Avoiding Errors in Adult Medicine (eBook)

Avoiding Errors in Adult Medicine 3
Contents 7
Contributors 10
Preface 11
Abbreviations 12
Introduction 13
PART 1 17
Section 1: Errors and their causes 17
A few words about error 17
Learning from system failures – the vincristine example 17
Failure to follow protocols (see Cases 2, 11 and 14) 19
Inadequate communication (see Cases 2, 3 and 34) 20
Poor and inadequate record-keeping (see Cases 9 and 31) 21
Lack of knowledge and not knowing one’s limitations (see Case 11) 21
Poor supervision and delegation (see Case 1) 22
Poor prioritization 22
Tiredness and stress: lack of resources 23
Psychological factors 23
Conflicts between system issues and personal responsibility: a healthy work environment 24
Evidence from the NHSLA database 24
The patient consultation 26
Failure to identify a sick patient 28
Inability to competently perform practical procedures 29
Failure to check test results or act on abnormal findings 30
Prescribing errors 30
Sources of error in the case of vulnerable adults 32
Failure to recognize vulnerability and abuse 32
Failure to act 33
Failure to document 33
Common pitfalls 33
References and further reading 34
Section 2: Medico-legal aspects 35
Error in a legal context 35
Negligence 35
Clinical negligence 36
Has there been a breach of duty? 36
Causation 37
Damages 38
The limitation period 39
Jurisdictions 39
Issues around consent 39
Validity of consent 40
Capacity 40
Devolving responsibility for consent to another 41
Mental Capacity Act and Lasting Power of Attorney 41
Respecting patient autonomy 43
An attorney refusing treatment 43
A patient without capacity refusing treatment 43
Emergency treatment 44
Information to be provided 44
Deprivation of Liberty Safeguards 45
Confidentiality 46
Disclosure without consent 46
Caldicott Guardians 47
Data Protection Act 1998 47
Access to Health Records Act 1990 48
The Human Rights Act 1998 48
PART 2 51
Clinical cases 51
Section 1: Civil liability, negligence and compensation 52
Case 1 A shaky excuse 53
What is your initial management? 53
What would you do now? 53
What is your diagnosis? 53
Expert opinion 54
Legal comment 54
References and further reading 55
Case 2 Making matters worse 56
What therapeutic options were available to Mrs Turnbull’s physician six years ago? 56
What treatment should Dr Wagstaff institute? 56
How should Dr Wagstaff reply? 56
Expert opinion 56
Legal comment 57
Case 3 Chase the bloods 59
What other diagnoses should be considered at this stage? 59
Was this a reasonable assumption? 59
What should Dr Briggs have done? 59
If it is believed an error has been made, is it reasonable to simply repeat the test? 59
Expert opinion 60
Legal comment 60
Case 4 Falling asleep en-route 61
What other information do you want to know? 61
What course of action would you advocate at this point in time? 61
What would you do now? 61
What are your thoughts about Mr Aziz’s overall management? How should the hospital review his care? What should his wife be told? 61
Expert opinion 61
Legal comment 62
Case 5 Bad luck or bad judgement 64
How should Dr Wilde manage Mrs Hardcastle? 64
Has Dr Wilde’s management been appropriate? Is there anything else that you would have done? 64
How should Mrs Hardcastle be managed? 64
Could Mrs Hardcastle have been managed any differently over this 24-hour period? Are there any further interventions that ought to be considered? 64
Expert opinion 64
Legal comment 65
Reference 66
Case 6 An opportunity missed 67
What is your differential diagnosis and how will you proceed? 67
What are your thoughts? 67
Expert opinion 67
Legal comment 68
Case 7 Better late than never 69
What is your differential diagnosis? 69
What investigations would you pursue and what management steps would you institute? 69
How do you think the trust should reply? 69
Expert opinion 70
Legal comment 70
Further reading 71
Case 8 Man down 72
What would you do now? 72
What do you think of Mr Brown’s management? 72
Expert opinion 72
