Q fever error

Case history

Barry attended the practice for Q fever vaccination prior to commencing work in the local abattoir. The GP registrar was not familiar with Q fever immunisation, so she discussed the process with her supervisor. The supervisor advised the registrar that she needed to perform a Q fever skin test to see if the patient had had any prior exposure to Coxiella burnetii. 

The registrar administered the Q fever skin test and asked Barry to attend for review in one week to have the test read. 

When the patient returned to the practice, he had significant induration and redness at the injection site, and he also reported quite a severe systemic reaction with fever and headache. 

After the patient had left the practice, the registrar discussed the results with her supervisor. It became apparent that the registrar had given an incorrect dose to the patient. She had not realised that she needed to dilute the liquid in the vial and administer a small dose intradermally to perform the skin test. 

Medico-legal issues

The GP registrar was very upset about the error and worried about the consequences for her patient. 

Her GP supervisor said he would seek advice from the government public health unit about the implications of the skin test error for the patient and how best to proceed. The supervisor recommended that the registrar contact MDA National for advice. 

When the registrar contacted MDA National's Medico-legal Advisory Service, she received immediate advice on how to manage the situation. The Medico-legal Adviser also asked how the registrar was feeling and she described her distress about the situation. They discussed personal support strategies and rehearsed the "open disclosure" conversation that the registrar was going to have with Barry. The Medico-legal adviser asked the registrar to contact her again once she'd had the follow up conversation with Barry. 

Following her discussion with the Medico-legal Adviser, the registrar contacted the patient to explain what had happened, apologise for the error, and advise him about the next steps. Barry was very understanding about the error, saying "Doc, I'm grateful you gave me an extra dose!".

Lessons learned

• Despite our best efforts, we all make mistakes - it is estimated that two errors occur for every 1,000 patients seen by a GP. The decisive factor in such an event is how we handle the situation. 
• Regardless of the outcome of an error for your patient, the following steps are appropriate when managing an error:
  
  a) provide and/or organise any immediate medical care for the patient
  b) as soon as possible, inform the patient about the error - what occurred, why and how it occurred and what impact the error will have on the patient in the short and long term
  c) apologise for the error
  d) inform the patient of the steps that will be taken to minimise the possibility of a similar mistake occurring in the future
  e) invite any comments and questions from the patient
  f) take steps to look after yourself e.g. discuss with MDA National and a colleague 
  
  
• Ensuring a mistake is managed appropriately and professionally is vital for the welfare of our patients - and us.
• If there is an error or an adverse event in your practice, please contact MDA National's Medico-legal Advisory Service for advice and support. 
  
  

If you receive a complaint or claim, contact MDA National’s Medico-legal Advisory team for advice and support on 1800 011 255. 

Resources

Managing mistakes article (see page 25)

Dealing with the stress of adverse events and medico-legal issues article