Pre-Registration Examination System — Level 2 (written)

An 80-year-old woman admitted with pneumonia becomes acutely confused overnight. She is disorientated in time and place, drowsy but rousable, with fluctuating attention. Her confusion was not present on admission. Oxygen saturation 93% on air, temperature 38.1°C. What is the most appropriate first step?

1. Arrange urgent CT brain Not first. Imaging is indicated for focal neurology, head injury, or delirium that fails to explain itself. Here there is a clear infective precipitant.
2. Apply physical restraints for her own safety Wrong. Restraint escalates agitation, risks injury, and raises serious legal and ethical problems.
3. Prescribe a benzodiazepine for sedation overnight Wrong, and likely to worsen things. Benzodiazepines prolong and deepen delirium, except in alcohol withdrawal where they are the treatment.
4. Identify and treat the underlying precipitants, and use non-pharmacological delirium measures correct Correct. This is delirium precipitated by infection and hypoxia. Management begins with finding and treating causes, infection, hypoxia, pain, constipation, urinary retention, drugs, plus reorientation, familiar faces, daylight, hearing aids and glasses.
5. Prescribe regular haloperidol Wrong as a first step. Antipsychotics are for the distressed or dangerous patient in whom non-drug measures have failed, at the lowest dose for the shortest time. They do not treat delirium and increase mortality in dementia.

The point: Delirium is acute, fluctuating and attention-based; diagnose clinically with 4AT or CAM. Treat the cause, optimise the environment, and reach for antipsychotics only for distress or danger that non-drug measures have not settled.

Source: NICE CG103 — Delirium: prevention, diagnosis and management NICE · tier 1, national regulator or guidance

You are an intern in an Irish hospital. You realise that yesterday you prescribed a dose of gentamicin ten times higher than intended. The nurse noticed and did not administer it, so the patient came to no harm. What is the most appropriate action?

1. Report it through the hospital incident reporting system and inform your supervising consultant correct Correct. Near misses are reported precisely because no harm occurred. They reveal the system weakness at no cost to a patient. Openness with your supervisor is a professional duty, not a career-ending admission.
2. Report it only if the nurse raises it formally Wrong. The duty rests with you and does not depend on whether someone else acts first.
3. Discuss it informally with a peer and move on Insufficient. Peer support matters, but it does not produce the system learning that formal reporting does.
4. Correct the prescription chart quietly and say nothing Wrong, and considerably worse than the original error. Altering documentation to conceal an incident is a probity issue regulators treat far more seriously than a prescribing mistake.
5. Take no action, since the patient came to no harm Wrong. Unreported near misses are how the same error reaches the next patient, who may not have an alert nurse.

The point: Near misses are reportable. Candour, incident reporting and early escalation are examined behaviours in every licensing exam in this catalogue, and concealment is what ends careers rather than the error itself.

Source: Medical Council of Ireland — Guide to Professional Conduct and Ethics Medical Council of Ireland · tier 0, exam blueprint / regulator