing zero by itself after a decimal point (e.g. 5 mg).
Carefully double-check that the prescription contains all of the required elements before giving it to the parent or
adolescent.
 Case: Omission of critical information on a
prescription

• Background
Following a thorough clinical assessment of a two-month-old infant, a family physician diagnoses a non-resolving upper
respiratory tract infection. He intends to prescribe amoxicillin 125 mg/5 ml strength solution, 2.5 ml, which would equate to 62.5
mg, three times per day for five days.
However, he actually prescribes 125/5 ml three times per day, which is twice the recommended dosage for the infant's weight.
After the mother leaves the office, the doctor realizes his error in dosage and notifies the mother.
The mother subsequently complains to the medical regulatory authority (College).
• Outcome
The College recommended that the physician weigh infants and children before prescribing medications to avoid medication
errors in the future.
• Think about it
Why is the weight of an infant or child so important when prescribing medications?
How could this prescription error have been prevented?
• Suggestions
Weight-based dosing is an integral part of paediatric care. To calculate the correct medication dose, the baby's current weight is
required. This is especially important with younger children due to immaturity of their organs.
The physician should have calculated the dose of amoxicillin based on the baby's weight and age.
The physician should have carefully double-checked the prescription before giving it to the mother rather than waiting until the
mother and baby left the office.
• Lessons learned
Obtain the child's weight prior to prescribing any medication.
Determine the appropriate dose of the medication based on the child's weight, age, and clinical condition.
Use mg/kg or mg/m2 as the basis for your dose calculations.
Double-check that all of the required elements are included on the prescription before giving it to the parent or adolescent.
 Case: Sedating an elderly patient

• Background
A 79-year-old man with symptomatic cholelithiasis is prescribed a narcotic analgesic intramuscularly (IM)
for pain while awaiting surgery. The patient's history includes cognitive deficits, anxiety, panic disorder and
obsessive-compulsive disorder, for which he is taking antipsychotic medications and an anxiolytic.
When the patient becomes very agitated, the physician prescribes additional antipsychotics and anxiolytics PRN.
Over the next 12 hours the patient receives excessive doses of both sedating drugs.
Despite these medications the patient remains intermittently agitated, and physical restraints are required.
The patient develops pneumonia, and suffers respiratory failure. At the request of the patient's family, no
resuscitative measures are performed.
The patient dies two days later.
• Outcome
A legal action ensued.
• Suggestions
Further investigations to identify the cause of the patient's severe agitation should have been conducted before
administering the excessive doses of medication.
Experts stated that while the patient's anxiety, aggressiveness, and dementia-like behaviour contributed to the
complexity of the situation, excessive doses of the antipsychotics and anxiolytics contributed to the patient's death.
• Lessons learned
When a patient's mental state deteriorates, it is important to investigate the possible causes of the
deterioration before prescribing chemical or mechanical restraints.
Include the maximum recommended dose as part of the medication order.
 Case: Inadequate assessment of an elderly patient

• Background
An elderly diabetic woman presented to a walk-in clinic complaining of dysuria and urinary frequency.
The woman had various medical conditions and was taking multiple medications including Diabeta (glyburide), Cozaar
(losartan), Adalat (nifedipine), and Coumadin (warfarin).
Following assessment by the clinic physician, the patient was diagnosed with cystitis and prescribed an oral quinolone
antibiotic.
The next day, the patient suffered a hypoglycemic reaction and was treated in the emergency department.
• Outcome
A medical regulatory authority (College) complaint followed.
The College concluded that the clinic physician's medical record was incomplete as it did not include the list of the patient's
multiple home medications. Any of the patient's medications could have potential drug interactions with quinolone,
hypoglycemia being one.
As well, as the patient presented with a non-complicated urinary tract infection, quinolone was not the first choice of antibiotic.
• Think about it
What should the physician have done when assessing the patient that could have prevented the hypoglycemic adverse drug
event from occurring?
• Suggestions
The physician should have reviewed the patient's co-morbidities and home medications to identify any potential drug
interactions before prescribing an antibiotic.
• Lessons learned
When prescribing a new medication to an elderly patient, it is important to consider potential drug interactions with other
medications the patient is taking.
Documenting a complete list of the patient's current medications in the medical record helps to trigger a review of potential
interactions with new medications.
 Case: Inappropriate prescription of an opioid

• Background
A 14-year old boy with infectious mononucleosis complains of difficulty swallowing due to his sore throat. The family
physician prescribes fentanyl transdermal patch at 25 mcg/hour. He also recommends hospital admission if the medication is
not effective within four hours.
The pharmacist questions the dosage, but she does not contact the family physician about her concerns as she often finds it
difficult to reach this physician. Rather, she advises the mother to monitor her son closely once the fentanyl patch is applied.
The mother checks on the boy as the pharmacist instructed until he goes to sleep.
The next morning she finds him to be unresponsive.
Resuscitative efforts are unsuccessful.
• Outcome
The coroner's report attributed the cause of death to be respiratory arrest secondary to fentanyl use.
• Think about it
What could have been done differently to prevent this adverse drug event?
• Suggestions
The family physician, especially if unfamiliar with the medication, should have confirmed the correct dosage.
It would have been helpful if the pharmacist had contacted the family physician to discuss the concerns about the dosage.
• Lessons learned
Always consider patient factors, such as co-morbidities, that may affect the dosage or necessitate closer monitoring for adverse
opiod effects. In this case, the contributing factor was the boy's enlarged tonsils which could potentially have led to obstruction
of the airway.
Provide adequate information to the patient or family members about the risks and potential adverse effects of prescribed
opioids, and the actions to take.
Respond to calls from pharmacists who seek to clarify your prescriptions.
 Case: High dose of morphine prescribed

• Background
A 65-year-old patient complains that Tylenol #3 is no longer effective for chronic osteoarthritic pain.
The family physician prescribes MS Contin (sustained-release morphine sulfate) 60 mg PO twice daily.
Seven days later, the patient develops respiratory failure.
The patient responds well to treatment.
• Outcome
Experts were of the opinion that high doses of narcotics and possibly an underlying lung disease resulting from
smoking were among multiple factors that contributed to the respiratory failure.
• Think about it
What are some of the patient factors to consider before prescribing an opioid such as MS Contin?
• Suggestions
Experts advise physicians to consider the following patient factors when prescribing an opioid:
 age
 weight
 degree of pain
 co-morbidities
 analgesic history
 whether the patient is opioid-tolerant
 whether the patient has a pre-existing pulmonary condition or a skeletal disorder that affects respiratory function
 Case: Inadequate monitoring of a patient on an
intravenous heparin infusion

• Background

Day 1
A patient who has been on life-long anticoagulant therapy for a mechanical aortic heart valve, is admitted for a cerebral
angiogram with lumbar puncture (LP) to investigate a neurodegenerative disorder.
The warfarin is stopped, and an intravenous (IV) heparin infusion is administered until six hours prior to the procedure.
Following completion of the LP, the angiogram has to be postponed due to other emergent cases.
Due to concern for a stroke, the neurologist instructs a resident ("resident A") to restart the heparin infusion without a bolus.
Later that evening the patient complains of low back pain; an oral analgesic is administered.
Day 2
The following morning the neurologist does not see the patient during rounds.
That afternoon the nurse contacts another resident ("resident B") because the patient is complaining of back and hip pain. The
resident prescribes opioids without assessing the patient.
Later that night the nurse notifies resident B that the patient is nauseated and vomiting; an antiemetic is prescribed.
Day 3
Early the next morning the patient is unable to void, and a urinary catheter is inserted. A third resident ("resident C"), who is
responsible for conducting rounds, has to respond to an emergency, so the patient is not reassessed that morning.
That afternoon, the patient becomes agitated and restless. Resident C is notified and prescribes lorazepam.
A few hours later the same resident is advised the patient cannot stand up. He sees the patient immediately and stops the
heparin infusion.
An urgent MRI reveals an anterior epidural hematoma.
The patient is also diagnosed with cauda equina syndrome and is left unable to walk.
• Outcome
Experts were of the opinion that this patient was at high risk for bleeding following the LP.
Given the patient's potential for bleeding, experts were also critical that the residents did not monitor the patient's neurological
status.
 Case: Inadequate monitoring of a patient on an
intravenous heparin infusion (continued)

• Think about it
How could this serious adverse drug event have been prevented?
• Suggestions
The residents and nursing staff could have been more aware of the patient's potential for bleeding and the importance
of monitoring her neurological status.
Had members of the medical team assessed the patient on daily rounds or when notified of the patient's ongoing
complaints, someone may have suspected the patient was developing an epidural hematoma or cauda equine
syndrome.
• Lessons learned
Sometimes it is difficult to appreciate the whole picture when multiple healthcare providers care for a patient.
Considering a patient's symptoms in isolation may not prompt the healthcare provider to consider a more serious
problem, particularly when the patient symptoms seem minor or expected post-procedure.
Patients on anticoagulant therapy with warfarin require monitoring. However, when a patient is at increased risk for
bleeding, it is important that this information is communicated to all members of the healthcare team.
If circumstances prevent patient reassessment when initially informed of a concern, try to reassess the patient within
an appropriate time frame or alert a colleague to assist you.
 Case: Failure to prescribe VTE prophylaxis

• Background
A patient is diagnosed with bilateral hallux rigidus and undergoes surgery to repair one side. Post-operatively, the
patient is treated for deep vein thrombosis (DVT) by another physician.
At a follow-up appointment the patient informs the orthopaedic surgeon of the DVT.
A year later the patient returns to the orthopaedic surgeon to have surgery on the other foot. The surgeon has no record
of the patient's previous DVT in the patient's chart.
The surgery is uneventful and the initial post-operative visit is unremarkable.
Three weeks later the patient dies from pulmonary embolus (PE), secondary to DVT.
• Outcome
Experts were of the opinion that, because the patient previously had a DVT, the orthopaedic surgeon should have
provided adequate thromboembolism prophylaxis.
The documentation in the medical record was inadequate as there was no notation of the patient's DVT following the
first surgery.
• Think about it
What should the orthopaedic surgeon have done that might have prevented the patient's death?
• Suggestions
The orthopaedic surgeon should have documented the patient's post-operative DVT in the medical record when the
patient advised him she had been treated for this complication following the first surgery.
• Lessons learned
Assess each patient for risk of VTE and prescribe adequate thromboprophylaxis if required.
Document relevant clinical information in the patient's medical record at the time of the patient encounter. In this case,
had the orthopaedic surgeon documented the patient's post-operative DVT at the follow-up appointment, it would have
prompted him to prescribe thromboprophylaxis prior to the second surgery.
1-That is incorrect
Many new medications are introduced to medical practice each year, many with great benefit to patients. A physician
should consult trustworthy pharmacology references, clinical practice guidelines, or knowledgeable colleagues for
information if uncertain about a medication's applicability, dosage, and monitoring requirements.

