Introduction
This essay reflects on a clinical scenario involving an 88-year-old lady who presented with an unwitnessed fall, was treated for dehydration and postural hypotension, and later experienced a missed insulin dose due to incomplete handover regarding her diabetes mellitus status. The oversight resulted in elevated blood glucose levels, highlighting critical gaps in communication and prescribing practices. The purpose of this reflection, from the perspective of a student in non-medical prescribing, is to evaluate the incident, identify contributing factors, and propose actionable strategies to prevent such occurrences. Key points include the importance of effective handover, the role of non-medical prescribers in patient safety, and adherence to clinical guidelines. This analysis aims to demonstrate a sound understanding of non-medical prescribing responsibilities while critically examining areas for improvement.
Incident Analysis and Contextual Background
The patient, an 88-year-old with a known history of diabetes mellitus managed with insulin, presented following an unwitnessed fall. The initial clinical assessment identified dehydration and postural hypotension as primary concerns, and treatment included intravenous (IV) fluids alongside monitoring of lying and standing blood pressure. However, the clinician failed to communicate the patient’s diabetic status during handover, resulting in a missed insulin dose and subsequent hyperglycaemia. This incident underscores a critical lapse in communication, a well-documented risk factor in patient safety (Leonard et al., 2004). As a non-medical prescriber, understanding the complexity of managing older patients with comorbidities is essential, as is recognising the potential for human error in high-pressure clinical environments.
The relevance of this case lies in the vulnerability of elderly patients to adverse outcomes from missed medications, particularly insulin, which requires precise timing to maintain glycaemic control. The National Institute for Health and Care Excellence (NICE) guidelines on diabetes management emphasise the importance of individualised care and timely administration of insulin to prevent complications such as hyperglycaemia or diabetic ketoacidosis (NICE, 2015). Thus, the failure to address the patient’s insulin needs represents not only a communication error but also a deviation from established best practices.
Critical Reflection on Non-Medical Prescribing Responsibilities
As a non-medical prescriber, my role involves ensuring holistic patient care, which includes verifying medication histories and advocating for seamless communication during handovers. Reflecting on this case, I recognise that I must actively seek comprehensive patient information, even when handover details are incomplete. The Nursing and Midwifery Council (NMC) Code stresses the importance of clear communication and accountability in clinical practice (NMC, 2018). Had I been involved, I could have questioned the handover content or consulted electronic patient records to confirm the patient’s full medical history, thereby identifying the need for insulin administration.
Furthermore, non-medical prescribers are trained to assess and mitigate risks associated with polypharmacy and comorbidities in older adults. While my understanding of diabetes management is informed by current guidelines, I acknowledge limitations in my critical approach during busy shifts, where oversight might occur without robust systems in place. This incident highlights the necessity for checklists or structured handover tools, such as the SBAR (Situation, Background, Assessment, Recommendation) framework, to ensure no critical information is missed (Müller et al., 2018).
Proposed Actions to Prevent Recurrence
To address the issue and enhance patient safety, several actionable steps can be implemented. First, adopting a standardised handover protocol, such as SBAR, can structure communication and ensure all relevant information, including chronic conditions and medications, is conveyed. Research suggests that structured tools reduce errors in clinical settings by providing clarity and consistency (Müller et al., 2018). Second, non-medical prescribers should routinely cross-check patient records and medication charts during transitions of care, even if this requires additional time. Third, interprofessional training on effective communication and the specific needs of elderly patients with diabetes should be prioritised to foster team awareness.
Additionally, leveraging technology, such as electronic health records with automated alerts for missed doses, could serve as a safety net. While these solutions are not without challenges—such as resource constraints or staff training needs—they represent practical approaches to complex problems. From my perspective, consistently applying these strategies demonstrates the development of discipline-specific skills in non-medical prescribing, aligning with patient safety priorities.
Conclusion
In conclusion, the missed insulin dose in this 88-year-old patient following an unwitnessed fall illustrates the critical importance of communication in clinical handovers and the responsibilities of non-medical prescribers in ensuring patient safety. Reflecting on this case, I have identified key lapses in practice, including incomplete handover and failure to verify patient history, which led to hyperglycaemia. Proposed actions, such as implementing structured handover tools, cross-checking records, and enhancing interprofessional training, provide practical avenues to prevent recurrence. The implications of this reflection extend beyond individual practice to systemic improvements in healthcare delivery, underscoring the need for consistent, evidence-based approaches in managing vulnerable patients. As a student of non-medical prescribing, this case reinforces my commitment to accountability and continuous learning to uphold patient safety standards.
References
- Leonard, M., Graham, S. and Bonacum, D. (2004) The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(suppl 1), pp. i85-i90.
- Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W.E. and Stock, S. (2018) Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open, 8(8), e022202.
- National Institute for Health and Care Excellence (NICE). (2015) Type 1 diabetes in adults: diagnosis and management. NICE.
- Nursing and Midwifery Council (NMC). (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
