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Prescribing medication–statutory Requirements

Requirement	Details you must include on every prescription (Medicines Act 101/1965 regs)
Prescriber	Full name, HPCSA registration & practice numbers, qualifications, physical & postal address, contact number.
Patient	Name, age / DOB, gender, physical address.
Medicine	Approved (generic) or proprietary name, dosage form & strength, total quantity (in words and figures), dose + frequency, route, specific handling instructions.
Validity / repeats	State the number & interval of repeats, or “no repeat”. Sign in ink or with advanced electronic signature; stamp or print professional details.

Controlled-substance Summary

SA Schedule	Max repeats / supply window	Script validity	Extra statutory rules
S2–S4 (e.g. amoxicillin, tramadol)	Up to 5 repeats within 6 months	6 months	Quantity per repeat = ≤ 30 days’ supply (chronic Rx may state longer interval if justified).
S5 (e.g. diazepam, codeine >20 mg)	Max 5 repeats in 6 months; specify interval	6 months	Anxiolytics/antidepressants: psychiatrist review if > 6 months; analgesics: second prescriber review if > 6 months.
S6 (e.g. morphine, oxycodone)	No repeats–fresh prescription each issue	30 days	Original written or advanced e-script; keep copy ≥ 5 years.
S7/ S8 (e.g. ketamine, cannabis for medical use)	None–single supply only	30 days	Before issue the prescriber must hold a section 22A(9) permit from the Director-General & name the patient on the permit.

• Electronic prescribing: SAHPRA 2021 amendment permits digital-only scripts if they bear an advanced electronic signature that is auditable. Paper or e-copy must be archived ≥ 5 years.

Conflict Management & the Impaired Colleague

• SPiES rapid framework (Association of Anaesthetists/SASA wellbeing tool, 2023)

Step	Actions
Seek information	Introduce purpose (reports that prompted concern), non-punitive, gather facts (listen, listen); explore stressors (family, finances, substance use, workload)
Patient safety first	Remove clinician from clinical area if unsafe; arrange cover.
Initiative	Offer immediate support and testing (taxi home, GP referral, 24-h helplines).
Escalate	Inform on-call consultant / clinical manager; activate hospital Employee Assistance Programme. If impairment suspected, submit confidential Form IP-01 to the HPCSA Impaired Practitioners Programme.
Support	Follow-up meeting within 48 h; agree written plan (sick leave, therapy, mentor). Document and store securely.

• Key legal & ethical points
  • Duty of care overrides colleague confidentiality where patient safety is at risk (HPCSA Booklet 2 Rule 25).
  • Keep a factual record of all discussions; avoid emotive language.
  • Encourage self-reporting; facilitate access to doctor-support groups (e.g. South African Doctors’ Support Group helpline 0800 21 22 23).

Structured Conversation with an Impaired Colleague – Nine Practical Steps

1. Clarify the purpose
   • State specific observations or reports that prompted concern.
   • Emphasise a supportive, non-punitive intent.
2. Listen
   • Invite the colleague to respond; avoid interruptions.
   • Reflect back key concerns to show understanding.
3. Listen some more
   • Allow silence; give space for additional information or emotion.
4. Explore stressors
   • Ask open questions about family, finances, substance use, workload, health.
5. Screen explicitly for mental-health issues
   • Acknowledge high suicide risk in doctors; ask clearly about mood, thoughts of self-harm.
6. Agree an ongoing support plan
   • Identify existing supports (GP, therapist) and gaps; document agreed actions.
7. Address on-duty impairment/intoxication
   • Facilitate immediate cover and safe transport home or to care.
   • Encourage self-reporting to the HPCSA Impaired Practitioner Programme; supply contact details for doctor support groups.
8. Promote appropriate leave
   • Recommend sick leave if fitness to practise is doubtful.
   • With consent, inform the Head of Department; keep confidentiality otherwise.
9. Summarise & invite questions
   • Recap the agreed plan, timelines and responsibilities.
   • Check understanding; schedule a follow-up meeting within 48 h.

• Document the discussion factually and store it securely in line with HPCSA and hospital policies.

Impaired clinician–organisational Response Pathway (after Spies Had Been implemented)

Step	Action
1 Report	Notify on-call consultant / head of department as soon as impairment suspected.
2 Formal meeting	Arrange confidential meeting within 24 h; expect possible anger or denial.
3 Objective testing	Offer breathalyser / toxicology screen or occupational-health eval.
4 Family involvement	With consent, engage supportive relatives or close contacts.
5 Rehabilitation plan	Confer with HPCSA Health Committee; determine fitness for duty and mandated treatment or abstinence monitoring.
6 Graduated return	Follow Angres criteria: immediate return, delayed return after rehab, or redeployment to non-anaesthetic role; maintain random testing & mentor reviews.
7 Chronic-disease model	Treat substance-use or mental-health disorders as long-term conditions with ongoing surveillance and relapse-prevention support.

• (Aligned with HPCSA “Management of Impaired Practitioners & Students”, 2023.)

