Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: A Sgt is in charge of the medical unit. A doctor at the rank of Lt Col who is renowned for being abrasive has prescribed a soldier penicillin despite being allergic to it. This is the second time the doctor has done this. What should the Sgt do?
• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers poor practice and or a lack of clinical competence in prescribing medicines by the doctor. It also covers military rank structure with a lower rank observing sub-standard clinical care and unsafe clinical practice by a higher rank and how they should deal with such a circumstance. In addition, it raises the issue of inappropriate professional behaviour by a higher ranking officer to a much lower rank.  In both instances it raises the issue of disclosure for the unsafe practice and behaviour by a junior person (or any witnesses) to an appropriate senior person without fear or reprisals.  

Step 2 – ANALYSE

Patient: two principles of Beneficence, Non-maleficence apply. Justice could also apply in relation to fairness and equality towards both individuals.  The patient has the right to receive care from a safe practitioner and not one that potentially could put their patient’s health and well-being at risk from harm due to a medication prescription error. In addition, any healthcare professional ought not to be fearful of raising a safety issue with any colleague. In turn, a colleague should never be abrasive in the workplace.  There must be acceptance and acknowledgement though that in some circumstances giving healthcare can be stressful.    

Clinical: This raises concerns about clinical competence by the medical doctor.  It seems difficult to understand why a doctor irrespective of rank fails to check either with the patient and or in the patient’s records prior to prescribing penicillin that, the patient is allergic to penicillin. The medical doctor, irrespective of rank is responsible for the prescriptions they sign. They must only prescribe drugs when they have adequate knowledge of the patient’s health and are satisfied that the medicine or treatment serves the patient’s needs. The doctor has exhibited unsafe practice to their patient by not checking with the patient or in the patient’s medical records prior to prescribing a drug that the patient is allergic to. Through the doctor’s actions there is potential of harm to the patient. If the drug had been administered, although the person giving the drug would be at error for not checking that the patient was allergic to penicillin, those actions would not exempt the doctor from blame as they too would be accountable for prescribing a drug they should not have prescribed. 

The International Council of Nurses Code of Ethics is at: ICN_Code-of-Ethics_EN_Web.pdf

At section 1.9 it states, ‘Nurses facilitate a culture of safety in health care environments, recognising and addressing threats to people and safe care in health practices, services and settings.’ All healthcare regulators code of practice, which are enshrined in legal statutes say that their primary function is the protection of the patient. This includes good and safe practice when administering medications and adhering to the following principles:

1. Make patient safety the first priority and raise concerns if the service or system they are working in does not have adequate patient safeguards including appropriate identity and verification checks.
2. Understand why patient identification is important especially with vulnerable patients and to take appropriate steps to protect them.
3. To avoid medication errors good practice involves ensuring medication is given to the right patient, the right drug, the right does, the right route and at the right time

In this international ethics code, it also states that nurses (this will apply to all healthcare professional) must also be fit to practice and have the skills, knowledge and competence to practice safely.

As an example of national UK guidance, the UK regulator, the Nursing Midwifery Council has a standards of proficiency document named ‘Future nurse: Standards of proficiency for registered nurses: This can be found at:  future-nurse-proficiencies.pdf (nmc.org.uk) At section 11, it explains the necessary standards for best practice in the administration of medicines.

The issue that the doctor is renowned for being abrasive could raise an issue of the junior person failing to report the incident to a senior colleague, which ultimately could continue the risk of the doctor harming patients by incorrectly describing medication they are allergic to.

Legal: The World Medical Association (WMA)at WMA International Code of Medical Ethics – WMA – The World Medical Association state under general principles paragraph 1 that, “The primary duty of the physician is to promote the health and well-being of individual patients by providing competent, timely, and compassionate care in accordance with good medical practice and professionalism.”    Clearly, competent care includes prescribing correct medication to patients.

Societal/Military: Re: the doctor’s abrasive behaviour, at paragraph 37 under ‘duties to society’ the WMA state that, “The physician should avoid acting in such a way as to weaken public trust in the medical profession. To maintain that trust, individual physicians must hold themselves and fellow physicians to the highest standards of professional conduct and be prepared to report behaviour that conflicts with the principles of this Code to the appropriate authorities.” Accordingly, the employer (adjutant) has the right to know about the fitness to practice of his employees (this includes clinical competence) and a duty to provide welfare support to military personnel. Moreover, they should have knowledge where any military person is not behaving at the professional standard and conduct expected of them. There is a risk here that the Sgt may fail to report the Lt Col due to the renowned abrasive behaviour which could be construed as not only bullying and intimidating of junior personnel but putting patients at risk.

The employer should act first to deal with concerns about a registrant’s fitness to practice, unless the risk to patients or the public is so serious that they need to take immediate action. In this case, it could be not allowing the Lt Col to prescribe any medication until an investigation and or risk assessment as to their competence has been carried out followed by some re-training and assessment to ascertain they are safe to prescribe.  Although unlikely in this particular circumstance, it could be that the employer believes they have reached a point where no further support could be provided and the issue is so serious it warrants referral of the Lt Col to their regulator. They could believe the Lt Col’s practice is impaired and there is possible professional misconduct.  Conversely, before any referral they may wish to consider if the Lt Col has shown insight and willingness to put their clinical concerns, right?

As an example of national guidance, the United Kingdom’s document titled ‘Good practice in prescribing and managing since and devices’ at Good practice in prescribing and managing medicines and devices (gmc-uk.org) is a useful guide for doctors to consider when prescribing medication and when you share responsibility for your patient with a colleague.  This guidance also gives important advice how to work safely in a variety of different environments.

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

This scenario balances military rank with professional clinical practice. There should invoke discussion about the dual loyalty of clinical professionalism and military obligations.

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

The Adjutant should be given factual information regarding the immediate implications of the Lt Col’s fitness to practice safely concerning prescribing medication. For patient safety and the reputation of the employer it may be good practice to prevent the Lt Col from prescribing any medication until their actions are investigated and a discussion with the Lt Col has taken place with a senior colleague to ascertain if any re-training is necessary. If there does appear to be some clinical concerns then only in the exceptional of circumstance (if there is risk of patient harm) should the Adjutant in consultation with senior doctors and the Commanding Officer consider any potential referral to the doctor regulator, the General Medical Council in the UK GMC.  From the start, it may also be beneficial to discuss with the Lt Col why they have prescribed medication that the patient is allergic to and if there is anything else that is causing them to behave aggressively to colleagues.

References:

International Council of Nurses (Revised 2021), The ICN Code of Ethics for Nurses at Code. Available at ICN_Code-of-Ethics_EN_Web_0_0.pdf; accessed 24 August 2023

Nursing Midwifery Council: Future nurse: Standards of proficiency for registered nurses. Available at future-nurse-proficiencies.pdf (nmc.org.uk); accessed 24 August 2023

Contributor - Lt Col Janet Kelly VR RGN RM DIpHSM MA (HRM) LLB (Hons) PGHCE PhD. Senior Lecturer in Midwifery, Healthcare Law & Ethics; University of Hull. Chair for the Nursing Midwifery Council's Fitness to Practise Conduct and Competence Committees (2013 to 2021). She has served as a commissioned officer in Queen Alexandra's Royal Army Nursing Corps both as a regular and reservist for over 30 years and is now at the rank of Lieutenant Colonel.