Much of our work is initiated by a clinician requesting that a cast technician apply, remove or modify a cast. We may also be asked to supply, fit, remove or adjust a certain type of brace or splint. The treatment request may contain highly specific instructions and it may be given to us verbally.
It should always be noted in the clinical care record of the patient. More often than not, a request for treatment will be offered to cast technicians on a pro-forma that provides the clinician with a set of options that can be selected by means of tick boxes.
Lately, I have received many printed sheets of tick boxes, which have been completed by people who are not the prescribing clinician. They were completed by staff who are assisting with running the clinic and they frequently do not have sufficient knowledge to complete the treatment request. This has led to several potential disasters; which were only prevented by me questioning the prescribing clinician.
The act of copying instructions from a previous entry in the clinical care record onto the treatment request pro-forma is a potentially risk-filled activity. The clinical care record may not have the last clinic attendance detailed because of work pressures in the typing pool.
The wrong instruction may be written on the treatment request sheet. The wrong tick box may be filled and it may still make some sort of sense (albeit that the instruction is incorrect) to the cast technician.
I was recently asked to provided a walking cast, where a child of seven years old had sustained a spiral fracture of the distal third of tibia. Radiologically, there was evidence of an external rotation injury and two clear lucent lines were visible running almost parallel to each other, with a segment of metaphyseal and diaphyseal tibia between the fracture lines. The child had been in an above knee cast for less than three weeks.
A radiological examination revealed a 5mm gap between the segments, with a central segment of around 1cm in width, plus a small amount of callus formation. The fragments had not moved in their relationship to each other but expecting a seven year old child to walk carefully, in a below knee cast so soon after the initial injury was clearly optimistic.
The treatment request had been completed by a qualified nurse who was administering the clinic. Noting and copying the previous clinic letter intention and using that as the basis for making the treatment request had almost resulted in disaster.
The incident qualifies as a ‘near miss’ because it was the practice in that location for clinician instructions to be followed without question. The severity of the issue was compounded by the treatment request sheet being undated and unsigned by the prescribing clinician. On the day itself, it may seem very easy to know that a specific request for treatment was presented (by a certain clinician) during a particular clinic.
Eighteen months further on in time and it will be difficult to remember the exact details without clear documentation of the where, when, why, how and who of that particular situation. Unsigned treatment requests are unacceptable practice and it is not professional to act upon them.
In the event of a later dispute, the cast technician will end up as the responsible person for doing the wrong thing, where the treatment was carried out but the prescription for the treatment applied by the cast technician was not valid.
For the prescription to be valid, it should ideally be legible and hand-written by the prescribing clinician. The prescription should be written on a document that is identifiable as clearly belonging to the patient for whom it is intended. This should preferably be in the patient's clinical care record. If it is made on a separate sheet, the prescription sheet should bear the patient's own unique identification marks... usually a a printed label bearing the patient's name, address, hospital number and date of birth.
The separate sheet should also detail the location, the date and carry the clinician's signature. Anything less is not really a valid treatment request and cast technicians will act on such requests at their own and the patient's peril. Verbal instructions from a clinician by telephone, should be backed up with a formal treatment prescription sheet just as soon as it becomes practical. Some organisations do not permit any treatment to be completed without a written prescription.
Technology has moved at a rapid pace and it is not uncommon to see computer administration systems which are used to administer the clinic environment. In these locations, the patients book themselves into the clinic by means of touch screens. Large screens spread throughout a clinic environment inform the clinic staff when patients are in the X-ray department, the plaster room, the waiting area or with the clinician.
Treatment options may be selected via a computer and very little writing takes place. The cast technician may be limited to stating cast on or off because free text space is limited. Patients who attend with cast problems are not recorded because they have not been given a formal clinic appointment.
The computer administration system does not let cast technicians write their own clinical attendance note. It is crucial that under such circumstances, the cast technician has no doubt about the provenance of a treatment request and what must be done to apply or vary the treatment.