RCA Calibration Tool: How to Use the Cases

Case 12

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Remember, before reading the analysis, ensure you have listened to the recording, made your own notes and completed your own assessment of the case.

This audio recording is of a consultation regarding a patient who had requested further medication.

Analysis

Summary

Cases for the RCA need to provide some challenge. On the whole they should be undifferentiated; i.e. not seen before single issue and provide some challenge. This consultation a review is an example of a type of case not to submit .There is no diagnostic or clinical challenge and the doctor potentially could have worried the patient with inaccurate explanations

Timeline

0.00 Doctor introduces himself and says understand wishes to discuss some medication.

0.20 patient says needs medication review for lansoprazole. Has been on 5 years for reflux, initially higher dose had had some tests.

0.58 Doctor asks about tests and patient had endoscopy a few years ago.

1.37 Doctor asks what endoscopy showed and patient says lots of acid and negative helicobacter. Doctor says also showed hiatus hernia.

No new information has been obtained so far, The doctor is picking on cues (eg tests).

2.30 Doctor asks about how affecting day to day patient; patient says only if runs out of tablets or misses taking or after alcohol/curry.

3.05 Doctor asks if has altered diet as a result and patient says drinks less beer and may take 2 lansoprazole after curry.

Superficially sounds good in that open question re effect on life, but the patient has already told us this and we are not seeing a new differential or information that will lead to a change in management.

4.35 Doctor asks about alcohol intake. Patient says now drinking less only Friday/Saturday.

5.10 Doctor delivers 14 units max alcohol lecture.

Inappropariate. The patient is drinking within guidelines and has already reduced again no need for alcohol lecture and doesn’t result in any change in situation.

5.31 Doctor asks if any other symptoms like problems with tummy. Patient says initial nausea. Regarding bowels – no change. Regarding stool – no black stools. Weight loss but because trying to.

Reasonable assessment of potential red flags.

7.00 Doctor asks about home life. Patient says odd job man; stressful as not much work during pandemic, doctor says stress can make acid worse and patient says not stressed.

Doctor is working hard to create a differential but it feels manufactured and unnecessary. It feels like this consultation would have been the “catch up” in a busy surgery… it’s not one for the RCA.

7.45 Doctor asks if any worries and patient says no should he be, could he get addicted and Doctor says can come to that.

8.22 Doctor asks if any expectations and patient says just my prescription.

Clunky ICE doctor doesn’t even answer question asked re addiction or what does the patient mean by that ?

8.50 Doctor says doesn’t sound like getting any side effects. Long term can thin bones, just wants to make aware, so may want to reduce at some point.

9.28 Patient asks what needs to do. Doctor says in future may want to consider reducing, but sounds like still needs Also needs to make aware risk diarrhoea with Clostridium difficile. Patient not aware.

Osteoporosis is a risk in those at risk – he isn’t. Clostridium difficle is associated mainly in hospitalised patients so these are for him low risk serious complications which potentially could have worried him and stopped him taking the effective treatment . Poor information is worse than no information

10.25 Doctor asks if concerned now, patien.t says no. Doctor says always safety nets, so if struggling sleep confused or anything abnormal get back to him

Safety netting needs to be appropriate to the situation. Is one actually needed here? Maybe if it stops working or if you notice black stools but not a disaster safety net

11.25 Indicates will be another review in 6 months

Why is a 6 month review needed? Why with a doctor ?

11.42 End

RCA Assessment

RCA assessment Overall: Clear Fail

Data Gathering: Fail

Hardly any new information is obtained. The past history is reviewed. There is no need to create a differential as the diagnosis is established. Job data is asked for as an aside rather than used. Current symptoms are reviewed however a pharmacist could have done the same review. Close to a Clear Fail.

Management: Clear Fail

No new management. A repeat prescription and a lecture on alcohol for someone already drinking within recommended limits. An inappropriate safety net.

Interpersonal: Clear Fail

The side effects described didn’t relate to the patient and could have worried and stop him taking an effective medicine. ICE was clunky and almost irrelevant he just wanted a repeat prescription There was no empowerment of the patient.

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