Your FY1 prescribed 10x the correct dose of digoxin to an elderly patient who has now developed bradycardia and nausea. The FY1 is in tears. How do you manage this?

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Accepted Answer

I would manage this in three parallel streams using **SPIES**.

**Patient safety first.** I would attend the patient, ABCDE, monitor, 12-lead ECG looking for bradyarrhythmia and digoxin effect, check U&E, magnesium and digoxin level, and call TOXBASE / the on-call toxicologist. **Digoxin-specific antibody fragments (DigiFab)** are indicated for life-threatening arrhythmia, K+ >5 in acute toxicity, or significant ingestion — I would discuss criteria with toxicology and my consultant.

**Seek information & escalate** — phone my medical consultant and the clinical site manager. This is a serious incident and they need to know now.

**Duty of candour.** Once the patient is stabilised, I — ideally with the consultant — would speak to the patient and family, **apologise sincerely**, explain what happened in plain language, outline what we are doing to put it right, and document the conversation in the notes. This is both an ethical and a statutory duty.

**Datix and governance.** I would Datix the incident framed as a *systems* event: was the prescribing chart clear, did the BNF look-up happen, was supervision adequate? I would expect a serious incident review or at least an M&M.

**Support the FY1.** She is a second victim. I would sit with her, separate her from the patient encounter once the immediate response is over, debrief, normalise her distress, and inform her educational supervisor and the GoSW. She should not be left alone or scapegoated. Learning, not blame.

I would also reflect in my portfolio and present the case at the next M&M with the FY1's permission, so the team learns.

Error disclosure — significant medication error by an FY1

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