A Clinical Risk Case Study- The Importance of Appropriate Risk Assessments Before Prescription

A Clinical Risk Case Study- The Importance of Appropriate Risk Assessments Before Prescription

Setting the Scene

An elderly patient attended their GP after experiencing pain and stiffness in their joints. The GP carried out a brief review and suspected that the patient was suffering from an arthritic condition, and consequently undertook blood tests. They were subsequently diagnosed with polymyalgia rheumatica.

The patient was prescribed a corticosteroid per national guidance. No discussion, however, took place around the risks of taking daily steroids and particularly the risk of osteoporosis and osteoporotic fractures. No bone protection was offered or prescribed to the patient, despite them being at risk of developing osteoporosis due to their age, gender and the result of a previous scan confirming the presence of osteopenia.

The patient’s symptoms were widely relieved initially, but they subsequently developed further symptoms and were diagnosed with osteoporosis and fragility fracture of the pelvis.

The main learning points from this review stem from the following events:

  • There was no consideration or discussion of the risks of taking daily steroids in relation to bone strength.

  • The GP did not review the patient’s prior history including recent scans and test results

  • There was not a deep enough consideration of the side effects of corticosteroid based on the patient’s individual presentation and other clinical risk factors.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

This case can prove to be a valuable learning experience for GPs across the country. TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

  • It is essential that GPs carry out accurate and appropriate assessments of their patient’s risk factors before prescribing. GPs need to consider their patient’s individual circumstances and clinical risk factors, as these may impact the decision as to what treatment is prescribed. GPs must ensure they discuss and consider the potential risks associated with the prescription, when compared to their patient’s clinical presentation and other co-morbidities.

  • In this case, the elderly patient was not individually assessed as their age and gender meant they were at a greater risk of developing osteoporosis. Despite this, they were prescribed treatment with the side effect of bone weakening without taking into account the need for bone protection.

  • In addition to considering the patient’s individual clinical presentation, GPs should also ensure that they take into account any tests that the patient has undergone previously. All tests carried out must be considered in full before prescribing treatments to patients in order to ensure that the chosen prescription does not expose the patient to unnecessary risks/harm. In this case, a scan undertaken prior to the appointment was not taken into account. The scan indicated that the patient was at risk of osteoporosis.

  • It is further important that GPs disclose any options of alternative appropriate treatment to their patient and the risks associated with these. In this case, had there not been an alternative treatment, a supplementary prescription of bone protection should have been considered, given the patient’s high-risk factor for developing osteoporosis.

  • GPs and other clinicians should be mindful when prescribing Corticosteroid to elderly patients. Corticosteroids can cause a number of side effects including:
    • Indigestion or heartburn
    • Increased appetite, which could lead to weight gain
    • Difficulty sleeping
    • Changes in mood and behaviour, such as feeling irritable or anxious
    • An increased risk of infections - especially chickenpox, shingles and measles
    • High blood sugar or diabetes
    • Weakening of the bones (osteoporosis)
    • High blood pressure
    • Cushing’s syndrome - symptoms such as thin skin that bruises easily, stretch marks on the thighs, and fat deposits in the face
    • Eye conditions, such as glaucoma and cataracts
    • Mental health problems, such as depression or suicidal thoughts

Many of these side effects are a greater risk to elderly patients given their exsiting co-morbidities, therefore, it is especially important that GPs are mindful of their patients’ existing conditions and previous medical history when prescribing treatment. All risks should be discussed with patients alongside risk prevention, which in this case would have been to prescribe bone protection alongside corticosteroid.

To Summarise

In summary, this case concerns the importance of carrying out thorough and accurate risk assessments of patients before treatment is prescribed. Corticosteroids should be prescribed mindfully, by weighing the benefits with the risks, in patients who are already at risk of the side effects associated with taking steroids on a daily basis.

TMLEP would like to highlight how important it is to consider each patient individually and assess the potential risks in light of the individual’s clinical presentation, age, gender and other clinical factors, such as test results.

References

  • Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group, Mr Maximilian Macdonald LLB (Hons) and Dr Shivani Tanna BSc MBBS DRCOG MRCGP PGCE. (2019). A Clinical Risk Case Study- The Importance of Appropriate Risk Assessments Before Prescription. TMLEP Clinical Risk Case Studies. 4 (3), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.