Legal comment 73
Case 9 Cry wolf 74
What course of action would be appropriate for the triage nurse? 74
What do you think about Dr Proudfoot’s actions? 74
Expert opinion 74
Legal comment 75
Case 10 Not a leg to stand on 76
Is this a reasonable course of action? 76
Was this preventable? 76
Expert opinion 77
Legal comment 77
Section 2: Unexpected death: the coronial system and clinical risk management 78
Case 11 A doubly bad outcome 79
What is the differential diagnosis and how would you investigate her complaint? 79
How does this new information influence your management plan? 79
What are your thoughts upon Dr Talbot’s management plan? 79
Expert opinion 79
Legal comment 80
Further reading 81
Case 12 Difficulty with diarrhoea 82
Would you have managed the situation in the same way? 82
Expert opinion 83
Legal comment 83
Further reading 84
Case 13 A flu-like illness 85
What diagnoses should occur to Dr Smethwick? 85
Should any other treatments have been instigated? 85
Is there anything else that you would do? 85
What should the hospital do at this stage? 85
Expert opinion 85
Legal comment 86
Reference and further reading 87
Case 14 Falling standards 88
Are there any other areas that Dr Manek should pay attention to? 88
Do you have any concerns about this plan? 88
Expert opinion 88
Legal comment 89
Reference 89
Section 3: An approach to complaints 90
Case 15 A woman with chest pain 91
What would you do now? 91
What is your differential diagnosis? 91
What would you do now? 91
What approach should the clinical director take when responding to this letter? 92
Expert opinion 92
Legal comment 92
Case 16 Clumsiness 94
What other diagnoses might Dr Miles consider? 94
What is you differential diagnosis at this point? 94
Do you have any comments about the management plan? 94
How should the hospital respond? 95
Expert opinion 95
Legal comment 95
Section 4: Competence 96
Case 17 A change in plan 97
Are you happy with the decisions made by Dr Webster? 97
Should Dr Webster talk candidly to Mrs De Souza? 97
How should Dr Webster react to these requests? 97
What should Dr Webster do at this point? 97
Expert opinion 98
Legal comment 99
Case 18 Starving to death 101
What course of action should Dr Esposito follow? 101
What are your thoughts on this plan? 101
What is your view? 101
Do you agree with Dr Blewitt’s thought processes? 102
What would you put down as the cause of death? 102
Expert opinion 102
Legal comment 102
Advance decisions 102
Withdrawal of treatment 103
Case 19 An irregular presentation 104
What are your thoughts about Mrs Dixon’s presentation? 104
What are your thoughts about Dr Ng’s initial management? 104
What is the likely diagnosis? 104
How should the service manager for medicine respond? 104
Expert opinion 104
Legal comment 105
Further reading 105
Case 20 Irrational but not incompetent 106
What should Dr Goldberg do at this point? 106
How would you assess Mr Walton’s competence to make a decision about his care? 106
Do you agree with Dr Mason’s course of action? 106
Expert opinion 107
Legal comment 107
Section 5: Restraint 108
Case 21 A challenging discharge 109
What would you do? 109
How would you manage the situation? 109
What would you do now? 109
What do you think about the position of the hospital security team? 109
Expert opinion 110
Legal comment 110
Deprivation of Liberty Safeguards (DOLS) 110
Security staff and restraint 110
Case 22 Ruling out the organic 112
What do you think is going on and how will you investigate Mr Giardelli? 112
What do you think of this course of action? 112
What is the likely diagnosis and the appropriate management? 112
Expert opinion 113
Legal comment 113
Case 23 Endless wandering 115
What should Dr Cheung do? 115
Expert opinion 115
Legal comment 116
Case 24 Can you please take these handcuffs off? 117
What issues will the admitting doctor likely wish to consider? 117
Expert opinion 117
Legal comment 118
Case 25 Own worst enemy 119
Should the SHO speak to Ms Barnes’s mother? 119