2-That is correct
Deferral of treatment until more information could be obtained about an unfamiliar medication might have avoided the
over-sedation in this case. For example, the pediatrician could have improved care by communicating directly with the
consultant to obtain advice.

3-That is incorrect
The pediatrician could have contacted the specialist to obtain advice regarding the [Link] consultants and
referring physicians have responsibilities in the consultative process. Referring physicians should provide sufficient
information to permit the consultant to assist in the care of the patient. Similarly, the consultant should provide timely
letters to the referring physicians. The most responsible physician for ongoing investigations and monitoring of the
patient should be clearly identified.

4-That is incorrect
While this may have played a role in this case, the pediatrician should not have ordered the increased dose of an
unfamiliar medication.

5-That is incorrect
While this may have played a role in the child's over-sedation, it is unlikely to be the primary reason for the medication
adverse event (accident in Québec).
1-That is incorrect
It is true the low incidence of TTP and its early non-specific symptomatology may contribute to diagnostic delay.
However, other factors in this case may have been more responsible for what happened.

2-That is incorrect
If symptoms or test results do not improve, the differential diagnosis can be reviewed, further tests ordered or
consultation obtained. In this case, follow-up may not have occurred for a number of reasons.

3-That is correct
This may have been the most important factor, resulting in the failure to follow up and repeat the platelet count. In this
case, the physician considered the initial somewhat low platelet count to be related to the side effect of the patient's
medication.

4-That is incorrect
Systems and protocols to support timely review of all test results are essential. The delay in following up the slightly
low initial platelet account may not have had a significant impact in this case, but may be used in legal proceedings to
cast doubt on the physician's quality of practice.

5-That is incorrect
This could also be an important factor. When patients have multiple medical conditions, the challenge is to recognize if
non-specific symptoms may be due to an unsuspected problem. The lack of compliance to her treatment for diabetes
might have created a bias in which the fatigue was attributed to her poorly controlled diabetes.
1-That is correct
This child had bacterial meningitis. She was sent home again and was very ill by the next day. Given the repeat visits and concern of the
parents, the development of a differential diagnosis would have been prudent in this case.
A differential diagnosis of meningitis is prudent with fever of unknown etiology. If a significant condition is unlikely but suspected, consider how
it should be ruled out. In some poor outcomes and in many medical-legal cases related to diagnosis, the physician did not order further testing
or consultation, despite the persistence of symptoms.

2-That is incorrect
Although educational handouts help patients recall the information discussed in the informed discharge process, this is not the best answer in
this case. Physicians may be uncertain of the diagnosis for some patients on the initial and even later visits. These patients should be made
aware of this uncertainty — what is known and not known — so that any continuation, escalation or change in symptoms would prompt re-
evaluation. An important aspect of this communication is to make the patient feel welcome to return and comfortable about seeking further re-
evaluation

3-That is incorrect
It is not helpful to suggest to parents that they are over-reacting. Experienced clinicians listen carefully to parents. This case involved multiple
visits and assessments by different physicians. This can be helpful in potentially providing different perspectives; on the other hand, continuity
of care may be lost.
In cases such as this, no one may see "the big picture." A pattern of persistent or worsening symptoms and repeated discharges from care
without a confirmed diagnosis should trigger a fresh assessment of the patient.

4-That is incorrect
Follow the clinical practice guidelines for the appropriate use of antibiotics in children with fever. In this case it is important to reassess the
patient, and reconsider the differential diagnosis before beginning antibiotics.

5-That is incorrect
Although this is a good answer it is not the best answer in this case, as it is best to develop a differential diagnosis prior to arranging further
testing or seeking additional input.
When investigating problems without a clear diagnosis, consider the worst likely condition. Document the rationale for your decisions.
1-That is correct
If a condition does not improve as expected with standard therapy, it may be helpful to reconsider and broaden the differential
diagnosis.

2-That is incorrect
Patients may prefer the convenience of telephone consultations. However, repeated telephone assessments pose risk, especially if
the patient is not improving as expected.
Consider using a "second call / third call" rule: after a second call for the same problem, consult another physician or speak directly
with the patient; after a third call for a persisting or worsening problem, see the patient in person.

3-That is incorrect
In this case, the skin diagnosis was not confirmed and the condition was not improving with standard therapies. An earlier formal
consultation might have led to a final diagnosis sooner.
Simple questions about the diagnosis and treatment of patients can often be effectively and efficiently dealt with in informal "corridor"
discussions between colleagues. More complex problems are better suited to a formal consultation with a specialist, enabling an
assessment to take place in a proper setting with sufficient time allotted.

4-That is incorrect
It is true that many conditions are difficult to diagnose initially. Depending on the clinical case, some conditions may even require a
trial of therapy, before further investigations take place, to rule out other pathology.

5-That is incorrect
When a patient's clinical condition does not improve, physicians are encouraged to directly reassess the patient, reconsider the
differential diagnosis, discuss the condition or possibilities with the patient, and possibly refer the patient to a consultant. Such
consultations may take time.
Dismissive comments that minimize a patient's complaint or that appear to blame a patient risk creating resentment and
dissatisfaction.
1-That is incorrect
The family history is important information to have. In this case the patient's mother had died of breast cancer at age 45.
The experts reviewing this case suggested an up-to-date history with risk factors and family history can determine the need for
diagnostic or screening investigations.
Some offices use questionnaires to streamline how information is captured and periodically patients complete these to make sure
data is up-to-date.

2-That is incorrect
The physician ordered routine screening rather than diagnostic mammography. This led to inadequate imaging in this case.
The diagnostic imaging request form should include the reason for the test, pertinent history, and any physical findings.

3-That is correct
If the workup concerning the patient's complaint about the breast lump had gone to completion in ruling out cancer, the cancer
might have been detected earlier with the potential for an improved clinical outcome. A legal action related to breast cancer may
be decided in favour of the patient if the workup did not go far enough to rule out breast cancer in the circumstances.

4-That is incorrect
Follow-up of previous complaints can help ensure things do not fall through the cracks. When the patient returned when she was
pregnant, the patient was not asked about any continuing breast symptoms. This might have triggered further examination or
testing.

5-That is incorrect
This patient was reassured by the physician's inability to feel a breast mass, by the physician's comments, and by the negative
mammography study.
Caution is required in reassuring patients they do not have a serious medical condition. Consider if all of the proper investigations
have been done, and encourage the patient to bring forward any ongoing concerns.
 CMPA :
Human factors
 Case: Airway challenge in a trauma patient

• Background
A 22-year-old male in a motorcycle crash suffers a severe laceration to the neck extending into his trachea.
On arrival at the hospital at 0100 hours, he is alert, oriented with vital signs HR 110, RR 20, BP 130/70, GCS 15, P02
98% on low flow oxygen.
The emergency physician pages the anesthesiologist on call, and learns that the doctor will require 20 minutes to
arrive. The patient remains alert and oriented.
The emergency physician performs a rapid sequence induction protocol (sedation and paralysis). Several attempts at
intubation with c-spine control are unsuccessful. An endotracheal tube (ETT) is placed correctly after seven minutes.
The staff moves away from the patient to allow an AP chest and c-spine film to be done. During this time, the oxygen
saturation decreases significantly, and the ETT is discovered to be dislodged from the trachea.
The patient has a cardiorespiratory arrest.
• Outcome
Although he is successfully resuscitated after several minutes, the patient suffers extensive hypoxic brain damage.
• Think about it
Did the emergency physician sufficiently appreciate the potential difficulty in airway management?
Did the team remain aware of the patient's status at all times?
Did everyone think ahead?
Did the emergency physician and this healthcare team demonstrate situational awareness?
 Case: 76-year-old woman suffers respiratory arrest

• Background
A 76-year-old woman dislocates her hip in a motor vehicle crash.
The treating orthopaedic team wishes to perform a closed reduction as quickly as possible. The orthopaedic fellow
orders sedation with IV narcotic and benzodiazepine.
The patient quickly becomes drowsy. A nurse places the patient on oxygen and an oxygen saturation monitor.
Two medical students decide to watch the reduction procedure as a resident assists the fellow. After two failed
attempts at reduction, the fellow orders a repeat dose of the medications to further relax the patient. The fellow
attempts to reduce the hip, with the resident stabilizing the pelvis.
Everyone on the team is focused on the reduction.
Several minutes later, one of the medical students looks up to the head of the stretcher and notices that the patient
has stopped breathing.
• Think about it
How might this have been avoided?
Did the team sufficiently appreciate the potential for respiratory compromise in this elderly woman?
Did the team monitor the patient's status at all times?
Did the fellow and staff perceive there was a problem with the patient's breathing?
Did everyone think ahead?
Did the fellow and healthcare team demonstrate situational awareness?
 Case: Transient neurologic symptoms treated with
angioplasty

• Background
An interventional radiologist (IVR) is treating a patient for subclavian steal syndrome.
The doctor has extensive experience with the balloon angioplasty technique, but is using a new type of catheter
for the first time. He encounters some difficulty inflating the balloon.
When asked, the nurse confirms that the protective sheath has been removed. After further manipulation the
surgeon is able to inflate the balloon.
Months later the patient has to undergo surgery to remove the sheath which had not been removed — it had come
off while in the artery and had remained there.
• Outcome
The surgery required to remove the sheath was successful.
• Lessons learned
Analysis of the reasons for this event revealed several problems:
The sheath was made of clear plastic so its presence wasn't obvious (the IVR was familiar with one that had a
coloured sheath).
The IVR and nurse had not familiarized themselves with the new catheter.
The IVR accepted assurances the sheath had been removed, even though it could not be found.
The nurse did not indicate she could not find the sheath as she assumed it had fallen under a drape or onto the
floor.
When the balloon finally inflated, the IVR did not consider the possibility that his manipulations had allowed the
sheath to come off intravascularly.
Subsequently, a new protocol for using the equipment was introduced and the need to change the sheath to
colored plastic was communicated to the manufacturer.
 Case: A problem with liposuction equipment

• Background
A woman undergoes liposuction of her lateral thighs.
Prior to starting the procedure, the plastic surgeon is aware the handle of the liposuction device has a history of
problems and has previously been returned to the manufacturer for servicing on at least four occasions.
Early in the procedure, the plastic surgeon notes that the liposuction device is not functioning properly and the handle
is becoming warm. He lies the device down with the handle on the paper drape covering the patient's left calf for
approximately five seconds.
A burn results which eventually becomes full thickness.
• Outcome
The burn ultimately heals, but the patient is left with a scar.
• Lessons learned
Since the plastic surgeon was aware that the handle of the liposuction device had a history of problems, he should
have:
 been extra careful to keep the warm handle of the device away from the patient or not have used this particular
device
 asked the surgery clinic to replace the liposuction device
 Case: Failure to attend to malfunctioning office
equipment

