A 51-year-old woman was brought to via ambulance to her local emergency department on a bank holiday weekend. She had been feeling unwell, dizzy and had developed a headache, whilst out shopping. She had also experienced some odd tingling and numbness in her left arm. She felt as though she may have a migraine due to the heat, the crowds, noise and bright lights in the shops. By the time she got to hospital she was feeling a lot better after a number of tests the doctor felt that she may have suffered a transient ischemic attack (TIA). The hospital had an ambulatory TIA hot clinic which ran 5 days a week. The doctor felt it was appropriate to follow the TIA pathway and discharge the patient with aspirin and simvastatin as to-take-out (TTO) medication (standard practice) with an appointment for Tuesday which was when the clinic would be next open. The doctor who was busy couldn’t find the TTO prescription pad so she wrote the order on the Stat prescription chart which is part of the ED patient record booklet. In error and without consciously realising it she wrote a stat one-off dose. The discharging nurse (an agency nurse) who was unfamiliar with the department gave the patient a stat dose of aspirin and simvastatin and told the patient she could go home after making sure she had a leaflet about TIAs and her appointment card for the clinic. The patient said that the doctor had said she would give her some medicine to help with her headaches until she was seen in clinic, the nurse checked the prescription and checking with colleague confirmed that a prescription written on the medication record was not a TTO. The nurse tried to find the doctor but she had gone home for the day. The nurse suggested to patient if she wanted Aspirin for her headaches she could get this over the counter at any chemist or supermarket which would be much quicker than waiting for her to find another doctor to write a prescription and it would be cheaper than the cost of paying for a prescribed medication. The patient happily agreed and made her way home after what had been a long day. The patient didn’t feel like going to the shops after leaving the hospital and went straight home. The next day Sunday she felt a little better so decided to leave going out to the shops and thought it best to put her feet up and enjoy a day at home. On the Monday evening an ambulance was summoned to the patients address by her friend who had called by the house anxious that she hadn’t showed up as planned for their lunch date. The patient had collapsed with dense left sided weakness, on arriving at hospital she was sent for a CT scan and it was confirmed she had suffered an embolic cerebral vascular accident. On reviewing the previous admission, the clinicians noted that she had not been discharged with the appropriate medication and the incident was reported and investigated.

Questions

• What type of incident do you think this is?
• What is the level of harm?
• Do you think the harm was avoidable?
• What fundamental errors did the doctor make?
• What fundamental errors did the nurse make?
• What could have caused and/or contributed to these errors?
• What could the organisation do to prevent this happening again? Is blaming the nurse or doctor going to stop this from happening again?