Question

What do you think the phrase “Orders are suggestions until you deem them safe and appropriate” means? Provide a fictitious example of when carrying out an order without ensuring it is safe and appropriate might cause a patient harm.

Answer 1

Medical error and patient harm have been described and studied for well over a century. However, apart from a few isolated pioneers, the medical and nursing professions did not appear to recognise the extent and seriousness of the problem or, if they did, were not prepared to acknowledge it. The great majority of clinical staff have always been safety conscious in their personal practice. Patient safety however is a broader endeavour that requires thinking beyond the individual patient to consider the characteristics of the whole system of healthcare. Patient safety is sometimes equated with preventing error .

Provide a fictitious example of when carrying out an order without ensuring it is safe and appropriate might cause a patient harm:

Florence is an 84-year-old lady with hypertension and rheumatoid arthritis. She lives at home on her own, and has weekly visits from her daughter who lives 35 miles away. She also receives daily support from a care worker to help with activities of daily living. She is currently prescribed:

 bendroflumethiazide 2.5 mg daily

 lisinopril 10 mg daily

 simvastatin 40 mg at night

 methotrexate 20 mg once weekly on a Wednesday

 folic acid 5 mg daily except on Wednesday

 paracetamol 1 g four times daily when needed.

On Friday evening, an on-call GP visits Florence because she has been feeling unwell with symptoms of urinary frequency, dysuria and urge incontinence for a few days. The GP diagnoses a urinary tract infection (UTI) and prescribes trimethoprim 200 mg twice daily for 3 days. On Sunday, the care worker is very concerned that Florence has deteriorated and is nauseous and confused. She calls an ambulance and Florence is admitted to hospital. A hospital doctor changes the trimethoprim to co-amoxiclav because her UTI symptoms have not improved. After a few days Florence is feeling much better, her UTI symptoms resolve and she is discharged from hospital.

The practice pharmacist checks the discharge summary and identifies a drug interaction with the trimethoprim and methotrexate.

• A prescribing error has occurred because it was not appropriate to prescribe trimethoprim to a person receiving methotrexate because of a serious and potentially life-threatening increased risk of haematological toxicity.
• The on-call GP prescribed an antimicrobial according to national guidelines for treating UTIs wiyhout seeking additional information regarding the same medicines in terms of drug interaction as the patient was already on so many medicines.