• Background
A 30-year-old woman is reassessed by her family physician for worsening complaints of chest congestion, cough, and
shortness of breath.
The patient's chest is clear on auscultation. Her oxygen saturation (SaO 2) is 78%, which the physician attributes to a
malfunction of the monitor rather than severe hypoxemia.
The physician prescribes antibiotics and orders a chest X-ray for a presumed diagnosis of pneumonia.
• Outcome
When the patient returns one week later for persistent symptoms, her SaO 2 is 73% and the chest X-ray report reveals
marked abnormalities.
The family physician promptly refers the patient to a respirologist who diagnoses her with lymphangiomyomatosis (a
rare pulmonary condition characterized by smooth muscle proliferation resulting in small airway and lymphatic
obstruction) and secondary bilateral chylous pleural effusions, chylous ascites, and pulmonary hypertension.
• Think about it
When the patient's SaO2 was only 78%, the family physician assumed it was due to a malfunction of the monitoring
equipment rather than severe hypoxia.
How could the family physician have determined if the SaO 2reading was correct or the result of equipment failure?
What should the family physician have done about the SaO 2 monitor and reading at this point?
 Case: Point-of-care guidance and alert not functioning
properly

• Background
An emergency department (ED) physician reads a shoulder X-ray as normal for a patient who had fallen and injured
his shoulder.
The patient is discharged home.
Three weeks later, the ED physician receives the X-ray report describing a complete subluxation of the shoulder.
The patient is notified and referred to an orthopaedic surgeon.
• Lessons learned
So what went wrong?
The hospital had an electronic system in place between the ED and the radiology department for radiological
investigations.
When a radiologist reviewed an X-ray that originated from the ED, the ED physician's X-ray interpretation could also be
viewed on the computer. If the diagnosis differed from the ED physician's, the radiologist would electronically notify the
ED physician of the discrepancy.
There was a problem with the computer system and the ED never received the radiologist's notification.
• Think about it
What systems have you worked with for follow-up of investigations?
How might this have been prevented?
Case: When no point-of-care guidance or alert is set up

• Background
Neither the general surgeon nor the operating room (OR) team reviewed the preoperative chest X-ray prior to a patient
undergoing an uneventful laparoscopic cholecystectomy.
Two years later, a chest X-ray reveals a large pulmonary mass.
A retrospective review of the preoperative chest X-ray indicates the mass was clearly present at the time of surgery.
• Outcome
The patient subsequently dies from lung adenocarcinoma.
• Think about it
Neither the surgeon nor the OR team reviewed the chest X-ray preoperatively.
The radiologist did not send a preliminary report of the chest X-ray to the surgeon.
The chest X-ray report was entered into the hospital computer system three weeks after the surgery.
There was no entry in the electronic health record to alert the physician that a report was available for review or sign
off.
 Case: Patients infected with virus

• Background
A patient with refractory headache, vomiting, blurred vision, and light headedness is referred for an EEG as part of a
neurological workup.
The EEG is performed by an employee of a clinic owned by a neurologist. There is no evidence of seizure and the final
diagnosis is migraine.
One year later, the patient is diagnosed with acute hepatitis B.
An investigation of the clinic reveals many patients contracted hepatitis B from contaminated EEG needle electrodes at
the clinic. Although a sterilization protocol was in place, it was not followed.
• Class action
The patient joined a class action suit alleging unsterilized needle electrodes used for the EEG studies caused the
hepatitis B infections.
Class action is a lawsuit brought by a group of plaintiffs with a similar interest in a particular issue in a litigation.
• Outcome
Experts were critical of the infection control processes at the clinic.
The patients that had acquired hepatitis B at the clinic were paid compensation
 Case: A 10-day-old infant undergoing circumcision

• Background
A 10-day-old infant undergoes a circumcision in his family physician's office and later develops Fournier's disease
(gangrene of the perineum).
The patient requires reconstructive surgery of the penis and scrotum.
• Outcome
Inspection of the physician's office reveals there are workplace deficiencies including lack of hand-washing and
disinfecting protocols, equipment that is difficult to clean, lack of appropriate sterilization, and irregular cleaning of the
surroundings.
In this case, the physician ceased doing procedures of any kind until the deficiencies were rectified.
 Case: Problems with a sterilization machine

• Background
A gastroenterologist learns from the hospital that there has been a problem for one month with the sterilization
machine used to decontaminate endoscopes.
The machine is difficult to use. One of the drains had not been connected properly by the technicians, although other
parts of the cleaning process were working properly. Over this time a patient with known hepatitis C was scoped.
A risk analysis by specialists in infectious disease determines the incomplete sterilization process was sufficient to
eliminate bacterial pathogens, but might not eliminate hepatitis B and C viruses.
• Outcome
The gastroenterologist takes part in a multi-patient disclosure to all of the potentially affected patients. Patients
subsequently undergo appropriately-timed testing for viruses. All test results are negative.
Several improvements are made to the sterilization equipment and process, with better training for all technicians.
Case: Failed alerts in an electronic health record (EHR)

• Background
A 37-year-old construction worker is employed in northern Canada. He develops severe radiating back pain following
heavy lifting. He is seen by a physician locum in a walk-in clinic.
The physician enters the history and physical examination, including weakness of the dorsiflexion of the right foot, into the
new electronic health record at the clinic. He makes a diagnosis of an acute herniated lumbar disc, orders a CT scan,
prescribes analgesics, and discharges the patient with arrangements for follow up.
The CT scan is done two weeks later and read the same day. The radiologist identifies a destructive process in the spine.
The report is emailed to the physician, however, it is never received.
Nine days later the patient's condition becomes much worse, he is admitted to hospital, and spinal tuberculosis is diagnosed.
The EHR had a diagnostic decision support tool; however, the audit system indicates the physician spent only 1.5 seconds
reviewing the suggested possible diagnoses. He was not familiar with its use and considered the list of possible diagnoses,
which included spinal tuberculosis, too time consuming to read.
The EHR had a tracking system for investigative reports which was not being used by the clinic as they had not been trained
on how to work with it.
The EHR also had a system for patient follow-up which the staff had not yet learned to use. The patient safety alerts had
been turned off to enable the system to run faster.
• Think about it
Why didn't the EHR prevent the delay in the diagnosis of the patient's spinal tuberculosis?
• Lessons learned
The physician and staff did not have adequate training on the EHR and were not aware of all the patient safety advantages it
could provide.
The tracking system for investigations and patient follow-up was not being used.
The decision support tool was considered too time consuming to use and was ignored.
1- That is incorrect
The physicians, nurses, and pharmacist were all highly competent professionals.
For efficient workflow, most hospitals use standardized times for routine administration of medication. This CPOE defaulted to the
closest standard time for administration of medications, but the physician did not know this. The pharmacist recognized the problem
but, in trying to rectify it, did not notice the date change. The nurses knew that antibiotics were ordered but over the shift changes did
not realize the patient was not receiving them.
Careful checking and rechecking of the medication orders might have helped.
Based on this event, the hospital made changes to the interface to the CPOE system. A clinical decision support alert now notifies the
pharmacists of inappropriate delays in the administration of medications.

2- That is incorrect
Multiple studies indicate that CPOE improves inpatient medication safety, but there can still be problems. One challenge is "alert
fatigue" in which a high number of alerts causes providers to ignore or override alerts without adequately considering if they are
clinically relevant.

3- That is incorrect
It is true the healthcare team could have communicated better. There was a failure to recognize that a patient with a life threatening
illness had not received antibiotics. This might not have occurred if the care plan had been communicated better across the team and
the antibiotic was understood to be a priority of treatment.
The overreliance on technology at the expense of direct communication can lead to false assumptions. Reliance on electronic
communication alone may not be sufficient, particularly in urgent and emergent situations.

4- That is incorrect
Although harm from medication unfortunately occurs relatively frequently there is a better answer for this case.
 5- That is correct
The delivery of safe healthcare depends in part on the vigilance of providers. Nevertheless, human fallibility means that
vigilance will periodically fail. Good systems of care anticipate such failures and incorporate safeguards.
Although CPOE systems may help improve medication safety, a significant human factors issue in this case is the
design of the user interface of the CPOE.
As is common, a "cascade" of factors in this case contributed to what happened. These included the lack of team
communication regarding the care plan and the checking of medications.
In a court of law, providers may be found liable for a patient's poor clinical outcome if it is proven they were negligent in
using the system. This highlights the importance of receiving orientation and training, making reasonable efforts to
understand how the system works, and reporting safety issues if they arise. Suppliers and healthcare organizations
may be found liable if negligence (civil liability in Québec) is proven in the design of their systems, the provision of
appropriate orientation and training, or the failure to correct recognized deficiencies.
 CMPA :
Adverse events
 Case: A middle-aged man coming into ER with chest
pain

• Background
A middle-aged male who smokes presents to the emergency department for evaluation of sudden onset of left-sided
chest discomfort. His symptoms include dyspepsia, and numbness and tingling in the left arm and leg.
Blood pressure is normal in both arms, the cardiovascular and neurological examinations are normal, and repeated
ECGs and serial cardiac markers remain negative.
After 8 hours of observation, the patient is discharged home to follow up with his family physician.
The patient continues to have intermittent chest pain, especially on inspiration.
Three days later, when examined by his family physician, the patient is febrile and a chest X-ray infiltrate suggests
left lower lobe pneumonia. He is started on antibiotics.
Three days later — 6 days after the initial hospital visit — the patient is seen by the family physician again and referred
to an internist.
The internist documents a blood pressure that is the same and is within normal limits in each arm, no cardiac murmurs
or rubs, and a normal neurological examination.
Another chest X-ray reveals a patchy consolidation in the left lung base. Laboratory work and an
ECG remains normal, apart from a mildly elevated white blood count.
The internist also diagnoses pneumonia but changes the antibiotics to cover a wider spectrum of organisms.
• Think about it
What do you think about the clinical care so far?
• Outcome
Two days later the patient collapses at home and cannot be resuscitated. A ruptured dissection of the
descending thoracic aorta is found at autopsy.
 Case: A middle-aged man coming into ER with chest
pain (continued)

The many unusual features of the case, such as:

• the pleuritic nature of the pain,
• the signs and symptoms suggesting pneumonia,
• the normal blood pressure in both arms, and
• the absence of a cardiac murmur
would understandably make aortic dissection difficult to suspect prior to any further clinical deterioration.
 Case: A child in the operating room

• Background
A toddler requires general anaesthesia in a small community hospital.
The anaesthesiologist, the operating room (OR) team, and hospital administration are all aware there is an ongoing
problem with the available capnometer which necessitates silencing the monitor alarms.
Despite this, the anaesthesiologist does not check the alarms for function or volume prior to surgery, and does not set
alarm limits appropriate to the patient's age on the other monitoring equipment (e.g. oxygen saturation,
electrocardiogram).
• Outcome
Following induction, the nasotracheal tube dislodges from the trachea.
The child develops hypoxia that goes unnoticed because the alarms are not audible.
Cardiac arrest follows, resulting in anoxic brain damage, bilateral blindness, and aphasia.
• Think about it
How could this harm be avoided?
• Suggestions
Knowing there is a problem with the capnometer:
• The hospital should fix the equipment problem.
• The anaesthesiologist should check the alarms on the other monitoring equipment (e.g. oxygen saturation,
electrocardiogram) to ensure they are functioning properly, set ageappropriate alarm limits, and set the audible alarms
at a sufficient level.
Knowing there is a problem with the capnometer:
• The anaesthesiologist should pay closer attention to the visual indicators on the monitoring equipment.
• Both the anaesthesiologist and other members of the OR team should observe the child more closely for signs of
hypoxia and cyanosis.
 Case: A 56-year-old woman with breast cancer

