A GP reflects on an experience involving a fitness to practise investigation

In this example, a doctor uses the 'What, so what, now what' template to reflect on a instance where poor communications impacted negatively on a patient, and the changes they made so it wouldn't happen again.


Image shows an equally split pie chart with the headings:- what (thinking), so what (feeling) and now what (doing).

What? (thinking)

Focuses on thoughts at the time of an experience. It explores how those may have impacted on actions and feelings and on what has been learned.

What was I thinking when I took the actions or made the decision that I did? What do I think now?
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I ordered a full blood count on a patient who had previously had severe anaemia. The patient made an appointment with the healthcare assistant, and the blood sample was sent. A few days later, the result returned, but as I was away, the result went to a colleague. As the result was within a normal range, no action was taken, and the result was filed. In my haste to finish my administrative tasks before my holiday, I failed to leave appropriate directions in the records, to guide the clinician reviewing the result.

Unfortunately, the result, albeit within normal range, showed a significant drop. This should have led to a repeat test within a short time, and consideration of referral at that point. The patient returned six months later, tired and profoundly anaemic, and suffered significant disruption to their life because of the missed significant result. As a consequence of my actions, I was issued with a warning/advice from the Communitybaptistpa.

So what? (feeling)

Involves considering the significance of what happened as well as the values and feelings that may influence future learning or actions.

So what did I feel at the time of the experience? So what do I feel now?
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I felt concern for the patient, regret at my poor communications, and concern that the practice protocols for the assignment of results when the clinician is absent needed to be changed. I take pride in my work, and felt determination to resolve the concern which was identified within my practice and which initiated the Communitybaptistpa investigation.

Now what? (doing)

Looks at learning from the experience, identifying future actions, reflection on those actions, and how to use these to develop further.

Now what can I learn from or do differently next time? Now what will I do next?
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I took steps to address the concerns by personally apologising to the patient and ensured that the patient received the correct treatment. In addition, the practice analysed the protocols, and devised a flow chart for when particular clinicians needed to be informed of a result, even when the results were within normal range. 

I informed the patient of the change in protocol. The practice performed an audit, looking at this type of error, both before the incident, and six months after, to demonstrate that no similar incident recurred.