Table 3 Delay in administering antibiotics

4.25 pm- [Following prompt initiation of the Sepsis Six] the consultant has prescribed one of the antibiotics.

4.45 pm Antibiotics are still not given. The nurse has moved on to another patient who has just been admitted.

5.05 pm- [FY1] asks how much the patient weighs. They can’t weigh him so he is going to estimate it. He is going to give the patient Gentamicin as well as the Amoxicillin. I watch as he reviews the consultant’s notes. Meanwhile the nurse is putting a bag of fluids up. I hear the FY1 ask the patient some questions about where he is [i.e. undertaking a dementia assessment]. The nurse then tells me she will give the antibiotics once the doctor tells her the dose of Gentamicin.

5.20 pm-The doctor prescribes the Gentamicin. The nurse gets caught up with relatives from another admission as the [new] patient has dementia and can’t tell her anything.

6 pm- The nurse is still with the relatives.

6.30 pm - Both the antibiotics are signed for by two nurses, but a nurse is still not available to administer them.

7.15 pm- Finally I watch as the nurse administers the patient’s antibiotic, almost 3 hours after they were first prescribed (Fieldnotes, Site 4)