• Background
A breast nodule is seen on a screening mammogram and investigations prove cancer.
The radiologist reviews the patient's previous mammograms and notes micro-calcifications and architectural distortion
are present on a mammogram done two years earlier.
• Outcome
Not all breast cancers can be identified on mammograms.
Some mammograms show very subtle or even no detectable signs of malignancy, for example, a mass, micro-
calcifications, architectural distortion, or an asymmetric or developing density.
Some malignancies are completely obscured by overlying and highly dense glandular and fibrous tissue.
• Lessons learned
It is common for radiologists to compare the current mammogram with one or more prior studies.
After a diagnosis of cancer, changes in the breast architecture that reflect the development of the cancer can be more
easily identified.
Knowing where to look, one may, in hindsight, identify subtle changes in breast architecture that, at the time, were
below the threshold of detection of a competent radiologist.
This is not an indication of negligence (professional civil liability in Québec) or a measure of poor performance.
The reality is that a disease must progress to a certain point to be recognizable within the sensitivity of the diagnostic
imaging used.
Sometimes, having done your best to eliminate hindsight bias, you may believe a lesion seen on a previous study
should have been "obvious."
An obvious missed lesion is generally considered to be one that most radiologists would have recognized on the
previous study.
 Case: Patient with cancer suffers from pain

• Background
An adult patient with cancer is suffering from severe pain.
As the first-year resident caring for the patient, you inadvertently order 10 times the required dose of a narcotic
due to a misplaced decimal point and the presence of a trailing zero.
The nurse administers the dose as ordered and the patient becomes very drowsy, apneic, requires a narcotic
antagonist, and temporary respiratory support.
Fortunately the patient makes a full recovery.
• Think about it
• Would you consider this to be an adverse event (accident in Québec)?
• Should the patient be told of the reason for the clinical emergency?
• Who should disclose this to the patient?
• Should the nurse be involved in the disclosure discussion?
• What would you say if you were disclosing this to the patient?
• Would you apologize?
• Outcome
The ordering and administration of the wrong dose of the narcotic was an adverse event because the patient was
harmed by healthcare delivery (i.e. the patient required additional care and monitoring).
 Case: A 64-year-old with syncopal episode

• Background
A 64-year-old woman is admitted to hospital following a syncopal episode. She is diagnosed with heart block and
treated with a pacemaker. Prior to discharge, a chest X-ray is done to investigate her chronic cough. You perform the
discharge summary.
One year later she is diagnosed with advanced lung cancer. The chest X-ray, done during the previous admission, had
revealed a nodule in the left upper lobe of her lung. The chest X-ray report was present in the medical record at the
time you did the discharge summary but you did not see it. As a result, it was not followed up.
The thoracic surgeon believes this nodule could have been resected if it had been diagnosed at the time of the
previous admission. The patient would have had a better prognosis and would have required less invasive treatment.
• Think about it
Would you consider this to be an adverse event?
Should the patient be told of the reason for the delay in the diagnosis of the lung cancer?
Who should disclose this to the patient?
What would you say if you were disclosing this to the patient?
Would you apologize?
• Suggestions
This delay in diagnosis is an adverse event and should be disclosed to the patient.
The thoracic surgeon should notify your attending staff or the most responsible physician at the time of the patient's
previous admission.
Your attending staff should have the disclosure discussion with the patient.
You are encouraged to offer to attend the meeting(s) to learn and to provide your own apology for your part in what
happened.
 Case: Young woman with black irregular nevus

• Background
You are working as a locum in a family physician's clinic. A young woman presents with a black irregular nevus which
she says has been increasing in size over the past year. She hadn't been too concerned about it as the family
physician had reassured her it wasn't anything to worry about.
You biopsy the nevus just to be certain there is no malignancy. Unfortunately the pathology shows a malignant
melanoma arising in a compound nevus.
• Think about it
Would you consider this to be an adverse event?
What will you say if the patient asks why this nevus wasn't biopsied earlier by her family physician?
Who should discuss this with the patient?
Would you apologize?
• Lessons learned
Most often, adverse clinical outcomes result from the progression of the patient's underlying medical condition.
The clinical appearance of this patient's nevus needed to evolve to the point at which a reasonable physician would
identify the need to perform a biopsy.
• Suggestions
An honest, simple explanation of the variable progression of the pathophysiology from nevus to melanoma should be
provided and should reassure the patient.
If the patient has additional questions, she may be referred to her family physician.
It is helpful to alert the family physician of the patient's concerns and the information you have already shared with the
patient.
The discussion should be supportive of the other healthcare providers and not judgmental of the care provided.
 Potential for harm event case: A patient is exposed to
unsterilized equipment

• Background
A patient is exposed to medical equipment that has been inadequately sterilized.
The equipment has been used to treat other patients, some of whom are known to carry HIV infection.
• Suggestions
If a potential for harm from the event exists in the future, then generally this should be discussed with the patient. The
likelihood and severity of future harm should be considered.
You may wish to seek the advice of other clinical and ethical experts, and legal counsel.
You may also want to arrange for follow up, further clinical testing, and post-exposure prophylaxis treatment as
appropriate.
If the event reached the patient, typically a patient should receive knowledge of the event even if it resulted in no harm
You determine that a small risk of transfer of the virus from the equipment exists.
 No harm event case: A patient with allergy to penicillin

• Background
A patient has a known allergy to penicillin, and this fact is recorded on the medical record. Despite this, you administer
penicillin to the patient, yet there is no allergic reaction
• Suggestions
In this case, a discussion with the patient would enable the patient to understand an allergy may not exist.
It is not always easy to decide whether to make your patient aware of an event in which there is no harm. Ask yourself:
What facts would the patient want to know?
Another approach is to use the "substitution test" — would you want to know if you were the patient or if one of your
family members was the patient?
 Near miss case: A near miss that need not be
disclosed

• Background
You draw up a vial of penicillin to administer to a patient with a known allergy to penicillin.
As you approach the bedside you become aware of the potential medication problem, and do not give the drug. No
medication enters the patient.
• Suggestion
As no medication enters the patient, you need not discuss this near miss with the patient.
 Near miss case: A near miss that might be
communicated to a patient

• Background
Two patients on a ward have identical last names and you almost give a medication to the wrong patient.
The mix-up of patient names is recognized just in time and nothing is administered to the wrong patient.
• Suggestions
In this situation, it would be sensible to alert both patients to the fact that they share the same name so that the
patients themselves can be more vigilant, contributing to their own risk management.
It would also be important to make system improvements so a similar occurrence would be less likely in future.
 Case: Near miss prior to surgery

• Background
Mrs. G is scheduled for important surgery. She takes warfarin for treatment of atrial fibrillation.
It is discovered in the operating room that Mrs. G. had not stopped her warfarin as instructed.
The surgery is postponed
• Lessons learned
If this near miss had not been discovered, Mrs. G might have bled significantly during the operation, perhaps requiring
a blood transfusion and other treatment.
• Think about it
Can you think of ways to lessen the likelihood of such problems occurring for other surgical patients?
 Case: Near miss with paralyzing drug

• Background
During preparation for an operation, a vial of the neuromuscular blocking agent succinylcholine is inadvertently used
instead of sodium chloride as a reconstitution agent.
Both vials have a similar appearance.
The anesthesiologist catches the substitution before any drug is administered and reports the near miss to the hospital
• Outcome
The hospital contacted the Institute for Safe Medication Practices Canada (ISMP).
ISMP Canada subsequently distributed a safety bulletin on the potential mix-up.
The manufacturer then made significant changes in the packaging and labeling of succinylcholine.
 Case: Near miss related to wrong-sided surgery

• Background
A 60-year-old male is scheduled for surgery on his right knee.
After having checked the patient's medical record and confirming the site with the patient, the orthopaedic surgeon
uses a permanent marking pen to initial the right knee in the centre of the operative field.
The surgeon arrives in the operating room and the left knee has been prepped and draped.
• Outcome
The surgeon knows he must see the initials before making any incision or puncture. The problem is caught in time and
the correct knee is operated on.
An analysis of this near miss resulted in several improvements in safety in the operating room.
"Operate through your initials" is one of several approaches used to help prevent wrong-sided surgery: preoperatively,
the surgeon marks the initials of the surgeon's name on the site that is to be operated.
 Case: A 16-year-old male with leukemia

• Background
A 16-year-old male is diagnosed with leukemia.
During the last cycle of chemotherapy, his oncologist is running behind schedule and asks a junior resident to
administer three chemotherapeutic agents to the patient. The pharmacy sends all three drugs in the same medication
pouch. The resident has had little orientation to the oncology service and attempts to seek clarity from the supervising
oncologist without success.
All three drugs, already in preloaded syringes, are administered intrathecally. However, one of the drugs, vincristine,
should be given intravenously.
The healthcare providers involved promptly provide the parents with information about the clinical condition of their
son, giving them an initial understanding of the facts about what has happened, as well as emotional support.
• Outcome
Despite all rescue efforts, the young patient dies 3 days later. The coroner (medical examiner) is immediately notified.
• Think about it
Could a similar medication adverse event occur in your hospital? What would be the response of your leaders?
 Case: A 45-year-old male with asthma

• Background
A 45-year-old male, being followed for difficult-to-control asthma, presents with cough and fever to his respirologist in a
hospital outpatient clinic. The clinical findings are sufficient to warrant a chest X-ray.
Antibiotics are prescribed for presumptive early pneumonia. The patient is discharged with instructions on symptoms to
watch for that would prompt him to seek further medical care. As for the X-ray, the patient is told that "no news is good
news," but if the report is positive then the patient would be telephoned.
The encounter is well documented in the medical record.
Months later, the patient returns because of worsening symptoms. At that visit, the report of the chest X-ray is
discovered in the medical record. An important finding suspicious for lung cancer has not been followed up.
• Think about it
What type of review should be undertaken to decrease the likelihood that a similar problem would occur to other
patients?
• Outcome
In this case, a quality improvement review is the preferred type of review. Given what is known, an accountability
review that would focus on the respirologist or other providers would not be appropriate.
The event is used as an opportunity to examine the existing administrative systems of several hospital departments
and how they follow up on test and diagnostic imaging reports.
The QI review identifies several potential failure points waiting to trap other patients and their providers.
The vulnerabilities are corrected.
 Case: Child with abdominal pain

• Background
A resident on her emergency medicine rotation assesses a young girl complaining of abdominal pain. After the initial
history and physical examination, she believes the young girl looks well, has no signs for concern on physical
examination and is likely suffering from constipation.
She discusses the patient with the emergency physician, who asks pertinent questions.
Knowing the resident's clinical skills and level of training, he believes she has assessed and diagnosed the patient
properly. He does not personally examine the patient, telling the resident to discharge her home.
• Outcome
The patient was readmitted the following morning with peritonitis from a ruptured appendix.
• Think about it
Is this a likely scenario in a busy emergency department?
How would you feel if you were the resident in this situation?
1-That is incorrect
Situational awareness refers to a person's perception and understanding of the dynamic information that is present in
their environment. It is keeping track of what is going on around you, and includes anticipating what might need to be
done.
Try again

2-That is incorrect
Hindsight bias refers to the situation in which knowing an undesirable outcome has occurred increases the belief that it
was predictable, should have been foreseen, and was therefore preventable.

