Someone’s looking over your shoulder... (Emma Graham-Clarke)

It’s been a funny old autumn. I seem to have had someone with me permanently — either being taught about critical care or doing one of several peer reviews that have been going on. I find that there’s nothing quite like having someone look over your shoulder as you prescribe to make you think twice about everything you write.

Then there are the questions — “why did you choose that particular drug for night sedation?”, “why have you changed the dose … ?” and so on.

Each pause, and each question, carries its own issues. “Why did I choose lansoprazole for the woman in bed 9?” That one is easy to answer — she’s absorbing drugs via her NG tube, we want to reduce the number of IV drugs she receives, I can use orodispersible tablets and it happens to be the formulary choice — no contest!

On the other hand, the man in bed 12 is a bit more of a challenge. The cardiologists have requested a low molecular weight heparin to anticoagulate him; the choice is simple — the formulary has only one — the dose is more of a problem. Up until today his renal function has been fine, but it’s taken a little bit of a dip today, his creatinine levels have risen and his urine output has dropped.

Most of the dose adjustments given in the reference books depend on the renal function being stable and his really isn’t. As a result I can’t rely on calculating a creatinine clearance for him and using that as a basis for dose adjustment. The ward round discussion doesn’t really clarify matters — we don’t know if this is a result of disease progression or just a one-off. I decide to err on the side of caution and go for a reduced dose.

By the following day his urine output has picked up and his creatinine levels have started to drop again — I review the prescription and increase the dose. Thinking about it later, could I have done anything differently? The answer is probably not — because generally I tend to be cautious.

Would one of my medical colleagues have done it differently? Now that’s a difficult question. I find we tend to approach prescribing from different perspectives — I start warily; they’re more bullish.

Having someone looking over the shoulder of late has made me stop and think about my actions. Even if they’re silent, I find I end up mentally asking myself questions, and challenging myself on my prescribing.

I would hope that I never become complacent when prescribing — but I do get into a comfortable way of working and being asked questions provides a good reality check. Uncomfortable as that can feel, it’s a good thing to happen.

 

Emma Graham-Clarke is consultant pharmacist for critical care at Sandwell and West Birmingham Hospitals NHS Trust