Prescription Error Flashcards
You are called to a ward by the nursing staff. They report that yesterday they called another doctor to review a patient. The doctor did not see the patient in person, but did prescribe gentamicin and vancomycin fixed dose three times a day. The patient is now reporting tinnitus.
You do not get on well with this doctor. What do you do?
This scenario raises the issues of patient safety and duty of candour.
Seek information
* Thank the nurse for raising the concern.
* Gather more information from the nurse regarding the situation.
* Review the patient’s notes to confirm if the doctor documented their review and the reasons for prescribing gentamicin and vancomycin.
* Cancel further doses of the antibiotics until a thorough assessment is completed.
Patient Safety
* See the patient immediately to ensure their safety.
* Conduct a clinical review with a focus on neurological status and tinnitus.
* Apologise to the patient if an error has occurred, and explain the short- and long-term implications.
* Escalate to seniors and explain to the patient that an investigation will be conducted.
* Arrange blood tests to check** renal function** and drug levels.
Documentation and Discussions with the doctor
* Document all findings, actions, and communications in the patient’s notes.
* Speak to the doctor in private to understand their perspective and clarify the rationale for their actions.
* If not satisfied with their explanation or if harm has occurred, escalate to the patient’s registrar or consultant.
Incident Reporting
* File an incident report to ensure the error is reviewed and to help prevent recurrence.
* Inform the doctor’s clinical or educational supervisor if needed, ensuring a constructive approach to addressing the issue.
What is duty of candour
Duty of candour is the duty we have to be open and honest when something goes wrong. It is important to explain the short term and long term consequences of this mistake as well as apologise. We also have a duty to be open and honest to colleagues and regulators as well as patients in order to take part in reviews or investigations.
You approach the doctor directly however they are dismissive. What do you do?
I would tell the doctor that I am duty bound to escalate this to ensure patient safety. I would inform them I would do an incident report as well as discuss this with the patient’s registrar or consultant.
What is incident report?
An incident report is a form that must be filled in after there are errors in care that did result in or could have resulted in unexpected or avoidable death, harm, or injury to patients or staff. They are often electronic and require details of the event. It triggers a process to investigate events and prevent them from happening again.
What happens to an incident report after it is filed? What would happen to the doctor?
What Happens After an Incident Report is Filed?
* The report is sent to the relevant department or team, such as the head of nursing for nursing-related events or the head of a specialty (e.g., orthopaedics) for specialty-specific incidents.
* An investigation follows, which may include a fact-finding meeting to determine:
* Why the event occurred.
* If it could have been prevented.
* Whether multiple factors contributed to the incident.
* The findings lead to an action plan aimed at preventing recurrence. Examples include:
* Extra staff training.
* System prompts or alerts on electronic prescribing systems.
* Updated guidelines or changes to equipment.
Implications for the Doctor
* The doctor may require additional training or closer supervision.
* If serious concerns are identified, they may need to stop working temporarily while issues are addressed.
* The focus is on learning and improvement, but actions will depend on the severity of the incident and the doctor’s response to support and remediation efforts.