3-That is incorrect
Authority bias is a cognitive predisposition that refers to declining to disagree with an "expert."

4-That is correct
Learned intuition refers to the phenomenon when a person having learned a complex process later considers it
intuitive despite the number of steps involved. The person does not easily recall the difficulty experienced when first
trying to learn the process. When someone else new to the process has difficulty with it and makes a mistake, others
can be critical of the individual when, in fact, the problem may stem from poor orientation or training.

5-That is incorrect
Heuristics are mental shortcuts. Availability heuristic refers to the overemphasis of recent or vivid patient diagnoses
when assessing the probability of a current diagnosis.
1-That is incorrect
Although harm most frequently results from the continuation of the patient's underlying disease process, in this case
the harm resulted from the inherent risk of the chemotherapeutic agent. A recognized complication such as this can be
reduced through medical research to develop better agents with fewer side effects.

2-That is incorrect
The infection in this case resulted from an inherent risk of an investigation or treatment: An expression of sympathy
and concern should be offered, such as "I am sorry you had this side effect." An apology with acceptance of
responsibility should not be provided.

3-That is correct
Certain complications or side effects may occur and are independent of who is providing the care. It is appropriate to
discuss this with the patient with an expression of sympathy such as "I am sorry you had this side effect."

4-That is incorrect
Even when the harm is determined to have resulted from a recognized risk inherent in the investigation or treatment
and an informed consent discussion preceded the event, most patients do not expect that the complication would
actually happen. A discussion is helpful.

5-That is incorrect]
Patients expect to be told about events in their healthcare delivery. The infection in this case resulted from an inherent
risk of the treatment: An expression of sympathy and concern should be offered, such as "I am sorry you had this side
effect."
1-That is correct
All Colleges in Canada expect that harm from heathcare delivery — whether it is from an inherent risk of an
investigation or treatment, or from problems in patient safety — would be discussed with patients.
The College in this case supported the care provided, but also made it clear the patient should have been made aware
prior to her discharge of the circumstances of the tear and repair, as well as any other potential complications that
might arise. It pointed out "patients are entitled to be informed of all aspects of their healthcare, including a right to
know about complications that have occurred."

2-That is incorrect
When a complication occurs, it is important to decide who should discuss it with the patient, and when. In medical care,
it will usually initially be the most responsible physician, but when more than one physician is involved, good
communication between or among the physicians will help ensure the patient receives both good care and adequate
information.

3-That is incorrect
It is generally better if the initial disclosure discussion occurs at the earliest practical time. Although not all the facts
related to the event will be available, the initial discourse is best done within 1 to 2 days after the event is recognized,
or when it is most appropriate for the patient and family. Subsequent disclosure meetings will provide further facts.

4-That is incorrect
Events that result in harm should be discussed.

5-That is incorrect

Generally disclosure is a clinical issue and only providers and their leadership are involved .
1-That is incorrect
Even though a small incision is used, laparoscopic surgery is a significant operation. An informed consent discussion
should not leave the patient with the impression that it is a minor procedure without the possibility of significant
complications.

2-That is correct
Empathy in medicine can be defined as "appreciation of the patient's emotions and expression of that awareness to
the patient." 1 Being empathic is an important quality of physicians.
Even with the best of medical care, a patient's outcome may not be what was originally desired or anticipated, and in
some cases may be entirely unanticipated. Patients expect to be informed about harm they have experienced,
whatever the reason for it, and this information needs to be delivered in a caring and empathic manner.

3-That is incorrect
The patient and family were upset because they felt the risks of surgery were not well explained, and the surgeon
seemed unwilling to explain what had happened when the complication did occur. The surgeon seemed uncaring.
Although this is a good answer, there is a better answer for this case.
Effective communication with patients and the healthcare team can improve patient outcomes and satisfaction.
Conversely, failures in communication may lead to patient harm, misunderstandings, complaints, and lawsuits.

4-That is incorrect
Good physicians recognize their limitations and do not hesitate to ask for help from colleagues. Good teams practice
drills together, so in a crisis they function better.

5-That is incorrect
Complications occur even in the best of hands.
The use of a surgical safety checklist can help teams anticipate the possible complications and have the right
equipment ready.
1-That is correct
An honest discussion with a patient about the occurrence of a recognized complication or an error may reinforce trust
and prevent allegations of a cover-up. Patients need to know such information to guide their decisions on further care

2-That is incorrect
The resident had difficulty with the saw vibrations and the surgeon did not take over. Staff surgeons and residents
need to recognize when the risk of patient harm outweighs the benefit for the resident of an opportunity to gain hands-
on experience.
When delegating, the supervising physician must decide on the appropriate level of supervision under the
circumstances, given the training level and experience of the trainee. Trainees should recognize their limitations and
not hesitate to voice any concerns about taking on a task unfamiliar to them, or to ask the appropriate questions to
clarify what is expected.

3-That is incorrect
The operative note in this case did not reflect the excessive bone removal or the poor fit of the implant. Later, the
patient interpreted this as a cover-up.

4-That is incorrect
The smaller-than-required implant meant the knee joint could dislocate more easily. The appropriate size might have
been better predicted and made available in the operating room that day.

5-That is incorrect
A patient's special circumstances might require discussion of potential but normally uncommon risks of the
investigation or treatment.
Patients should be informed about the participation of medical trainees in their care. Some patients might refuse. This
is the patient's prerogative.
1-That is incorrect
This event is a "near miss," as no harm to the patient resulted. As a general approach, a near miss need not be disclosed to a patient,
although there are certain exceptions.
A patient should receive knowledge of a near miss if there still is an ongoing similar safety risk for that patient, or if the patient is aware of
the near miss.

2-That is incorrect
A near miss is an event with the potential for harm that did not result in harm because it did not reach the patient, owing to timely
intervention or good fortune. It is sometimes called a close call

3-That is correct
A patient should receive knowledge of a near miss if there still is an ongoing similar safety risk for that patient, or if the patient is aware of
the near miss and an explanation will allay concern and promote trust. In this case, the patient should be made aware that another patient
with the same name is on the same ward. This will allow the patient to be alert to this risk. Staff should be alerted so safeguards can be
put in place. This case also reinforces the need for always checking that you have the correct patient.

4-That is incorrect
This event is a "near miss," as no harm to the patient resulted. In fact, near misses are important opportunities to recognize weaknesses
and put system safeguards in place to prevent actual harm events from occurring in the future.
Many hospitals have near miss reporting systems. Offices and clinics should encourage staff to report near misses.
The legal obligation to report near misses varies across provinces.
In Québec, the law requires the completion of an incident report for near misses in government-run institutions such as hospitals. The
report is kept on the patient's medical record. In such a situation, it is prudent to alert your patient to the incident, the report, and any
subsequent preventive measures put in place. This will lessen the likelihood of any misunderstanding and mistrust in the future.

5-That is incorrect
This event is a "near miss," as no harm to the patient resulted. In this case, the inaccurate identification band poses an ongoing risk to the
patient and the inaccurate information should be corrected as soon as possible. In addition, the patient is likely aware of the event and
would be reassured by learning of the corrections.
Trainees should report adverse events (accidents in Québec) (or if using WHO ICPS terminology, "patient safety incidents"), potential-for-
harm, no-harm events, and near misses to their supervising staff physician.
In near miss events, the supervising physician can decide who should speak with the patient, depending on the nature of what has
happened.
Following an adverse event, however, the supervising physician should lead the disclosure discussions. Trainees should be encouraged
to take part in such discussions as a learning experience.
 CMPA :
Professionalism
 Case: Taking advantage of a false assumption

• Background
A third-year medical student is introduced by her supervisor as Dr. A to a patient in the emergency department.
The supervisor does not explain either Dr. A's status as a medical student or her role in the patient's care.
Having determined that the patient requires sutures to close a laceration on her forearm, the supervisor
asks the patient if she would mind if Dr. A performed the procedure. The patient seems indifferent as to who does
the procedure, stating that "one doctor is as good as the next."
The medical student realizes the patient believes she is an emergency physician. This makes the student feel
uncomfortable. However, knowing the suturing experience will help her in her surgery rotation and not wanting to
discourage the supervisor from providing additional learning opportunities, she does not correct the patient's
assumption.
• Think about it
Although hands-on learning opportunities are important, is it appropriate to mislead patients about your
educational status?
How does the failure to correct a patient's assumption about a student's status threaten both the patient's safety
and trust in the healthcare system?
How might the pressure to perform lead a medical student to consider compromising ethical values?
• Suggestions
Informing patients of a medical trainee's status is integral to both patient safety and respect for the patient.
Medical students and residents should introduce themselves and identify their educational status to patients.
The patient may refuse to be assessed or treated by a trainee for all or part of their care. Reasonable attempts
should be made to meet a patient's needs in these circumstances
 Case: Too rushed to think

• Background
A clerk on a surgery rotation is asked by the surgeon to discharge a patient. The surgeon informs the clerk that if he
completes the discharge in time, he will have the opportunity to assist with the next surgery, an appendectomy.
Having never had the opportunity to assist with a surgery before, the clerk is eager to participate and rushes through
the patient discharge instructions.
Despite being given clear instructions from the surgeon, the clerk, in his excitement and rush, fails to inform the
patient about appropriate follow-up, including signs and symptoms indicating a need for further medical care.
• Think about it
Are the clerk's actions unprofessional in this situation?
What other factors might be causing the clerk to act in this way?
What effect could the clerk's omission have on the discharged patient's clinical outcome?
What can the clerk or supervisor (surgeon) do in this situation to prevent patient care from being compromised?
• Lessons learned
Every patient deserves appropriate care and attention, and this is a responsibility of physicians and trainees.
While exposure to surgeries and other procedures may be exciting, it is unprofessional to compromise a patient's
care to further your training.
 Case: Request for a disability note

