You are an ED consultant in a large ED and you have just started your shift in resus. The team have just transferred a patient to ICU: Paul, a 42/M, presented with anaphylaxis after eating peanuts. He has a known peanut allergy.
Due to significant airway compromise from angioedema, he was intubated. Due to persistent hypotension, a R jugular CVC was inserted to administer inotropes. Unfortunately, the night ED registrar lost control of the wire during the procedure and subsequent imaging has confirmed that the wire is in the SVC and R atrium. The ICU team have successfully inserted a CVC and have arranged for interventional radiology to retrieve the wire. You have debriefed and counselled your registrar.
You are now being asked to speak to Paul's wife, Katrina. She is aware of Paul's condition but has not been notified of the CVC incident. You are to inform her of the incident and answer any questions she may have.
- expression of regret/apology
- factual description of what happened
- opportunity for patient or family to relate their experience
- discussion of potential consequences
- discussion of how adverse incident is being managed and what is being done to prevent recurrences