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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 - Should the matter also be dealt with through routine local incident reporting arrangements?

Routine local incident reporting arrangements

Background

Dr Wang, a speciality trainee in her second year, works in a GP practice. 

She is asked to go on a visit to see a patient complaining of headache, nausea and a possible rash. In preparation she checks the doctors’ bag contains the appropriate drugs, as the patient's symptoms indicate meningitis. 

Scenario 

Dr Wang notes that the bag contains penicillin, but it is out of date. Fortunately there is up to date penicillin in the stock room.   But she is concerned about possible future risks to patients if the doctor’s bag again contains out of date drugs.

What the doctor did

Dr Wang discusses the issue with her GP supervisor, and the practice manager, Mrs Tudor, later that day. 

She learns that there is a system in place for the practice nurse, Ms Billing, to check the drugs in the doctors’ bag each month but that this has not been done. 
Her GP supervisor advises her to make a record of what has happened by completing a significant event audit form. The following day a 'significant event' meeting is held.

In the meeting notice that the process of checking drugs in the emergency bag is the sole responsibility of Ms Billing.  They also find that whilst Ms Billings has been off sick for some weeks, no one has been assigned this responsibility in her absence. 

It is agreed that Mrs Tudor should immediately develop a shared calendar, with regular alerts for checking drug stock items. Ms Billings would continue to review the drug stock when back from sick leave but it would be accessible to and checked by the manager and practice nurse who would be able to assign someone else to look at it in her absence. They agree to reviewed the arrangement in six months to ensure it's working well.