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Flashcards in SJT paper rationale Deck (48):
1

Contacting colleague about their mistake
- most appropriate action

Preferable for you to contact the person directly, rather than asking someone else to do so

2

Patient to be discharged but feels they should stay in hospital
- most appropriate action

Most appropriate: ask their concerns

Least appropriate: coerce them into leaving by saying they are taking another patient's bed

Note: do NOT discharge patients until you are sure they are MFFD (if there are any doubts or the patient/family are concerned - ask for senior help)

* any patient concerns must be taken seriously; speaking to relative probably does not directly affect the patient concerns

3

Finishing late again and missing a social event
- most important considerations

Most important: patient safety

Then: your own wellbeing (which impacts on patient safety)

Least important: disappointing your friends/ missing the social event

* note: don't send a text message for handover of important details as it may not be received and acted upon (better to ask someone else to pass the message onto them)

4

Prescription errors

Most urgent: prevent any immediate prescription errors as can directly impact on patient safety

Who to tell:
- PATIENT (duty of candour)* and PRESCRIBER (they may have made a mistake, or may know something you don't)
- Then... senior colleague
- Then... ward pharmacist

*If patient is confused, this may not be essential as they won't retain it anyway

5

Clarifying drug choice for a patient

Most: contact person who prescribed the drug (if it has already been prescribed)

Next: contact senior member of own team (knowledge of the patient and the specific indication, e.g. pre-splenectomy antibiotic choice)

Next: ward pharmacist

Then: on-call microbiologist (don't have knowledge of the patient)

Then guidelines: BNF > local guidelines > national guidelines

6

Breaking bad news

Most appropriate: Advise that senior will talk to them

Then: you can discuss any patient's concerns

Note: ensure you know ALL necessary information before disclosing information to patients

7

Raising concerns about another FY1 colleague

Most appropriate: speak directly to the FY1*

(possibly advise she talks to her supervisor)

Then: talk to a senior (nurse in charge - sets standards on ward; medic)

Finally: snitch on her

*if another colleague was the one to make the observation, they should speak to the person in question first of all (not you)

8

When there is uncertainty whether the patient’s situation has changed and the family is involved
- who to involve?

Most: senior colleague (ideally consultant*)

* note: generally, you should go to a consultant rather than asking them to come to you

9

Concerns about colleagues treating you unfairly
a) who to speak to?
b) should you request to move teams?
c) what if a nurse is treating you unfairly?
d) when may it not be suitable for you to speak to the person in question directly?

a) Most: speak to the colleagues directly

- Then: ask for senior advice (note - this is not the most appropriate, as it doesn't address the issue)

- Should also ask colleagues if they have been experiencing similar things

b) Requesting to switch teams does not solve the problem of team-working - this should be a last resort once other options to resolve the issue have been tried

c) If a nurse, you should first try to speak to them. If this fails, speak to your line manager (consultant supervisor) who will then inform their line manager (nurse supervisor)

d) If you have previously tried and failed (or they were abusive, dismissive, etc.) - it should state this in the stem if this is the case

10

You feel you are not receiving sufficient learning opportunities on the wards
- who to speak to?

Most: consultant - offer to involve in OP/theatre, etc.

Then: Foundation programme director

What about supervisors?

11

You hand a routine job (eg. blood) over to the FY1 taking over from your shift and they refuse it due to being too busy
- action?

Most: be assertive with them and clarify to them their responsibilities

Then: find someone else to do it* (or do it yourself, providing this is practicable - not if it needs taking in 2 hours time)

*Do not delegate to someone else to find a suitable person, find them yourself

12

Patient speaks Urdu, no English - how should you deal with this?

Most: find a Doctor who speaks Urdu to see them

Then: get a translator

If delay and concerns about patient welfare: contact senior for advice

Last resort: phone relative to act as translator

13

Patient needs urgent discharge for work-related meeting but senior doctor is running 45 minutes late.
- What to do?

Most: find another senior doctor who can discharge them

Then: phone the doctor running late to clarify if this is ok, then review with them when they arrive

Then: advise patient on right to self-discharge
NEVER discharge patients as FY1

14

Patient/family are complaining or angry about something
- what should you do?
- when is it appropriate to ask a nurse to speak to them?