What would you do now? 119
How would you decide whether Ms Barnes should be allowed to go home? 119
Expert opinion 119
Legal comment 119
Section 6: Miscellaneous 121
Case 26 All eggs in one basket 122
What diagnoses are in your mind? 122
What should Dr Fentiman do? 122
Expert opinion 122
Legal comment 123
References and further reading 123
Case 27 A major mix-up 124
What treatments should be instituted upon Mr Johnson’s arrival at hospital? 124
Do you agree with this decision? 124
Who should be informed of this death? 124
Expert opinion 125
Legal comment 125
Reference 125
Case 28 Under the radar 126
What should be the key elements of Dr Williams’ management plan? 126
Would you have acted differently? 126
What do you think of the trust’s stance? Is the trust acting within the law? 126
Expert opinion 127
Legal comment 127
Reference and further reading 128
Case 29 A cantankerous recluse 129
Are there any particular diagnoses that it would be important to consider? 129
Are you content with Mr Peacock’s management to date? 129
Expert opinion 130
Legal comment 130
Case 30 Keep an open mind 131
What possibilities should cross Dr Singleton’s mind? 131
Should Dr Singleton have considered any other course of action? 131
Expert opinion 132
Legal comment 132
Further reading 132
Case 31 Healthcare acquired infection? 133
What is the differential diagnosis, what investigations would you arrange and what treatment would you institute? 133
What further tests would you consider in relation to the anaemia? 133
What should be done now? 133
Expert opinion 134
Legal comment 134
Case 32 Backing the wrong horse 136
What would you advise? 136
Any other possible diagnoses? 136
Expert opinion 136
Legal comment 137
Case 33 A surprising turn of events 138
What do you think is the likely diagnosis? 138
What should Dr Wallace do? 138
What would you do? 138
What options are available to the consultant at this point? 139
Expert opinion 139
Legal comment 139
Patient confidentiality 140
Discharge of patients who are clinically fit and refuse to be discharged 140
Case 34 Funny turn 141
What is your differential diagnosis? 141
What do you think of the diagnosis and the advice? 141
Do you agree with the consultant? 141
Expert opinion 141
Legal comment 142
PART 3 Investigating and dealing with errors 143
1 Introduction 143
2 How hospitals try to prevent adverse errors and their recurrence 143
Guidelines and protocols 143
Clinical audit 144
Global trigger tools 145
Incident reporting 145
Whistleblowing 147
Professional appraisal 147
3 The role of hospital staff 148
Medical director 148
Clinical director 148
Occupational health 149
PALS 149
Legal services 149
Communications department 150
Clinical governance 150
Risk management 150
4 The role of external agencies 150
NHS Litigation Authority (NHSLA) 151
National Clinical Assessment Service 151
The Healthcare Quality Improvement Partnership (HQIP) 152
The Care Quality Commission 152
Benchmarking 152
5 Hospital investigations 153
Complaints management 153
Root cause analysis 153
Disciplinary procedures 154
6 Legal advice – where to get it and who pays 157
(a) NHS treatment 157
7 External investigation of errors and incidents 159
The Parliamentary and Health Service Ombudsman (PHSO) 159
Negligence claims and the litigation process 160
Coroner’s Court 161
Fatal accident inquiries 163
Criminal matters 164
Public inquiry 166
General Medical Council in practice 166
Nature of the letter and the complaint 167
Case investigation 167
Interim orders 168
The Case Examiners 169
Performance assessments 169
The decisions of the Case Examiners 169
Warnings 169
Undertakings 170
Referral to a Fitness to Practise Panel and erasure 170
A trainee physician under the spotlight at the GMC (based on a real case) 171
The GMC in future 173
8 The role of the doctor 176
Witness statements 176
Formal requirements 176
Content 176
Apologies 177
9 Presenting oral evidence 178
10 Emotional repercussions 180
11 Conclusion 180
References 180
Index 183