Adverse Event Reporting Framework

Use SAFESTAR for Any Clinical Incident

Letter	Action	What you do	Timing / follow-up
S	Stop further harm / Secure the patient	Airway–breathing–circulation check, halt the offending process, isolate any contaminated lines, call for senior help.	Immediately
A	Assess & assign SAC level	Measure vital signs, review notes, confirm drug/device, decide SAC 1 / 2 / 3 (or near-miss).	Within minutes
F	Fix / mitigate now	Give antidote, extra monitoring, move to PACU/HDU, adjust treatment plan, document orders.	Within first hour
E	Explain (duty of candour)	Apologise, give factual explanation to patient ± family when stable, outline next steps; record the discussion.	Same day
S	Submit incident report	Complete eQuate/Datix form, keep syringes/labels, upload to secure server; tick “near-miss” if appropriate.	≤ 24 h (SAC 1 within 24 h to province/SAPS)
T	Team debrief & secure records	Brief theatre/PACU staff, capture statements, save monitors & logs, activate PSIRF “learning response”.	≤ 48 h
A	Analyse (RCA / human-factors review)	Use London or fish-bone tool, identify system barriers that failed, agree SMART actions.	SAC 1 formal RCA ≤ 60 days; SAC 2 ≤ 60 days; SAC 3 concise review
R	Review & re-audit	Implement fixes (label change, checklist step, education), set audit date, share learning at M&M and on QI board; feed into hospital & national databases.	Re-audit 3–6 months; monitor KPIs quarterly

Anaesthesiologist Attributes and Governances

Attributes

Attribute	Why it matters in daily anaesthetic practice
Clinical competence & vigilance	Maintains situational awareness, anticipates physiologic changes and acts early to prevent harm.
Integrity & honesty	Drives truthful charting, open disclosure after incidents and accurate drug recording.
Effective communication	Enables clear SBAR hand-overs, closed-loop commands during crises and empathic consent discussions.
Accountability & reliability	Turns up punctually, completes pre–use equipment checks and follows up post-op patients.
Team-centred leadership	Coordinates multidisciplinary teams, delegates appropriately and models civility under stress.

Governance

Key requirement	Practical advice to the new colleague
1 HPCSA & hospital credentialing	Hold up-to-date HPCSA specialist registration, annual licence fee paid; be credentialed for listed procedures and upload copies to HR & theatre manager.
2 Clinical-governance engagement	Attend monthly M&M and QI meetings, log incidents on eQuate/Datix, complete two departmental audits or PDSA cycles per year.
3 CPD & teaching	Record ≥ 60 CEU / 24 months (≥ 10 ethics); schedule weekly teaching for juniors and book study leave early; keep a digital CPD portfolio.
4 Contractual & risk cover	Understand PSA-governed hours, overtime limits, leave and PMDS appraisal; maintain malpractice indemnity ≥ R10 million and personal income-protection insurance.
5 Time and data-management	Use the EMR correctly (e-consent, operation notes), check e-mails daily, block diary slots for admin/research, and protect rest to mitigate fatigue risk.

SASA Practice Guidance

Scope of Anaesthesia Practice by Experience Level

Practitioner	Independent cases (ASA)	Supervision requirements	Notes
GP without DA or < 3 yrs post-DA	I–II	III with on-site specialist; IV–V refer	Paediatric: only minor elective > 2 yrs experience.
GP ≥ 3 yrs post-DA / “experienced” (> 75 % anaesthesia work for ≥ 3 yrs)	I–III	Major/complex III under indirect specialist oversight	Held to specialist standard in litigation.
Registrar	As per training logbook	Ideal 2:1, may extend to 4:1 low-risk; 1:1 high-risk	Consultant must be immediately available.
Specialist	Full scope within current competence	Peer support when learning new techniques	Maintain CPD & skills passport.

• (SASA Practice Guidelines 2022)

Ultrasound Guidance

Application	Evidence & 2022 SASA recommendation
Central venous access (IJV)	Standard of care–reduces complications & attempts (Level A).
Peripheral nerve/plane blocks	Preferred if provider trained; improves success & lowers LA dose (Level A).
Arterial cannulation	Evidence mixed; recommended for small children, difficult anatomy (Level B).
Focused TTE (FATE)	Core competence for peri-op haemodynamic assessment; does not replace formal echo if pathology suspected.

Adult Procedural Sedation

• Suitable only for ASA I–II outside theatre; airway exam mandatory.
• Titrate to effect; avoid fixed boluses.
• Continuous capnography & SpO₂; BP q 5 min.
• Recovery by trained personnel with written discharge criteria

Safe TIVA (SASA / AAGBI 2021 alignment)

1. All providers to complete accredited TIVA course & annual pump validation.
2. Use TCI where possible; standardise propofol (10 mg mL⁻¹) & remifentanil (50 µg mL⁻¹).
3. Infusion line: Luer-lock, anti-reflux valve, ≤ 1 mL dead space; label clearly.
4. Deploy processed EEG (e.g. BIS) whenever neuromuscular blockade is used.
5. Apply identical monitoring standards in remote sites and during transfers
6. Visibility of IV cannula / CVC throughout the case; secure lines but leave insertion site unobstructed.

