26. Acting openly and honestly when mistakes are made

13 November 2020

What do you do if a patient returns to your practice with a condition you missed during your eye examination?


Your first patient of the day is David Dudley, aged 60. He presents with intermittently uncomfortable eyes but all the results from the eye examination are within normal limits, including intra-ocular pressures of 16mmHg R and 12mmHg L. You suspect dry eye as the cause of the discomfort and suggest ocular lubricants. Your second patient, Rachel Willoughby, is an asymptomatic 45 year old who presents for a routine eye examination. Again, all results are normal and you find intra-ocular pressures of 11 mmHg R and 9 mmHg L. Your third patient, Doris Harding, is 85 and also attending for a routine eye examination. When you measure her intra-ocular pressure you find it to be 10mmHg R and L Upon this reading you become suspicious that your tonometer may be inaccurate: you check the calibration of the tonometer and discover the tonometer was incorrectly calibrated and is in need of repair. You use a different tonometer to re-examine Doris (finding her pressures to be 14 mmHg and 15 mmHg) and for the rest of your clinic. At the end of that day, you go on holiday for a week. When you return, your optometrist colleague Sanjay tells you that he saw Mr Dudley while you were away as he was complaining of blurry vision and a constantly painful right eye. Sanjay found intra-ocular pressures of R 32mmHg and L 18mmHg and arranged a fast track emergency referral using the local protocol with a tentative diagnosis of right eye angle closure glaucoma.

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