Medication error — insulin overdose disclosure
PLAB 2 & PRES 3 · communication · hard · 8 minutes
Candidate brief
You are an FY2 doctor/SHO on an acute medical ward. Mrs Aisha Khan, 61, was prescribed 4 units of rapid-acting insulin before lunch but was mistakenly given 10 units. She subsequently developed symptomatic hypoglycaemia, which has been treated. The medication chart and administration record have been reviewed with the medical registrar, confirming the error. Mrs Khan is now clinically stable. Explain what happened, apologise, address her concerns and discuss the monitoring, investigation and follow-up plan. The medical registrar is available nearby.
What examiners look for
Patient safety comes first. Assess and treat any continuing harm before beginning a detailed disclosure conversation. Use clear words. State exactly what was prescribed, what was administered and what effect it had. A suitable opening is: “I am sorry. You were prescribed 4 units of insulin, but 10 units were given. This caused your blood glucose to fall too low.” An apology should be sincere and personalised. Avoid vague expressions such as “an unfortunate event occurred.” Do not speculate about why the error happened or blame an individual before the incident has been properly reviewed. Explain what is known, what remains uncertain, what treatment has been provided and what monitoring is still required. Do not promise that nothing else can happen or that the error can never recur. Explain the practical steps being taken to reduce the risk. Open disclosure may require more than one conversation. Give the patient a named contact, arrange an update and involve relatives only with consent. Document the clinical event and disclosure in the healthcare record. Complete the separate patient-safety incident report according to local policy. Reporting is intended to support learning and prevention. It must not replace immediate care, honest communication or follow-up.
Guideline references
- https://www.gmc-uk.org/professional-standards/the-professional-standards/candour---openness-and-honesty-when-things-go-wrong
- https://www.gmc-uk.org/professional-standards/the-professional-standards/candour---openness-and-honesty-when-things-go-wrong/being-open-and-honest-with-patients-in-your-care-and-those-close-to-them-when-things-go-wrong
- https://www.england.nhs.uk/long-read/patient-safety-incident-response-standards/
- https://www.england.nhs.uk/long-read/patient-safety-incident-response-framework/
- https://www2.healthservice.hse.ie/organisation/qps-incident-management/open-disclosure/
- https://www2.healthservice.hse.ie/organisation/national-pppgs/hse-open-disclosure-policy-communicating-with-patients-and-relevant-persons-following-patient-safety-or-notifiable-incidents/
- https://www2.healthservice.hse.ie/organisation/qps-incident-management/open-disclosure/patient-safety-notifiable-incidents-and-open-disclosure-act-2023/
- https://www2.healthservice.hse.ie/organisation/national-pppgs/hse-national-clinical-guideline-for-the-diagnosis-and-treatment-of-hypoglycaemia-in-adults-with-diabetes-mellitus-in-acute-and-non-acute-settings/
- https://www.nhs.uk/conditions/low-blood-sugar-hypoglycaemia/
- https://www.medicalcouncil.ie/news-and-publications/publications/guide-to-professional-conduct-and-ethics-for-registered-medical-practitioners-2024.pdf
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