Clinical Practice Recommendations at Different Hospital Levels in South Africa

• South African facilities should meet at least WFSA Level 2 monitoring; SASA classifies every “highly-recommended” item as essential.

Monitoring & staffing	Level 1 (rural clinic / ≤ 100 beds)	Level 2 (district / 100–300 beds)	Level 3 (regional / referral ≥ 300 beds + ICU)
Anaesthesia professional present & vigilant	✔︎	✔︎	✔︎
Pre-use check of machine, circuits, drugs	✔︎	✔︎	✔︎
WHO Safe Surgery Checklist utilised	✔︎	✔︎	✔︎
Supplemental O₂ for GA / deep sedation	✔︎	✔︎	✔︎
Pulse oximetry–continuous (audible)	✔︎	✔︎	✔︎
Non-invasive BP (≤ 5 min interval)	✔︎	✔︎	✔︎
Clinical airway & ventilation assessment (bag movement / stethoscope)	✔︎	–(replaced by capnography)	–(replaced by capnography)
Capnography–continuous	✘ (optional)	✔︎ (essential for all GA & deep sedation)	✔︎
Inspired O₂ analyser + hypoxic-guard	✘	✔︎	✔︎
ECG–continuous	✘	✔︎	✔︎
Temperature–continuous electronic	✘	✔︎	✔︎ (multi-site if > 6 h / paediatric)
Neuromuscular transmission monitor	✘	✔︎ when NMB used	✔︎ (routine)
Disconnect alarm when ventilated	✔︎	✔︎	✔︎
Volatile-agent / gas volume analyser	✘	✘	✔︎
Invasive arterial pressure (where indicated)	✘	✘	✔︎
Urine output for long / high-volume cases	✘	✘	✔︎
Post-anaesthesia care unit (PACU)–O₂, suction, ventilator, pulse-ox, trained staff	✔︎ (minimum 1: 2 nurse-patient ratio)	✔︎	✔︎
Defibrillator immediately available	✔︎	✔︎	✔︎

• Legend–✔︎ mandatory; ✘ not required.
• Note–District hospitals should prioritise rapid acquisition of capnography, continuous temperature and neuromuscular monitors, as strongly recommended by SASA Practice Guidelines 2022.

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Past Exam Questions

Conflict Resolution in the Operating Room

During a neurosurgical case, the surgeon discovers that a vital instrument is not available. He becomes angry and starts shouting at the scrub sister that the surgical tray is ALWAYS missing instruments and that he cannot operate like this. The sister becomes passive and withdrawn.
What are the main points that need to be considered and dealt with in this conflict resolution scenario? (10)

Attributes of a Medical Professional

a) List 5 personal attributes required of a medical professional and specialist anaesthesiologist in the clinical context. (5)

b) As a senior consultant, you welcome a new colleague into your department. He asks for advice in terms of self-organisation and self-management. How would you advise him about the requirements for practising full-time in a public institution? (5)

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References:

1. South African Society of Anaesthesiologists. (2022). Practice Guidelines 2018 Revision.
2. South African Health Products Regulatory Authority. General Regulations to the Medicines & Related Substances Act 101/1965 (rev. 2017). sahpra.org.za
3. SAHPRA. Guideline to the Scheduling of Substances and Medicines (SAHPGL-CEM-NS-02 v3) 2022. sahpra.org.za
4. South African Society of Anaesthesiologists. Practice Guidelines 2022. sasaweb.com
5. World Federation of Societies of Anaesthesiologists. WHO-WFSA International Standards for a Safe Practice of Anaesthesia (revised 2021). wfsahq.org
6. South African Society of Anaesthesiologists. Practice Guidelines 2022–Monitoring & Equipment (Ch. 3 & Appendices). sasaweb.comsajaa.co.za
7. HPCSA. Management of Impaired Practitioners and Students (Guidelines, 2023)
8. SASA. Guidelines for the Safe Use of Procedural Sedation & Analgesia (Adults) 2020-2025. sasaweb.com
9. SASA. Paediatric Procedural Sedation Guidelines 2021-2026.
10. Apfelbaum, J. L. and Connis, R. T. (2019). The american society of anesthesiologists practice parameter methodology. Anesthesiology, 130(3), 367-384. https://doi.org/10.1097/aln.0000000000002551
11. O’Shaughnessy, S. M., Lee, J. Y., Rong, L. Q., Rahouma, M., Wright, D., Demetres, M., … & Kachulis, B. (2022). Quality of recent clinical practice guidelines in anaesthesia publications using the appraisal of guidelines for research and evaluation ii instrument. British Journal of Anaesthesia, 128(4), 655-663. https://doi.org/10.1016/j.bja.2021.11.037

Summaries:

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© 2025 Francois Uys. All Rights Reserved.

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