Case Scenarios

1. Case Scenarios Risk management in primary care 19 January 2010

2. Case of AW (1) • 10 yr old boy – asymptomatic • Mother says – red urine • Dipstix – blood +++, protein +++ • Diagnosis – urinary tract infection (UTI) • Treatment - antibiotics

3. Case of AW (2) • 2 wks later – same signs and treatment • Further 5 visits – MSU negative • 6th wk visit – referred to paediatricians • Hospital appointment - 3/12

4. Case of AW (3) • 1/12 later – patient collapses at home • Admitted to hospital – renal failure • Treatment – dialysis: ? transplantation • Diagnosis – glomerulonephritis

5. Root Cause Analysis • Missed/Failure in Diagnosis • Delay in Diagnosis • Competence of Doctors • Failure in Appropriate Referral • Failure to Explain to Mother

6. Case Scenario 1 • Parents of 2 year old child are divorcing. • All are your registered patients. • Mother’s solicitors request a report from you in support of her application for a residency order in her favour; prohibiting father unsupervised access. • Child’s father has poorly controlled epilepsy – several grand mal seizures per month. • What are your responsibilities? • How to resolve conflict between these responsibilities?

7. Case Scenario 2 • Jake is 15, has haemophilia A. • Parents are separated, lives with his mother. • Father brings him with haemarthrosis. • Usually compliant, Jakes refuses treatment. • Fathers to sign consent. • What do you do?

8. Case Scenario 3 • Receptionist checking target vaccinations. • Finds 5 year old had pre-school booster. • 10/52 later another pre-school booster and MMR. • Mother expressly refused MMR vaccination. • Complaint - unnecessary vaccination. - MMR when wanted single vaccines. • What do you do?

9. Case Scenario 4 • Nurse asks you to sign repeat prescription for a patient - Diazepam, Prozac • Later you see the patient and ask if she received the prescription. • She knows nothing about it. • On checking, patient never had these medications and no records or notes of repeat prescription. • Checks on the prescription, shows nurse’s signature on the back. • What would you do?

10. Case Scenario 5 • 23 year old epileptic female • Taking Phenytoin • Wants to start contraceptive pill • Given standard 30 mcg Oestrogen COC • 6 months later, unplanned pregnancy

11. Case Scenario 6 • Patient on Lithium • 2-monthly repeat prescriptions • No blood levels for 9 months • Admitted with Lithium toxicity • No system for monitoring toxic drugs

12. Case Scenario 7 • 45 year old with urinary tract infection • Given Trimethoprim by GP • Developed severe unpleasant rash • Patient had a previous allergy documented in paper records but not on computer

13. Case Scenario 8 • 40 yr old man rarely attends GP • Home visit request – cough, malaise • O/E – chest infection – amoxycillin • No better – call – telephone response • OOH visit - ↑ antibiotics • OOH record – further visit required – fax to GP • No visit • Patient collapsed, septicaemia, died

14. Case Scenario 10 • 75 yr old man seen at home visit • Suffered loss of consciousness while walking • Witnessed twitching of limbs • Awake, orientated, unable to move R arm • Referred to A/E – Fracture R humerus • Discharged home – collar/cuff • Given sodium valproate • What are clinical risks? • What steps may be taken to manage them?