Scenarios

A set of educational resources is developed to be used by tutors to assist learning in medical error and develop changed behaviours.

  • Six virtual patients, adapted from real cases, written to make it likely that users will make poor choices. These are termed error virtual patients (EVPs). Each case will focus on two or three types of medical error.
  • Resources to complement each case, focusing less on the clinical issues and more on the decision making and cognitive aspects of case management.
  • Tutor training to maximize the potential impact of these resources.
  • These are incorporated into PBL type tutorials with medical students looking at error awareness, recognition and avoidance.

 

Exemplar case 1: Neonatology

Case outline

An infant is born at 34 weeks gestation following preterm labour. He endures a difficult birth ending in an emergency caesarean in response to an abnormal CTG. After resuscitation, he is admitted to the neonatal unit for oxygen and feeding. After 4 hours he develops increasing difficulty in breathing, low temperature and grunting. His oxygen saturation levels fall. He is intubated and ventilated and a chest radiograph taken.

Learning Objectives

  • Problems of prematurity
  • Transition at birth
  • Respiratory distress syndrome
  • Neonatal infection
  • Patent ductus arteriosus

Errors covered

  • Ignorance
  • Sloth

 

Exemplar case 2: Difficulty in breathing

Case outline

A 2-year old child is seen in a family practice setting with a mild fever, cough and mild difficulty in breathing. The doctor is told that he has had recurrent chest infections starting at 11 months and has had multiple courses of antibiotics. The patient is rapidly assessed with history and examined.

Learning Objectives

  • Normal respiratory findings in children
  • Stridor and wheeze causes
  • Childhood asthma
  • Croup
  • Pneumonia
  • Bronchiolitis
  • Inhaled foreign body

Errors covered

  • Fixation

  • Sloth

 

Exemplar case 3: Vomiting

Case outline

A 6-month old girl is being observed in the emergency room, and the doctor sees with a view to her being discharged as the parents are used to his problems and are keen to go home. He is known to have GORD. This seems to be worse than normal with more vomiting and pain, possibly related to the reflux. There is no diarrhoea, and the vomitus is liquid – water and juice similar to what he  just drank. A full examination shows a pale, unhappy child with a mildly distended abdomen. Some blood tests have been done, which are normal.

Learning Objectives

  • Assessment of the GI system of a child
  • Causes of vomiting, diarrhoea, abdominal pain and distension
  • Gastro-oesophageal reflux disease
  • Pyloric stenosis
  • Malrotation and volvulus
  • Intussusception

Errors covered

  • Playing the odds
  • Communication
  • Lack of skill

 

Exemplar case 4: Growth

Case outline

Davina, a baby girl now three weeks old. Infant born in good condition. No resuscitation needed. Apgars: 8 at 1 minute, 10 at 5 minutes. Auxology: weight 1.62 Kg, length 47 cm, head circumference 31.5 cm . Management: Early feeding with NGT and breast milk. Feeding established at 7 days – breast. No other interventions. On examination, Davina is small and has very little subcutaneous fat. She is alert and does not look dysmorphic.

Learning Objectives

  • Infant and child nutrition
  • Normal growth in childhood
  • Normal nutritional needs for children
  • Hormonal control of growth
  • Monitoring growth – measuring and growth charts
  • Hormonal causes of disordered growth
  • Nutritional causes of poor growth
  • Cystic fibrosis
  • Coeliac disease
  • Cow’s milk protein intolerance

Errors covered

  • Poor triage
  • Fixation

 

Exemplar case 5: Seizures

Case outline

Rory Gallagher, a four month old boy. His mother has brought him to check him over to make sure nothing is wrong. He’s had a cough for the last 3 days. This has unsettled him and put him off his feeds. She is not sure if he is hungry or not – he is crying a lot and seems to want to suck, but then only takes a few mouthfuls of feed before breaking off and crying again. His cry seems unusual. He was born normally at term, that he is the mother and her boyfriend’s first child, that he is smiling, fixing and following with his eyes, and is beginning to control his head better. He is up to date with his immunisations too.

Learning Objectives

  • Emergency management of seizures
  • Types of seizure in childhood
  • Investigation of seizures
  • Meningitis and encephalitis
  • Brain tumours
  • Non-accidental injury
  • Causes of coma in children

Errors covered

  • Bravado
  • Insufficient skills
  • Fixation

 

Exemplar case 6: Blue baby

Case outline

Bella Potter was born at 41 weeks gestation with a birthweight of 3.0kg. Her initial scan at 17 weeks was reported normal, as was a subsequent scan at 22 weeks. This was mother’s first pregnancy. She used to smoke, but denied smoking during pregnancy. She is otherwise well and had no complications during her pregnancy. Baby cried at 30 seconds and was dried and warmed, with no further resuscitation required. Apgars were scored at 8 at 1 minute, 9 at 5 minutes. Respiratory: RR 70/min, subcostal recessions. Grunting. Clear breath sounds, air entry audible.

Learning Objectives

  • Changes in the heart at birth
  • Assessing cyanotic children
  • VSD, Fallot’s tetralogy and other heart defects
  • Presurgical management of children with CHD

Errors covered

  • Timidity
  • Poor teamworking
  • Poor triage