Statement Review for Datix
CASE STUDY
Dr X is working as an F2 (Foundation Year Level 2) in Cardiology. During a night shift, Dr X was handed over by a team of evening doctors to review an 84-year-old patient who was being treated for decompensated heart failure with IV diuretics and infective endocarditis with IV antibiotics. At the time of the handover, the patient was drowsy and a CT Head had been requested.
The patient was taken down to the CT scan room, but on arrival, Dr X noted that the patient was too agitated for them to obtain any quality CT images as they were unable to keep still. Dr X called the Cardiology Registrar to obtain their opinion on sedating the patient – the Registrar agreed and suggested a small dose (1mg) of Midazolam, advising that further doses could be administered later, if required.
Dr X made a call to the ward to inform the team of the situation, and asked a nurse to bring: a paper prescription chart, Midazolam vials, a syringe, diluent, needles and a flush. On the nurse’s arrival, they asked Dr X to confirm the appropriate dose – Dr X advised that they needed to administer 1mg initially, and then they could decide if any further doses were required based on the patient’s response. Dr X checked the strength of the Midazolam with the nurse, who advised it was 5mg/ 1ml – they had a total of 2ml in their syringe so Dr X reminded them to only administer 1mg.
After administering the medication, Dr X quickly realised that the nurse gave the patient 5mg. As well as this, the nurse had not brought a paper prescription chart with them on their arrival to the patient.
Dr X immediately assessed the patient who was quieter and did not appear to be agitated anymore. The team proceeded with the CT scan, and Dr X re-examined the patient afterwards – they remained stable. The patient was taken back to the ward, and Dr X suggested neuro-observations using the Glasgow Coma Scale (GCS) at every hour through the night, and to re-contact Dr X if any concerns arose regarding a drop of respiratory rate, saturations or fall in GCS. The Cardiology Registrar was also informed about this, and was in agreement with the proposed plan.
MDS ADVICE & OUTCOME
When preparing a statement, it is paramount to detail your version of events in an open and honest manner. It is important to fully reflect on the incident to develop your learning and clinical practice. Dr X has been able to recognise that confusion arose between ‘mg’ and ‘ml’, along with their verbal instructions to bring a prescription chart to the patient. Going forwards, Dr X appreciates the importance of all prescriptions being written down, with doses checked and administered according to the Trust policy.
The patient did not suffer any side-effects.
LEARNING POINTS
- The Academy of Medical Royal College and COPMeD define reflective process as ‘the process whereby an individual thinks analytically about anything related to their professional practice with the intention of gaining insight and using the lessons learned to maintain good practice to make improvements where possible’.
- Reflection allows doctors and medical students to: demonstrate insight by identifying actions to aid learning, development or improvement of practice, developing greater insight and self-awareness, and identifying opportunities to improve quality and patient safety in organisations. There is a strong public interest in doctors being able to reflect in an open and honest way.