Disclosing a medication error to a family — OSCE

Station brief (8–10 minutes)

A three-year-old was given ten times the intended morphine dose because of a decimal-point slip on a handwritten chart. The child became bradypnoeic, was reversed with naloxone and is now stable. The parents are frightened and are asking what happened. The prescribing registrar is distressed. You are the senior registrar. Conduct the initial open disclosure with the parents, explain how the error was able to happen using a systems framework, and outline the steps the unit will now take. Address the registrar's wellbeing. Do not invent local statutory wording. [12] [3]

Tasks for the candidate

1. Open the disclosure honestly: acknowledge what happened, express regret, and offer a senior point of contact. [12]
2. Explain, in plain language, how a single slip reached the child through the system defences that should have caught it. [3] [8]
3. Outline the structured response: make safe, escalate, report, root cause analysis, open disclosure, support the second victim, and implement and measure change. [12]
4. Address the registrar as a second victim and describe a just-culture approach to the error. [4] [3]
5. Invite the parents' questions and agree a plan for ongoing communication and follow-up. [12]

Expected performance

Must hit. Acknowledges the harm and apologises sincerely without minimising or hedging; explains that a calculation slip was able to reach the child because of latent conditions (the handwritten chart with no dose-range checking, the missing independent double-check); commits to a full investigation that looks at the system rather than blaming the registrar; names the registrar as a second victim needing support; agrees a clear follow-up plan and a named contact. [12] [3]

Merit. Uses plain language rather than jargon; explains the Swiss cheese idea accessibly; distinguishes honest error from at-risk and reckless behaviour in a just culture; commits to specific corrective actions (computerised order entry with weight-based dose checking, an independent double-check of high-alert medicines); offers to share the investigation's findings with the family. [3] [6] [8]

Fail. Blames the registrar to the parents; hedges or conceals the error; speculates about cause before the facts are clear; offers no follow-up or named contact; ignores the second victim; or promises specific disciplinary outcomes. [12] [4]

Sample candidate structure

"I'm very sorry that this happened to [child]. They were given too much of the pain medicine because of a mistake in the way the dose was written down, and that made their breathing slow. We treated it straight away and they are stable now, and I want to be honest with you about what happened and what we are doing about it. The mistake should not have been able to reach [child] — we have checks that are meant to catch exactly this kind of slip, and those checks did not work. We will investigate why, looking at how the system is set up rather than just at the individual, because that is the only way to stop it happening to another child. The doctor who wrote the dose is very upset, and we are looking after them too — they came to work to help children, and this has been hard for them. I will be your point of contact, I will come back to you with what we find, and I will tell you what we are changing. What questions do you have for me now?" [12] [3] [4]