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REFLECTION: CASE STUDIES

Reflection gives the brain an opportunity to pause amidst the chaos, untangle and sort through observations and experiences, consider multiple possible interpretations, and create meaning. This meaning becomes learning, which can then inform future mindsets and actions (Porter 2017).

 

The following case study offers you the opportunity to practise the skill of reflection and apply your knowledge and skills to a hypothetical case:

Case Study One

Mr. Karpinski, a 73 year old male was admitted with a diagnosis of atrial fibrillation. After a period on the cardiology ward, Mr. Karpinski was discharged on three times a day 200mg of Amiodarone for a week with an instruction to reduce this to a once a day dose of 200mg after one week. He was readmitted three weeks later with syncope when he was found to still be on Amiodarone three times a day.

  • Which members of staff are involved in this case?
  • At what points could the error have taken place in this case?
  • What human factors might have led to this error?

 

The GMC advises that doctors must be satisfied that procedures for prescribing are secure and that:

  1. the right patient is issued with the correct prescription
  2. the correct dose is prescribed, particularly for patients whose dose varies during the course of treatment
  3. clinical records should include:

 

  1. relevant clinical findings
  2. the decisions made and actions agreed
  3. who is making the decisions and agreeing the actions?
  4. the information given to patients

 

​https://www.gmc-uk.org/-/media/documents/Prescribing_guidance.pdf_59055247.pdf

 

As a doctor, if it was found that you had made an error in writing the prescription:

  • what actions would you take?
  • who should you contact?
  • who else might you talk to?
  • how might you feel?

 

Reflection: What, Why, How

Reflection can help manage the emotional impact of professional life. This can be personal or shared with a colleague/ trainer/ appraiser the next few examples illustrate a professional approach to managing your emotional health and personal development

What do you want to reflect on? This should contain enough information to allow you to recall the event.

Mr. Karpinski, a 73-year-old male, was admitted with a diagnosis of atrial fibrillation. After a period on the cardiology ward, Mr. Karpinski was discharged on three times a day 200mg of Amiodarone for a week with an instruction to reduce this to a once a day dose of 200mg after one week. He was readmitted three weeks later with syncope when he was found to still be on Amiodarone three times a day.

 

Why do you want to reflect on it?

I would like to reflect on what happened for him to have been prescribed the medication wrongly and what steps I can put in place to prevent this happening to someone else. 

 

What do you hope to get out of this reflection – how will it help you?

To consider and review my own prescribing practices

To review the process of organising tablets to take home and giving them to the patient

To improve my prescribing skills and practice

 

How have you been affected by this?

I felt terrible when I admitted this patient and found out the reason for his admission and syncope. Especially as this was a situation that could have been prevented and should not have happened to him.

It was hard for me not to be so upset and feel so responsible initially until I realised that a lot of people had been involved and this could lead to an improvement process.

 

How will this affect your practice and make you a better doctor?

I have recognised the importance of empowering the patient to be in control of their own medication when they go home and make sure that they understand how to reduce dosages and why this is so important. 

I need to talk to the nurses who discharge patients to see how and what information they give them and find out if there is any extra reinforcement that they could need.

 

What are your overall conclusions from this episode? How do you feel about the reflection?

I am glad I undertook this reflection because I now have a very different take on what happened. I can see the bigger picture and how what I do interacts with what other colleagues do. It was useful to review the GMC guidance on prescribing and to discuss this incident with nursing and pharmacy colleagues about what we could do collectively in the future to stop this happening again.

 I really appreciate the need for better communication and clarity when communicating with patients – by checking what patients understand and thinking about putting in extra safety measures with vulnerable patients. I can sort of see what Continuous Improvement looks like

(Continuous improvement of patient safety. The case for change in the NHS 2015).

https://www.health.org.uk/publications/continuous-improvement-of-patient-safety

 

The Academy of the Royal Colleges has an excellent Reflective Toolkit which offers a range of reflective templates and examples of SCIs on which to reflect.
https://www.aomrc.org.uk/wp-content/uploads/2018/09/Reflective_Practice_Toolkit_AoMRC_CoPMED_0818.pdf

 

HEE has also undertaken video interviews with senior clinicians reflecting on SCIs and trainees which offer perspective and advice.