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OSCE: actor and procedure stations · Core02 / 22

Disclosing a syringe swap: paralysed before she was asleepActor: a 35-year-old teacher on the day-surgery ward after knee arthroscopy

Actor: open disclosure of a drug error and apology

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Duty of candour: full disclosure, why it happened, full apology, prevention, support, further care.
  • Relaxants have no hypnotic or analgesic action; give them only to anaesthetised patients.
  • Paralysed awareness: awake but unable to signal; awareness carries a high rate of PTSD.
  • A syringe swap is a sentinel event, reviewed for labelling and drug storage faults.
  • Disclosure makes patients less likely to change doctors and increases their trust.

The patient

Actor: a 35-year-old teacher on the day-surgery ward after knee arthroscopy. A syringe swap gave her rocuronium before propofol; she was awake and unable to move for about a minute. Her oxygen saturation stayed normal with mask ventilation. She is shaky and tearful. Task: tell her what happened and respond to her.

The examiner asks

Answer aloud, then press Show.

  1. Open

    How do you open?

    Show the answerHide the answer
    • I'm here to talk with her about the error at the start of her anaesthetic this morning. Patient
    • I was your anaesthetist today. Is now a good time, and would you like someone with you? Communication
    • Could you tell me, in your own words, what you remember?

  2. Explain

    Explain what happened.

    Show the answerHide the answer
    • I'm very sorry. I made a mistake, and it caused you real distress. (Communication)
    • I gave the muscle-relaxing drug before the sleep drug, because two syringes were swapped.
    • For about a minute you were awake but couldn't move. Then the sleep drug took effect.
    • I breathed for you with a mask throughout, and your oxygen level stayed normal.
    • We don't yet know exactly how the swap happened. A review will find out, and I'll share it.

  3. Respond

    She says: 'I couldn't breathe. I thought I was dying.'

    Show the answerHide the answer
    • That must have been terrifying: unable to move, unable to tell anyone. (Communication)
    • What you felt was real, and it makes complete sense that you're shaken now.
    • Experiences like this can bring nightmares or flashbacks later. If they come, there is help.
    • I'd like a psychologist to see you, whatever you're feeling right now.

  4. Respond

    She says: 'I'm going to complain, and I'll get a lawyer.'

    Show the answerHide the answer
    • You have every right to do that, and it won't change how we care for you. (Communication)
    • Here is how to reach patient relations; they'll log your complaint and reply in writing.
    • Whatever you decide, I'll keep you updated on the investigation.

  5. Close

    How do you close?

    Show the answerHide the answer
    • I've reported this as a safety incident today, so it is properly investigated. Communication
    • We're reviewing how relaxant syringes are labelled and stored, so it can't happen to anyone else.
    • You'll get a written account of what happened and what we're changing.
    • Here's my direct number. I'll phone you tomorrow to see how you are.
    • I document the conversation, the apology and the referral, and record the event in her notes. After surgery

Fatal mistakes

  • Denying or minimising the error.
  • Becoming defensive when she threatens legal action.
  • No clear apology.

Checked against: Patient Safety Incident Reporting and Learning Systems: technical report and guidance (2020) · Miller 10e · Barash 9e

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