24


Over to you…


Repeat offender I REFER TO the case report “Repeat offender” (Casebook 19(1)). It’s always very sad when a patient has been harmed, though one goes to work to see and help patients harbouring no bad intent or motivation. In the end it seems the practice was found liable even though it was initially issued by the locum. That, perhaps, would be because whenever a doctor signs a script, it is his responsibility to check what he/she is signing is safe and appropriate etc. I often labour this point to those who “shove” a wad of repeat scripts in front of me in surgery; I tell them that it takes much longer for a locum to go through them and delve into the patient records as appropriate, before signing off these scripts. I have been told that the patients’ usual doctor can often simply sign them off quickly without due deliberation, because they “know their patients”. As the father of risk management Professor James Reason once said, it’s important to have the vigilance of a squirrel – I agree! We are, after all, dealing with that most sacred of things – a human life and health. That said, as humans we were not designed to be vigilant all the time, or as an architect patient of mine said to me: unlike my job, you doctors have to be nice and polite all the time, and that is impossible to sustain. The


art is to reconcile the two... Dr Noor Ahmad, GP, UK


I WRITE TO you with regards the case “Repeat offender” from Casebook 19(1). As a medical


student I find reading Casebook an extremely interesting, albeit slightly frightening, experience. During my placements at medical school I am sure that I have seen numerous instances where medications have been re-prescribed and it seems that confusion as to why a medication was prescribed is not an uncommon occurrence. However, in none of the cases that I have seen has any contact been made with the relevant specialist to ascertain whether the prescription is indeed correct or still required. This is a situation where I greatly sympathise with


We welcome all contributions to Over to you. We reserve the right to edit submissions. Please address correspondence to: Casebook, MPS, Granary Wharf House, Leeds LS11 5PY, UK Email: casebook@mps.org.uk


doctors, and especially GPs. In the current climate of medicine, there are new drugs being introduced all the time. Whilst it appears easy to say that all GPs should check prescriptions they are unfamiliar with, I think this places a huge burden on primary care physicians. This is a situation that I find extremely daunting as a medical student, and it highlights to me the need to keep informed with publications such as Casebook, as well as ensuring better education and training of both medical


students and junior doctors. Nuru Noor, medical student, UK


Missed opportunities I AM INTERESTED in your comment (Casebook 19(2)) that any woman referred for an IUD fitting (or TOP) “should have an STD screen plus or minus antibiotic cover as appropriate”. My impression is that the majority of such women do not have any tests for STDs (based on risk assessment). Those who do usually have a test only for chlamydia. Few of those are given antibiotics contemporaneously with the IUD insertion. The regimen chosen is generally one recommended for uncomplicated chlamydia, which may not be effective


ALL - EXCEPT AFRICA 23


A dosing disaster THANK YOU FOR the last edition of Casebook, which was an interesting and informative read. The case report “A dosing disaster” (Casebook 19(2)) was particularly relevant to me as a junior doctor. You also mentioned that 11% of patient safety incidents occurring between April and September 2010 were medication related (Casebook 19(2)). Writing up drug charts is usually the


responsibility of junior doctors, a task which can take up a significant amount of time, especially for elderly patients with multiple co-morbidities being on a long list of medications. Often I find myself being interrupted in this task for various reasons and surely your case report highlights the importance of concentrating on the task at hand. Although most hospitals will have pharmacists checking patients’ drug charts, there are few simple means that we junior doctors can implement in our routine practice to prevent these errors. It is both quick and easy to cross-check


the newly written-up drug chart against the patients’ brought-in medications or list again at the end, especially if we have been interrupted during our task. It is also not uncommon for elderly patients to bring in medications that have been stopped a long time ago. Requesting a


A dosing disaster M


rs E, a 29-year-old solicitor, who was 35 weeks pregnant,


was admitted to hospital for antihypertensive treatment as she had developed pre-eclampsia. She had a history of epilepsy, which was well controlled by treatment with phenytoin and phenobarbitone. She had been prescribed these medications since her teenage years and had decided to continue with them throughout her pregnancy after appropriate advice and counselling. On admission to the obstetric ward Mrs E was clerked in by Dr F, a junior doctor who was on-call and had no prior experience with phenytoin prescribing. As Dr F was completing a drug chart for Mrs E, she was distracted by an urgent telephone call and on her return she incorrectly charted Mrs E’s phenytoin at three times the appropriate dose. Two days after admission, Mrs E entered into


spontaneous uncomplicated labour and delivered a healthy baby boy. However, six hours later she began to exhibit symptoms suggestive that she was developing a psychiatric disorder. Initially


she was distractible and expressed paranoid ideation about other patients on the ward; she soon became psychotic, reporting auditory hallucinations of voices discussing her actions. Mrs E was assessed by psychiatry specialist trainee Dr T. Dr T did not look at Mrs E’s drug chart and only reviewed her medical notes. These detailed her medication, but did not supply dosing information. Following his assessment Dr T made a diagnosis of puerperal psychosis; no differential diagnosis was recorded and the possibility


LEARNING POINTS


■■ Something as apparently simple as incorrectly charting a patient’s regular medication can have serious consequences. This task is regularly undertaken by junior doctors who may not be familiar with certain medications.


■■Because the psychosis emerged in the post-partum period, it was assumed that puerperal psychosis was the correct diagnosis. It is important to keep in mind other possible causes for Mrs E’s presentation.


■■When a patient does not respond to treatment as expected, it is always wise to re-examine their history and double check even the most obvious but unlikely explanations for their condition.


■■ Normally drug charts are checked by a pharmacist, but it is unclear whether this happened on this occasion. Every hospital should have a procedure where a pharmacist checks a patient’s medication, but this is sometimes overlooked. Regardless of any protocol, the prescriber has the ultimate responsibility for anything they chart.


■■A large number of medications can cause psychiatric difficulties under circumstances of use, abuse or withdrawal.


of drug toxicity was not considered. Sedation was initially prescribed, but during the next 24 hours Mrs E’s symptoms failed to improve and she became more agitated. As a result, an antipsychotic medication was started. Over the next 12 days and despite increasingly high doses, Mrs E failed to respond to antipsychotic medication and her psychotic symptoms continued. It was noted that she appeared to be increasingly confused, had slurred speech and was observed to have an abnormal gait. A referral


was made for a neurological opinion to exclude an organic brain syndrome. On reviewing Mrs E’s drug chart, the on-call neurologist noticed the medication error and on examination of Mrs E he was also able to identify other symptoms of phenytoin toxicity. Phenytoin administration was immediately stopped and once Mrs E’s toxic levels had subsided her psychotic symptoms resolved. No long-term damage was caused to Mrs E’s health, but she made a complaint against the hospital. SG


repeat medication list from the patients’ GPs will help identify any discrepancy and possibly point towards yet


undiagnosed cognitive or social issues. Dr Yaasir Mamoojee, junior doctor, UK


OVER TO YOU


ASIA CASEBOOK | VOLUME 19 | ISSUE 3 | SEPTEMBER 2011 www.medicalprotection.org


MARK THOMAS / SCIENCE PHOTO LIBRARY


CASE REPORTS


PSYCHIATRY DIAGNOSIS/INVESTIGATIONS/SYSTEM ERRORS


UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 2 | MAY 2011 www.mps.org.uk


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28