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in these circumstances, still less if antibiotics are only given when the results of tests are available. In view of your comment, I wonder if current practice is digging a
medicolegal minefield? Dr Humphrey Birley, GUM physician, Wales
IN THE RECENT volume (Casebook 19(2)) you have a comment on “Missed Opportunities” in your Over to You section. I’d like to query your response: “In any situation where a woman is being referred for a TOP or for the fitting of an IUD, she should have an STD screen plus or minus prophylactic antibiotic”. Please can I refer you to FFPRHC guidance November 2007:
www.ffprhc.org. uk/admin/uploads/ CEUGuidanceIntrauterine ContraceptionNov07.pdf This says that prior to fitting an IUD, consideration of STD must be done; sexual history should be taken and some women may be higher risk, but that STD screen isn’t necessarily required. Is it therefore just a question of documenting that sexual history
has been taken? Dr Corinne Shepherd, GP, UK Response
Many thanks for your comments and also for drawing our attention to other information relevant to the case report “Missed opportunities” (Casebook 19(1)) and our response to Dr Stevens’ letter about the same report (Casebook 19(2)). It is not the place of Casebook to provide comment on specific clinical aspects of case reports; rather we seek to highlight potential medicolegal pitfalls in practice. In this particular case, failure to carry out an appropriate examination and relevant investigations according to the patient’s history led to an adverse outcome for the patient. The patient had a past history of PID and was
intending to have a TOP: therefore, STI screening should have been considered. We acknowledge that practice varies in different settings and that the approach may need to be tailored to the particular circumstances, but the key medicolegal learning points to come out of this case remain the same – document relevant history and carry out the appropriate investigations.
More on “A dosing disaster” LIKE MOST OF your readers, although I enjoy reading the case presentations, this enjoyment is always tempered by the thought “there but for the grace of God go I”. I most sincerely hope never to play a starring role in any future case presentation. Now to the meat of the matter.
In many of the cases I can understand what might have gone wrong but in the case of “A dosing disaster” (Casebook 19(2)) I confess that I am more than a little perplexed. In the first part
of the story: ■■ Although the admitting doctor was unfamiliar with the drugs he/she was prescribing, a BNF or its equivalent was not available somewhere in the ward nor in the doctor’s pocket.
■■ The nurses doing the drug round had read the prescription at least five to six times before delivery without noticing the mistake. It used to be (still is?) normal nursing practice to record the medications on admission in the nursing notes. This discrepancy should have been noted there.
■■ The patient herself failed to notice the incorrect dosing and draw it to anyone’s attention.
■■ The admitting consultant and/or the registrar overlooked this mistake when they did a ward round of the new patients the day of
or after admission. In the second part
of the story: ■■ The psych trainee failed to read the drug chart.
■■ The patient was never reviewed by a psych doctor other than the trainee.
In the third part of the story: ■■ The nurses and the admitting consultant’s team (including the consultant) failed to read the drug chart for almost two weeks.
■■ The doses of medication were increased – by whom? – but the remainder of the drug chart seems not to have been read.
The commentary does draw attention to the fact that the prescriptions were not reviewed by a pharmacist. While this may be desirable, I am not sure how common this practice may be. The story sounds like it may have occurred in a large teaching hospital (a presumed centre of excellence) as it is unlikely that there would be an on-call neurologist in any smaller unit. Given the presumed superiority of such institutions it seems difficult to understand that no-one seems to review
the drug charts of patients who have been admitted or who are unwell.
While it has been some time since I worked in obstetrics I can recall my professor insisting on reviewing every drug chart of all patients under his care on every ward round. Given the case here I can appreciate the wisdom in his approach even further. As he would explain, this practice is “basic medicine” – a sentiment with which I fully concur. I am also disturbed that the patient was never reviewed by a consultant other than the admitting one. While many trainees may be excellent at their jobs surely a patient requiring a consultation deserves an expert opinion? I think your commentary may be too narrowly focused and unfairly so on the initial prescriber. Those who were responsible for her continuing care share at least some of the blame, if not the majority of the blame. Suggesting that the review of drug charts is the responsibility of the pharmacist rather than that of the admitting consultant seems a little odd. My impression here is that this particular institution may have a number of deep-seated problems. I sincerely hope that this
YOUR LEADING MEDICOLEGAL JOURNAL
impression is incorrect. David Mitchell, UK
Tunnel vision
WHY YOU MIGHT NOT BE RIGHT FIRST TIME
PAGE 12 Valid consent HOW IT APPLIES IN PRACTICE Does the suit fit? SELECTING THE RIGHT MEDICAL INDEMNITY Difficult interactions DEALING WITH THE TESTING PATIENT
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OVER TO YOU
ASIA CASEBOOK | VOLUME 19 | ISSUE 3 | SEPTEMBER 2011
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VOLUME 19 | ISSUE 2 | MAY 2011 VOLUME 19 | ISSUE 2 | MAY 2011
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