• Background
You are working as a clerk with a dermatologist in the outpatient department. You have carefully reassessed a patient
with a resolved contact dermatitis. You explain how to avoid contact with the offending allergen and reassure the
patient that she can return to work.
The patient asks the supervising dermatologist to sign a disability form for her to remain off work for an additional two
weeks so that she can go on a vacation. She threatens to take legal action if the dermatologist does not sign the form.
• Think about it
Should the dermatologist sign the disability form to avoid the threat of medical-legal difficulty?
What are the pressures on the dermatologist?
What could the dermatologist say to this patient?
• Lessons learned
Physicians are regularly asked to sign forms on behalf of patients to allow them to receive disability, sick leave, or
injury benefits.
Physicians are responsible to ensure the reports they prepare are timely, accurate, honest, and reasonable.
Even if a patient threatens legal action, a physician is obliged to refuse to provide an inappropriate report that conflicts
with their medical judgment.
 Case: Providing accurate information to others

• Background
A first-year medical student is given an assignment to interview a patient and develop a case report for grading.
While writing the report the student realizes that he did not ask the patient about allergies. Knowing that the case report would
not be used in the patient's care but would count toward the student's final grade, he writes a fictitious summary of the
patient's supposed allergies and hands in the report.
The student achieves an exceptionally high mark and receives a comment from the tutor commending his thoroughness.
Two years later, the former medical student, now a clinical clerk, is asked to see a patient and obtain a history.
Before reporting back to his supervisor, the clerk realizes that he did not ask the patient about her family history. Anxious to
finish up the day and start the weekend, the clerk thinks back to the time in medical school when he did not get caught for
falsifying data in the case report assignment.
The clerk records "no relevant family history" on the chart.
• Think about it
Do you think the clerk would have considered falsifying patient information if he had been caught doing so on his past
assignment?
What system and provider factors may drive individuals to compromise their integrity and potentially compromise patient
safety?
A fast-paced environment such as healthcare might require that students and physicians complete tasks more quickly than
would be ideal. What are some strategies that might help students to complete tasks thoroughly and accurately?
• Suggestions
Strategies that might help students to complete tasks thoroughly and accurately include:
 time management
 informing supervisors of obligations to be elsewhere at a certain time
 allotting some leeway time at the end of the day to relieve pressure when running behind schedule
 Case: Asking a mother to remove her veil

• Background
A plastic surgeon is seeing a child about a fingertip injury. The patient's mother is veiled so that only her eyes are
visible. The surgeon asks the mother to remove her veil so he can see who he is speaking with.
The mother takes great offence to this request and complains to the regulatory authority (College) that the plastic
surgeon had tried to frighten her and had made inappropriate comments.
• Outcome
The College requires the plastic surgeon to undertake sensitivity training.
 Case: Cancelling an appointment for surgery

• Background
A surgeon cancels an appointment for a patient who is HIV positive. After another surgeon performs the planned
procedure in the same clinic, the patient complains to the medical regulatory authority (College) that the cancellation
constitutes discrimination on the basis of a medical condition.
The first surgeon explains to the College that given the risk of post-operative infection, he believes surgery on HIV
patients should be done only in hospital, not in an outpatient setting.
• Outcome
The College ruled the physician had indeed discriminated against the patient on the basis of his medical condition.
 Case: The meet and greet

• Background
A family physician always has "meet and greet" interviews before accepting new patients.
After being rejected, one interviewee complains to the College.
The physician's response to the College is that the patient had multiple problems that she felt should be handled by
specialists
• Outcome
The College ruled the physician had indeed discriminated against the patient on the basis of the medical condition.
The College pointed out that the family physician could follow the patient's general condition and progress, while
conditions outside the physician's expertise could be referred to specialists.
 Case: Sexual orientation

• Background
A fertility specialist refuses to perform artificial insemination for a same sex couple.
The couple complains to the human rights tribunal in their jurisdiction.
The specialist's reason for refusing is that a previous same sex couple for whom the service had been provided had
involved the specialist in a legal action after the couple separated.
• Outcome
The human rights tribunal ruled that this was indeed discrimination on the basis of sexual orientation. They noted the
specialist readily provided the service to heterosexual couples, despite the fact such relationships can also break down
and engender litigation.
 Case: Mitral valve replacement surgery

A 65-year-old female needs mitral valve replacement surgery.

Use the sliding scale below to see how her information needs might change based on her cultural background.

1. The patient coming from a hierarchical culture may expect and accept that physicians have more power and
influence than she does. As such, she'll expect to be told what to do and to be supervised by the physician. She
likely would not consider taking the initiative to ask questions or challenge the physician's opinion even though she
may not understand or may inwardly disagree with the physician's suggestions.

2. Misunderstandings may occur if, for example, the physician is from a hierarchical culture and the patient is from a
highly egalitarian culture. The physician who doesn't have an understanding of these differences in values may
perceive the patient's assertions and questions as a lack of respect. Alternatively, a patient from a highly
hierarchical culture who is used to being told what to do, may be at a loss to decide if a physician from an
egalitarian culture asks them to choose from a variety of treatment options.

3. The patient coming from an egalitarian culture more likely has a sense of empowerment, is used to making
decisions in an autonomous way, and may seek background information. This patient will expect to be asked about
her preferences and expect to have the freedom to choose among treatment options. She will be quite comfortable
disagreeing with her physician and will be more likely to complain if her expectations are not met.

Hierarchical Egalitarian
1 2 3
 Case: Prescribing the wrong medication

In a moment of distraction, an emergency physician orders penicillin for a 13-year-old known penicillin-allergic female with a
streptococcal throat infection. The patient is given the medication and develops anaphylactic shock which is treated.
Use the sliding scale below to see how the physician might respond to the adverse event and how willing she might be to
disclose her role in the event, based on her cultural background.

1. The doctor coming from a collectivist culture likely cares deeply about belonging to a group and about feeling accepted
and respected by that group. As a collectivist, she is an approval seeker who deeply cares about the image she
projects to others. She might find it unthinkable to admit to having made a mistake, for fear of bringing dishonor to her
family or cultural group.

2. A conflict may arise when a physician who is very concerned about maintaining the honour of his family decides not to
disclose or to report an adverse event. While the physician's motivations may have been sincere, the Canadian
medical-legal context requires that physicians be honest about adverse events. A patient who discovers that a
physician willfully did not disclose an adverse event will likely be angry and lose faith in the physician. Similarly, if a
court or medical regulatory authority (College) were to become aware of a physician's willful non-disclosure, they could
take a very unfavorable view of the matter and issue sanctions or disciplinary measures.

3. The individualist doctor may be more motivated by self-improvement than the approval of others and does not see her
achievements or failures as reflective of her family's but rather of her own self. As such, the individualist physician may
not see disclosing adverse events as a reputation-threatening exercise, although she may nevertheless find it difficult.

Collectivist Individualist
1 2 3
 Case: Discussing a DNR order

You are admitting a 75-year-old terminally ill male to the hospital for dehydration secondary to his inability to adequately eat and
drink at home. His illness is very advanced and you wish to discuss end-of-life care and resuscitation status with him. When
you ask the patient and his family whether they would agree to a Do Not Resuscitate (DNR) status, they answer, "Maybe, but it
is difficult."
Use the sliding scale below to see how understanding a person's culture and communication style can help you decipher that
answer.

1. Families coming from a culture that values direct communication are likely comfortable telling you explicitly about their
wants, needs, and expectations. Honesty and straight-forwardness are valued, as is the correct use of terms. Direct
communicators may be perceived as blunt and have no difficulty saying "no.“

2. Physicians who are used to direct communication and are unaware of indirect communication modes may take such
families' answer as an agreement or acquiescence when, in fact, what they really mean is to say "no." People who may
normally be direct in their communication style may nevertheless become indirect when under stress.

3. Families coming from a culture with an indirect communication style will likely highly value the maintenance of harmony
and courtesy, in addition to honesty. Indirect communicators primarily want to avoid causing themselves or anyone else
any embarrassment. Their wish to continue respecting others will lead them to express themselves by implying what
they mean rather than by saying it directly. To an indirect communicator, the rudest answer to a question is "no," so
consider framing your questions in a way that would not require a yes or no answer.

Direct Indirect
1 2 3
 Case: A request from a new patient

A 64-year-old obese male with diabetes, congestive heart failure, a below knee amputation, hypercholesterolemia,
hypertension, and chronic hepatitis books an appointment to see a new family physician. Although he already has a
family physician, he lives too far away and the new physician's office is much closer. This physician's practice is so
busy that she has been considering closing it to new patients but she has yet to do so. Upon reading the patient's
history, the physician feels overwhelmed by the demanding medical needs of this patient and considers not accepting
him into her practice.
Use the sliding scale below to see how the physician's decision may be influenced by her own cultural background.

1. The physician who was raised in a universal culture will likely believe there are over-arching guiding principles that
apply to all situations and that can be used to determine the rightness or wrongness of specific beliefs and
practices. As such, the physician, despite feeling overwhelmed at the thought of taking on this new patient, will
nevertheless accept him into her practice because she realizes she cannot discriminate against him on the basis of
his numerous medical needs.

2. The situateionalist physician will argue that every situation is different and that absolute rules are inappropriate
because they are too inflexible. In this case, the situationalist physician might argue that she cannot possibly take
on a medically demanding patient because she had been planning on closing her practice anyway, or because it
would be unfair to her other patients, or because the patient already has a family physician.

Universal Situational
1 2
 Being asked to hide a cancer diagnosis

• Background
An elderly Chinese widow is operated on for a bowel obstruction. During surgery it is found that she has a tumour of
the descending colon, which is completely resected with no evidence of peritoneal or nodal spread. The surgeon
speaks to the patient's family while she is still recovering from the anaesthetic. Her eldest son thanks the surgeon for
the information and indicates that his mother should not be told about the tumour given that no further treatment will be
required.
• Think about it
How would you ensure that you meet your legal and professional duties as a physician practising in Canada, while
respecting the patient's and her family's cultural wishes.
• Suggestions
Meeting your obligations does not mean sacrificing respect for others' cultural traditions, beliefs, or wishes. You can
find balance by:
Offering to tell the truth and full disclosure to mentally capable (competent) patients. Respectfully acknowledge the
wishes of the family, but explain you have a legal and ethical duty to inform patients of the medical condition and
options for treatment.
Determining whether patients appear to understand the risks and benefits of not being fully informed about their
condition, including their entitlement to make their own decisions under Canadian law.
If possible, speaking to patients in private to ensure they are not being coerced into a decision.
Considering the involvement of a cultural broker to facilitate your mutual understanding.
• Lessons learned
Respect the patient's wishes and confirm the identity of the person to whom the patient wishes to delegate the right to
be informed or to consent to treatment. Document your conversation and don't hesitate to revisit the topic as required.
When necessary consider getting a second opinion from a colleague .
 Being told not to speak to the patient

