prescription error

Question 1

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.

Answer 1

i would do a quick AE to of the patient
to fist see if they are safe

and i would try to understand from the patient what she understands from her situation
the clinical indication behind the iv antibiotics
and if she did have a consultation with the doctor before these medications where started

i would then like to review her notes to see for any documentation fro the doctor i question if they hay review

i would then try to see more information from the nurse

I would stop the iv antibiotics - if there is a clinical indication for antibiotics and i need further clarity on other options then i would lift up the phone to a microbiologist for their advice

i would also like to check the patients renal function and their if this drug is being monitored on bloods

then I WOULD PROCEED TO DO A DUTY OF CANDOUR

I would document everything

DO INCIDENT REPORTING !!!

i would then see if i can talk to the doctor in questions

Question 2

What happens to an incident report after it is filed? What would happen to the doctor?

Answer 2

It will be sent to those involved

investigation in to the event, which may involve a fact finding meeting, why the event happened, if there was anything that could have stopped it, or if there were multiple issues that caused their event.

prompt an action plan to prevent this happening again, for example extra training for staff, prompts on computer systems, guidelines or changes to equipment.

in this CASE maybe a formal warning might be even to the doctor , or require extra supervision or training