Most: Apologise, ask/address any concerns they have

Then: explain the reasons for issues

Finally: tell them the formal complaints procedure

Only appropriate to ask nurses to speak to the patients when there is an issue with the NURSING care, rather than the MEDICAL care

- Note: never contradict a concern/complaint (eg. they complain about a nurse being rude and you say you have always found them to be nice - this is showing you aren't taking the complaint seriously)

15

You have an excessive workload - solutions
a) If your FY1 colleague is in theatre
b) If your FY1 colleague has no work to do
c) In general

a) Most: Ask them to return to ward to help you out, address any concerns you have with them directly (then, involve senior colleagues if necessary)*

b) Always speak to them first directly (note - do not speak to their educational supervisor without speaking t to them)

c) - If a senior is delegating jobs disproportionately to you, speak to them directly about your concerns first
- Ask colleagues to help out (short-term solution): ask fellow FY1 or seniors
- Notify consultant/ supervisors about workload (long-term solution)

16

Where there are concerns for patient safety, team-working or workplace bullying, is it ever OK to do nothing?

No.
It is always your place to act in some way

17

Prescribing treatments without assessing the patient

Potentially dangerous (e.g. laxative in the constipated patient - could be dangerous if they have bowel obstruction)

18

Handovers (best to worst)

- Face-to-face verbal (even if it means finishing late)
- Written down and handed directly to person who is taking over
- Handover to another doctor to pass the messages on
- Write in the patient notes (may not be seen for a while)
- Leave a message in the handover room (may not be seen at all)

*Note: Where possible, you should be leaving work on time and handing over important, outstanding tasks is vital in this

19

Aggressive patients
a) threatening violence
b) currently violent (just punched a nurse)
c) when is explaining to patients that their behaviour is unacceptable not important?

a) call security, explain to patient their behaviour is unacceptable, ensure other patients aren't distressed

b) call security, attempt to talk to the patient to calm him down, check that the nurse who was punched is OK

c) when they don't have capacity or insight into their actions (confusion, dementia)

20

Your colleague not coping

- Talk to your colleague - understand their concerns*
- Advise them to talk to senior member of the team
- Advise them to speak to their educational supervisor
- Advise them to take time off work

* If it is impacting on patient safety (eg. they are making mistakes), it is still more appropriate to address the concerns on their own wellbeing first before mentioning that this is impacting on patient safety

21

Incident reporting.

Immediate:
- patient safety,
- patient explanation (duty of candour)
- gather relevant information
- call for help if needed

Then:
- Notify nursing team (nurse in charge)
- Notify medical team (senior)
- Ensure documentation

22

Your performance is dropping due to a medical condition
- who do you speak to?

- GP
- Senior colleague
- CLINICAL supervisor (as it is a clinical issue)

23

When to ask nurses for help?

- Nursing issues (eg. observations, hygiene, etc.)
- Immediate care of unwell patient
- Patient/relative with a nursing issue (or at least a 'non-medical issue')
- If you are engaged in a time-critical task (eg. writing up a drug chart), it may be preferable to ask a nurse to do a task for you (eg. calling your FY1 colleague) rather than doing it yourself

24

When to speak to clinical supervisor?

-

25

When to speak to educational supervisor?

-

26

MUS patient repeatedly attending ED for chest pain. Cardiology consultant has previously said no cardiac cause of the chest pain. You examine her today and find NAD.
- How should you manage her?

- Ask her what her concerns are (you might find a cause for the pain here - e.g. stress, anxiety)
- Reassure that there is no cardiac cause for her pain
- Ask a senior colleague to speak to her

27

Colleague turns up to work drunk.
- What do you do?

- Ask if he has been drinking alcohol
- Tell him that he should go home immediately as he is unfit to work
- Seek advice from a senior colleague about how to manage the situation

note: exploring any underlying cause for this may be fruitless while he is drunk - the immediate concern is patient safety (if he is currently with a patient this is a safeguarding issue and must take precedence)

28

Escalating to seniors
a) When to speak to senior colleague?

b) When not to speak to senior?

c) Registrar or consultant?

a) - Immediately if evidence of patient safety concerns, especially if time-critical (eg. your colleague is drunk and is due to operate in 1 hour)
- If you are unsure
- Where patients are concerned/families are involved*

*However, you can first speak to the patient/family to defuse a situation and hear their concerns (then at a later time, a senior can speak to them

b) do not speak to senior doctors about non-urgent FY1 duties when it can be avoided

c) Generally contact registrar first for issues about medical management

29

Consultant shouts at an FY1 colleague in front of patient
- what should you do? (what are your concerns)

- Suggest to the consultant that the patient may have been upset by it (concern for patient welfare)
- Talk to your FY1 colleague
- Advise they talk to their educational supervisor
- Speak to other senior colleagues

30

Patient prescribed penicillin by your FY2 but you think she may be allergic from your clerking of her.
- what do you do?