• Background
A patient requires a cesarean section for failure to progress. Her husband refuses to let the male physician speak to
her about the situation, insisting that he must speak only to him.
• Think about it
How would you approach this situation in a culturally safe mindset?
What are the issues you need to address?
Practice writing a progress note which summarizes your discussions.
• Lessons learned
Whatever your clinical decision may be, documenting your rationale for it will allow others to understand the
circumstances you faced and thus how and why you came to make that decision.
 Case: Patient refuses to see the physician

• Background
A 28-year-old pregnant woman presents to the female physician that she expects will deliver her baby.
The physician explains the policy for physician coverage of the labour and delivery unit which advises patients that
they must be evaluated and treated by the physician who is on call, regardless of gender, race, and so on.
The patient becomes very upset, as she believed this physician would be delivering her child. Due to her religious
beliefs she will not agree to a male physician under any circumstances.
• Think about it
What should the physician do next?
Is the hospital policy appropriate?
What are the potential risks for the physicians?
What are the options for the patient?
What if the patient requires urgent care at any point in her pregnancy?
• Lessons learned
When such situations arise, physicians may be placed in a difficult ethical and legal position, particularly when the
patient requires urgent care and there is a shortage of other available physicians.
While physicians following policies like the one in this case may not intend to discriminate against the patient, there is a
risk that this may be perceived as a form of discrimination.
 Case: An allegation of discrimination is dismissed

• Background
A pain specialist terminates a patient from his practice after discovering that the patient has been selling some of the
drugs he prescribed.
The patient complains to the College that this is discrimination on the basis of a disability.
• Outcome
The College found no wrongdoing on the part of the physician, who had carefully documented his assessment and
advice. The patient had also signed a treatment contract which included a warning that a breach would result in
termination.
The physician was deemed to have acted in accordance with the Code of Ethics, that is, terminating care for a
legitimate reason.
• Lessons learned
If it becomes necessary to terminate a patient from your practice, ask yourself if the reasons are "legitimate". (Refer to
your College guidelines or contact the CMPA for advice.)
Document any discussions with the patient.
 Case: Respecting a patient's questionable choice

• Background
A 45-year-old woman is found wandering a hotel lobby without clothes, yelling at other guests. Upon assessment at
the hospital, she is found to be acutely psychotic and not mentally capable (competent). Her husband indicates that
she is aware of her mental illness and that she has chosen to take vitamins and cleansing baths based on her beliefs
about the origin of her illness.
• Think about it
What considerations are important for you?
• Suggestions
The prudent physician should consider the standard of care for the clinical situation and be careful not to abdicate his
responsibilities to advise the patient or her substitute decision maker about that standard. Respectfully pursuing a
discussion with the patient's substitute decision maker and striving to educate him about the unscientific basis of their
choices and about the available conventional medical therapies is important, even if a cultural difference is present.
• Lessons learned
Physicians have a professional obligation to treat patients according to the recognized standard of care. Simply
accepting a clearly erroneous position without discussion may be unacceptable. The prudent physician should try to
understand the substitute decision maker's concerns, and educate the person about the appropriate medical therapies
and their scientific basis. In this case, once given the explanation the husband agreed to the indicated therapy.
 Case: Reasonably accommodating treatment

• Background
A 68-year-old devoutly religious woman undergoes evaluation just prior to the start of a period of fasting. She has a 10-year history of
poorly controlled Type II diabetes managed with oral hypoglycemic agents and diet. She is accompanied by her 8-year-old grandson,
who serves as her interpreter. The patient's diabetes is out of control and when you discuss the significant risks of fasting and not
taking her medications in a timely manner, she refuses to alter her planned fas
• Think about it
How would you approach the patient regarding those concerns?
Is relying on the 8-year-old grandson as an interpreter appropriate?
What other resources could you use in managing this patient?
• Suggestions
Devoutly religious patients may practise a complete fast (water and food) for a prolonged period. While exemptions from the fast are
usually allowed for health reasons, some patients may nevertheless interpret the taking of oral medications or even the application of
eye drops, as breaking the fast.
Your goal should be to partner with the patient to ensure she understands the importance of diet in the management of diabetes.
Rather than telling her to act in the way you think she should, make reasonable efforts to provide the information she needs to make
an informed choice. If the patient still chooses to fast, respect that decision and manage the patient as best as you can. This may
include providing information about on how to recognize the signs and symptoms of a possible complication and how to seek care.
Document all your efforts and the rationale for your decisions.
Relying on a young child to convey important health information is not appropriate. Finding a more suitable interpreter should be
considered.
• Lessons learned
Consider enlisting the help of another family member in discussions about a patient's care.
Consider obtaining the help of a trusted member of the clergy from the patient's community to translate and explain who is exempt
from the fast.
Consider referring the patient to a physician of the same faith as the patient to assist in discussions and to provide a second opinion
regarding the planned fast.
• Think about it
How much do you know about fasting or other cultural practices that may affect patient care?
 Case: Nowhere to park

• Background
On a busy Saturday afternoon, a physician is looking for a parking spot at a shopping mall. Fortunately, a car is just leaving a
spot and the physician stops to wait until the space is clear.
Another vehicle approaching from the opposite direction is able to quickly turn into the vacant spot before the physician. An
argument and physical altercation takes place.
Subsequently, the driver of the second vehicle initiates a College complains
• Outcome
The College discipline committee found that the physician "...committed an act of professional misconduct in that he engaged
in conduct unbecoming of a physician." It further stated that "...abusive behavior towards others cannot be tolerated or
considered lightly. Such behavior undermines the public's respect for and trust in the profession."
The physician was reprimanded before the committee and the result was recorded in the College register.
In addition, the physician was required to pay the College for the costs of the proceedings.
• Think about it
Why is it necessary for physicians to be held to a higher standard of conduct than the general public in their personal lives?
What would you think of your family doctor if you knew that the doctor had behaved unprofessionally in a non-clinical setting?
Was the parking space worth the threat to the physician's license and professional reputation?
• Lessons learned
By statute and professional necessity, Colleges are required to hold physicians to a high standard of both professional and
personal conduct.
Professional consequences may arise from behavior or actions in either the professional or the personal sphere.
Complaints concerning professional care or personal conduct can lead to serious consequences such as the loss of license,
suspensions, fines, payment of costs, and loss of professional reputation.
 Case: Unhappy breakup

• Background
Four months after the breakup of a common-law relationship, a family physician receives notification of a College
complaint lodged by her ex-partner.
The complainant alleges that she had altered his medical record without consent, and that she regularly abuses
marijuana and alcohol.
• Think about it
What would you do if you found yourself receiving this complaint?
• Outcome
With assistance from legal counsel, the family physician was able to objectively and impartially refute all assertions in
her written response to the College. Supportive character testimonials were obtained from several of her colleagues.
At a meeting with the College registrar, the physician was composed, honest, and sincere.
The College dismissed the complaint.
• Lessons learned
Colleges consider the evidence carefully, which may result in exoneration of the physician.
 Case: Inappropriate conduct during an examination

• Background
A family physician is asked to see and examine a young woman as an urgent appointment for counseling regarding an
unwanted pregnancy.
As he is rushed, the physician does not leave the room while the woman is undressing. The office has run out of
drapes so he gives the patient a small hand towel to cover her lower abdomen.
The physician proceeds to do an internal examination without explaining to the patient what he is doing. He does not
have a chaperone and when exiting the room leaves the examination room door open while the patient redresses.
• Outcome
The woman complained to the College, stating she felt traumatized and sexually abused by the experience.
• Think about it
List the poor decisions made by the physician.
How could the physician's behaviour impact the patient?
How would this impact the patient's future relationships with healthcare providers?
• Lessons learned
It is not uncommon for physicians to face allegations that they have violated a boundary while performing intimate
procedures or examinations (for example, gynecological examinations.
 Case: Investment advice gone awry

• Background
A stockbroker follows up with his cardiologist concerning coronary arterial disease.
While indulging in small talk, the cardiologist asks what stocks are recommended. The broker replies, and after
finishing his afternoon clinic the cardiologist purchases those stocks from a different broker.
On a later visit, the cardiologist tells the patient that he has lost money on those stocks. The broker feels badly, but
also wonders how this would affect the quality of care he would receive.
• Possible patient outcomes
The patient may no longer trust the doctor's medical advice, fearing the cardiologist may give inferior care, "to match
the advice he got."
• Think about it
Can you think of any other outcomes that could harm the patient, physician, or both?
What are some questions you can ask yourself to assess whether boundaries are being blurred in the doctor-patient
relationship?
The patient may go elsewhere, with undesirable delays in treatment.
 Case: Business relationships with patients

• Background
During a routine office visit a family physician becomes aware that an elderly patient has land for sale. He has cared
for the patient for many years and they often discuss business.
The physician enters into a sales agreement with the patient to buy the land. The physician's lawyer drafts a purchase
agreement after having the land surveyed for water and sewage requirements.
Before the sale is finalized the patient changes his mind.
The physician starts a legal action to recover his legal and survey costs. Because of the legal action, the physician
terminates the doctor-patient relationship, prompting the patient to complain to the medical regulatory authority
(College).
• Lessons learned
The College concluded the physician's conduct was unprofessional.
The physician subsequently abandoned the legal action and wrote a letter of apology to the patient.
The College accepted the physician's letter of apology and his commitment not to enter into personal transactions with
patients.
 Case: Should I hire my patient?

• Background
A young female physician is starting her practice after finishing residency and having her first child. She is challenged
by the demands of work and managing her home and family.
During a routine clinic visit a patient tells her that she is a house cleaner and looking for work. The young doctor is
thankful for the fortunate timing and hires her patient. The patient is grateful for the income.
• Think about it
Is it appropriate to hire a patient?
In what ways can this influence the doctor-patient relationship?
Can you identify potential medical-legal risks with this case?
How might hiring your patient lead to a College complaint or legal action against you?
• Lessons learned
Physicians should avoid entering into business deals with patients.
At least one College has noted that these transactions can result in a finding of professional misconduct, and the
finding can be based solely on the power imbalance between the physician and patient.
Patients may feel pressured to enter into a personal transaction with their physician out of fear that refusing might
jeopardize their relationship with the physician or the quality of care they will receive.
 Case: I know what you mean

• Background
A medical student sees a 16-year-old patient for persistent headaches. When the student asks the patient if she is
experiencing a high level of stress in her life, the patient confides that her parents are going through an acrimonious
divorce.
The medical student describes her own experiences with her difficult divorce, saying "It is really difficult for me; my
spouse doesn't understand the rigors of medical training. Some days I don't know if it is all worth it."
• Think about it
Discuss the appropriateness of the medical student's comment.
How might a comment like this make the patient feel?
• Lessons learned
While it may be appropriate in some circumstances to share with your patients limited general information about
yourself (for example, a favorite sports team, the fact that you have a pet), it is generally improper to disclose detailed
personal information or share intimate details about your personal life (e.g. relationship problems).
 Case: Who is your doctor?

