This scenario forms part of the learning materials to support our Raising and acting on concerns decision tool

Back to the Raising and acting on concerns decision tool - Faced with a concern about patient safety, are you yourself in a position to put the matter right?

Identifying and acting on patient safety concerns 

Background

Dr Doyle is a specialty trainee in her third year. She works in a busy medical ward in a hospital in Northern Ireland.

She has become aware that patients on the ward receiving transfusions for post chemotherapy anaemia, are not being given adequate information about the risks.

Scenario 

Dr Doyle notices that when patients are advised that they require a transfusion the details around risks (including adverse effects) are not being given. She recognises it is likely that this information is not being imparted as the clinician is probably focusing on the improvement the transfusion will give to the patient. Dr Doyle is concerned as she recognises that no matter how beneficial a procedure maybe, a patient should be well informed of risks.

Dr Doyle brings her concerns to her clinical supervisor, Dr Foster. She tells Dr Foster of her concern that patients may not be receiving the information they need about transfusions, which in turn may affect their decision around accepting chemotherapy. 

As an immediate action they agree that Dr Doyle will ensure, for the rest of the week that patients under her care are given the patient information leaflet about blood transfusions and she will go through this with them.  She will answer any queries from patients about the benefits and risks, and refer any questions that she is unsure of to senior colleagues. 

What the doctor did

Dr Doyle ensures that she records in the patients' notes the main points of the discussion about proposed treatments, the fact that the patient has been given the transfusion leaflet, a record of capacity related to the decision and the patient's decisions. She informs other doctors of the leaflets so they can also use them.

Dr Foster and the Clinical Director carry out a review of the service. They identify that consultation times are not long enough. The also identify that trainee doctors are not fully informed of the risks associated with transfusions and in turn are not confident in relaying them to patients.

Arrangements are made for additional training – including sessions targeting knowledge and communication skills. Checklists are introduced across the ward, which include a question about whether discussion around risks and relevant information leaflets have been provided to patients.