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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.
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.
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