- Cross out the prescription on the drug chart, dating and initialling it
- Ask the patient if they are penicillin allergic and review their notes to find any evidence of it

31

Drug doses.
- patient requests that you administer double the normal dose of her usual medication as she has read evidence that this is beneficial

- Tell her that you cannot administer above the normal dose without senior consultation

32

Inappropriate/abusive behaviour from a colleague
a) what is the guiding principle?
b) if they are inappropriate to a patient?

a) All staff members have a right to work in a respectful environment (and to speak up to ensure this); patients have a right to be respected

b) - Take them to one side for a private conversation
- Tell them they were inappropriate
- Inform a senior

33

Social media posting.
a) Confidential data
b) Social event (getting drunk, etc.)
c) Receiving messages / friend requests from patients

a) Advise to take down immediately,

b) Advise to take down immediately,

c) Respond to inform them it is inappropriate to contact them via social media and politely decline request (next best option would be to simply ignore it - but then they may repeat the action)

34

Escalating concerns about patient's medical care (eg. on warfarin before an operation) - who to escalate to?

- Senior present at work on own team (eg. specialty trainee)
- Senior present at work in different but related team (eg. anaesthetist involved in patient's upcoming op)
- Senior not present (eg. consultant at home)

35

Difficulties with supervisor
- they aren't replying to emails

- Contact their secretary first, then if no response inform the FP director, then if no improvement ask for an alternate supervisor

36

Breaches of confidentiality.
a) By a colleague (eg. leaving handover sheet on table at home)
b)

a) - Inform them of the breach (they may not realise); then advise them to destroy/remove the confidential info; then encourage them to inform their consultant/supervisor

The most pressing issue is acting on the current breach, (e.g. informing the perpetrator of their wrongdoing) and preventing any further breaches (eg. by destroying the information)

37

Doctor refers a family member to you directly to circumvent usual procedure
- what do you do?

- Tell them that this is inappropriate according to GMC guidance
- Advise they instead take their family member to A+E or go via their own GP

38

Referring to another speciality (eg. you are on A+E with a patient who has suspected ACS and try to refer to cardiology as per local guidelines, but they decline)
- what should you do?

- Seek senior support from your own team to help with both the ACS patient and the referral decline
- Then try again to refer (if necessary go higher up than before, i.e. consultant rather than registrar)

(note: make sure you have all the necessary information you need before referring - if you don't, you will piss of the speciality you are referring to)

39

Patient dead, death certificate needed quickly for religious burial reasons. You have been asked to see this patient but have never met them.
- what should you do?

- Contact the ward manager to see if there are any other doctors in the hospital who are able to sign the death certificate
- If this fails, escalate the relatives' request to the on-call consultant

You MUST NOT complete a death certificate yourself for a patient you have never met. You should also avoid calling doctors who are not on shift to do this (better to find someone who is on shift who has seen the patient

40

Family/patient ask questions which are above your pay-grade (eg. about the management and prognosis of a very rare rheumatological disease)
- what should you do?

- Contact a senior to come and talk to them
- Tell them they should wait to speak to a senior
- Explain what little you do know, but without giving any misinformation
- Explain that you are not expected to know this as an FY1 doctor

"Prior to any conversation you should check the clinical notes (C) to ensure you can communicate with the relative in question and to give accurate information"

41

Assessing ability to cope at home/ appropriate discharge

Ask patient
Ask OT to assess
Ask family

42

DNAR on frail person with no obvious DNACPR
- what to do?

- Commence CPR
- Ask nurses to look for DNACPR
- Discuss the benefits of continuing

43

You are on your break and nurse tells you about a very unwell patient just admitted
- what should you do?

You should finish your break (C)
Assess the patient (H) without delay,
Ask the nurse to return to the patient and take a full set of observations (E).

44

One colleague makes allegations about another
- What should you do?

- Emphasise the severity of making such allegations
- Advise they talk to the person in question
- Seek senior advice

(paper 2 advises not to start investigations as an FY1 but what about paper 1?)

45

FY1 doctors should always work within...

their limits !
- escalate when appropriate

46

Breaching confidentiality as an FY1

- Should consult a senior

47

If a colleague is in breach of GMC guidance or hospital protocol, it may be appropriate to politely....

...remind them of GMC guidance / hospital protocols

48

Staying late
- what duties are important and which can wait?

Reviewing patients - important to complete

Operational tasks (eg. non-urgent paperwork) can wait and can be handed over