Hannah, a 28-year-old woman, had a history of recurrent abdominal pain and had been on a waiting list for several months for a laparoscopy to diagnose the problem. She was duly admitted and investigative surgery was undertaken under general anaesthetic. Prior to discharge, Hannah experienced severe cramps and vaginal bleeding. The nurse on duty recognized that she was having a miscarriage.
Question
– What factors may have been present that led to the misdiagnosis of her pregnancy?
That night, the patient had to be rushed to the emergency room for treatment of hypoglycaemic shock.
What were the factors contributing to this patient becoming ill?
– Who should this error be reported to?
– Who should do the reporting?
– How should the information be used once
received?