• Background
You are asked to see the wife of a physician colleague in the emergency department. She has fallen and has a
suspected fracture.
When obtaining the patient's history, she tells you she has been taking a large number of sedatives and anxiolytics
prescribed for chronic stress-related symptoms by her physician husband.
• Think about it
Should the husband be prescribing for his wife?
Why is it inappropriate to prescribe for family and friends?
Are there any circumstances when it might be appropriate to prescribe for family and friends?
• Lessons learned
Section 20 of the CMA Code of Ethics states: "Limit treatment of yourself or members of your immediate family to
minor or emergency services and only when another physician is not readily available; there should be no fee for such
treatment."
 Case: The box of chocolates

• Background
A patient has been receiving care for several months following a motor vehicle collision. Her attending physician tells
her she will soon be ready to return to work.
At her next visit she brings a large box of chocolates for the staff, and a bottle of expensive single-malt Scotch for the
doctor "to thank them for all the care."
The doctor examines her and says he thinks she is ready to return to work, but the patient asks him to renew her
disability "just for another month."
• Think about it
How should the doctor respond to his patient?
• Suggestions
The doctor had already come to a conclusion based on his medical judgment. The patient was asking for something
the facts didn't support.
In accepting the gift, he may have signaled a willingness to accede to her wishes. To do so would be a breach of the
doctor's integrity and the trust placed in him by the disability insurer and her employer.
 Case: Gift-bearing patient

• Background
A resident is monitoring an elderly man after a bowel resection for colon cancer. The patient's admitting history
indicates that his wife recently died and his grown children live far away. After his last visit he comments on how good
a job the resident did, adding how much the resident reminds him of his daughter.
One day the patient brings a box of cookies and a bouquet of flowers to thank the resident for taking care of him in
hospital. The patient is doing well until a week later, when he develops a superficial wound infection and he visits the
clinic without an appointment on a very busy day.
The patient catches the resident's eye, asks if she enjoyed the gifts, and could the resident see him for just a minute.
The resident decides to quickly see him when an exam room opens up.
• Think about it
What boundaries were crossed?
How could this conversation and the resident's response impact the other patients who might have overheard?
How could the resident respond to the patient to let him know that jumping the queue is inappropriate?
• Suggestions
Medical students can easily find themselves dealing with boundary issues. In the excitement of clinical work, benign
crossings may seem inconsequential or even go unnoticed, but may ultimately result in a difficult situation.
The medical student in this case was caught on a slippery slope, which began with accepting the patient's gifts.
Although the initial boundary crossing was benign, she then crossed a second boundary in giving him preferential
treatment by seeing him ahead of others on a very busy day.
 Case: A dinner date

• Background
A young, unmarried male physician has just begun practice and is new to the region. One of his first patients has
recently separated, and they go on a dinner date.
Later, the patient's separated spouse learns of this and lodges a complaint with the College.
• Think about it
When personal and professional boundaries are blurred, how might the physician's ability to objectively assess and
advise the patient be affected?
Would you consider the patient to be vulnerable, considering that she had recently separated from her spouse?
Do you think the patient would have made the same decision (to go on a date with her physician) if she was not
working through issues in her marriage?
How might a practice in a rural or isolated setting (e.g. when a physician provides care to an entire community) pose a
challenge for maintaining professional boundaries?
• Lessons learned
Consider the slippery slope from this dinner date to sexual relations. A sexual relationship — of any type — between a
physician and patient constitutes sexual abuse. Consent by the patient is not a defence to an allegation of sexual
abuse.
 Case: Patient attracted to the therapist

• Background
A patient with multiple stressors and no local support system is seen in the emergency department. Psychotherapy is
recommended and takes place over the coming months.
The patient wants to develop a social relationship with Dr. A, which is refused. After consultation, the patient's care is
transferred to another psychiatrist (Dr. B), who is the same sex as the patient. However, the patient continues to send
gifts and ask for dates with Dr. A, who feels harassed and threatens to take legal action.
The patient continues to demand a social relationship with Dr. A, and finally sues Dr. A, claiming "countertransference"
(referring to the physician's emotional involvement in the therapeutic interaction).
• Outcome
The court found that Dr. A had diagnosed and treated the patient properly and the boundaries had been observed by
Dr. A, despite the patient's attempts to cross them.
Transferring the patient to another provider was appropriate in this circumstance.
 Case: Using your smartphone in the workplace

• Background
Angela, a first-year resident on call for orthopaedic surgery, is paged to the ward to assess an elderly female patient
with fever after hip replacement surgery. The patient is not seen for several hours, and by the time Angela sees her,
the patient is hypotensive and requires admission to the intensive care unit (ICU).
• Hospital complaint
The family launches a complaint at the hospital that their mother was not seen promptly. In their complaint letter, they
mention seeing Angela on the ward at several points earlier that evening talking animatedly and texting on her phone,
seemingly oblivious to her on-call responsibilities.
• Outcome
Angela is required to meet with the postgraduate program director and to write a personal reflection about how her
digital distraction could have resulted in a more serious patient outcome. The hospital considers whether it should
develop a policy to guide smartphone usage by its employees.
• Think about it
How often do you access texts, emails, or social media during the day? Could the frequency of your smartphone
usage cause you to be distracted from your responsibilities?
 Case: Blogging about patients

• Background
Gerard, an emergency physician working in a small town, posts on his secure personal Facebook page about a
particularly difficult day at work. In his post, he mentions how he is aggravated by "worthless drug-seekers" who are
the "scourge of society," displacing the needs of patients with "real concerns."
• College complaint
Gerard receives a notice of complaint from his provincial regulatory authority (College), which was made by the relative
of a patient he saw in the emergency department on the day of his Facebook post. The relative indicated the post had
been forwarded to him by a friend, a family physician who is one of Gerard's Facebook contacts.
• Outcome
The complaints committee is concerned about Gerard's unprofessional comments and the impact on the profession.
Gerard receives a verbal caution and is required by the College to attend a one-day course on professionalism.
• Think about it
Does your post breach any privacy or professional obligations? Does what you post reflect what you would say in
person to patients or others? Are you likely to feel the same way tomorrow, after your post has been viewed by others?
 Case: A colleague's unprofessional behaviour

The Canadian Medical Association (CMA) Code of Ethics states that physicians are ethically obligated to report "to the
appropriate authority any unprofessional conduct by colleagues."
• Background
A fourth-year medical student is completing her internal medicine rotation. She has become close friends with one of
the first-year residents and frequently attends the same social events.
The student notices that the resident often drinks excessively. She has discussed this with her friend, recommending
that she seek assistance from her family physician.
One evening, the student is on-call with the resident and smells alcohol on the resident's breath. She becomes
concerned about the patients' safety as she believes the resident's performance is compromised.
• Think about it
What factors should the student consider when deciding whether to report the resident?
Answer: The risk of harm to patients.
What should the clerk do in this situation?
Answer: Immediately seek help from a supervisor to assess the resident's competency to continue.
What reporting responsibilities do treating physicians have when concerned about physician patients?
Answer: Determine if the resident should stop practising until she can be referred to the provincial physician health
program for assessment and treatment if necessary.
Contact the CMPA for advice on reporting requirements to the College.
• Lessons learned
While reporting a physician colleague or physician patient can be difficult and upsetting, it is important to understand
your reporting obligations in these types of circumstances.
1- That is incorrect

2- That is incorrect

3- That is incorrect

4-That is correct
The CMA Code of Ethics states: "Limit treatment of yourself or members of your immediate family to minor or
emergency services and only when another physician is not readily available; there should be no fee for such
treatment."

Treating family members, even episodically, is problematic because:

it is difficult to be objective
care often becomes fragmented (for example, between you and the patient's family doctor)
maintaining confidentiality of information is difficult
medical record keeping is usually inadequate
Some Colleges consider family members to include people with whom the physician has close personal or emotional
involvement, such as friends. To minimize the risk of a boundary violation, physicians who are asked to treat a friend
should consider whether their personal relationship might affect their ability to provide quality care. If so, the physician
should generally decline to treat the person and refer the individual to another physician. The physician should clearly
document these discussions.
The College for each province/territory can provide more information about treating family members.

5- That is incorrect
1- That is correct
Romantic relationships between physicians and patients are boundary violations and are forbidden. The penalties are
serious.
Patients need objective advice about their healthcare. Clinical advice and care may be less objective if personal and
professional boundaries are blurred.
More information about professional obligations and expectations may be found on the College website for each
province/territory.

2- That is incorrect

3- That is incorrect
Colleges are mandated to review all complaints received and investigate those of potential significance. The potential
consequences of complaints coming from an individual who is not a patient are identical to those stemming from a
patient: dismissal (of the complaint), counselling, a written or verbal caution, or referral to a committee such as a
discipline committee or a physician wellness program.
A review of CMPA files identified College cases involving complaints from non-patients. Of these, nearly half were
complaints made by physicians about other physicians. Most others were from pharmacists, nurses, physiotherapists,
social workers, office staff, hospital employees, worker compensation agencies, law enforcement personnel, and
members of the public.

4- That is incorrect

5- That is incorrect
1- That is incorrect
In this case such questions are helpful in contributing to the development of a diagnosis. Posing such questions
prematurely in an interview without sufficient foundation and without explanation for why they are asked may result in a
patient questioning their necessity and the motives of the physician.

2- That is incorrect
Colleges typically suggest that physicians offer to have a chaperone present during sensitive examinations or
procedures. Although a good answer, there is a better answer for this case.

3- That is incorrect
Physicians are responsible for ensuring that professionalism and appropriate boundaries are maintained with patients
at all times.
Whatever the gender of the patient or physician, in order to minimize misunderstandings in these situations physicians
should adequately and clearly explain to patients the procedure or examination, and why it is being performed.

4- That is correct
Misunderstandings commonly occur if no explanation is provided to a patient prior to relevant questions about sexual
history or before physical examinations of the breast, genitals or rectum. It is best to explain the reasons for such
questions or examinations so that the patient will recognize these are necessary and part of good clinical care.
It is not uncommon for physicians to face allegations that they have violated a boundary when performing intimate
procedures or examinations. Patients may be uncomfortable with, or afraid of, these procedures or examinations. To
minimize misunderstandings in these situations, physicians should adequately and clearly explain the procedure or
examination, and why it is being performed. As well, physicians should obtain the patient's informed consent for the
specific procedure or examination.
Many Colleges encourage physicians to give the patient sufficient privacy to undress (and re-dress) and to avoid
altering or removing a patient's clothing without first obtaining express consent.
5- That is incorrect
Without receiving an explanation, a patient may have not understand the reasons for questions or intimate
examinations. Respectful communication is an essential element of the doctor-patient relationship. Certain types or
styles of communication with patients are likely to be unappreciated. These include addressing patients in an
inappropriate or too familiar way, asking inappropriate personal questions not related to the patients' concerns, and
using offensive or vulgar language.
While physicians can be relaxed and cordial with patients, it is important to keep a work-related distance. In the doctor-
patient relationship, patients depend on and trust their physician. Consequently, physicians must ensure they are
professional and maintain appropriate boundaries with patients at all times