Intro to Practice of Medicine + Making Mistakes Flashcards

1
Q

Define the basis of deontology.

A

it is in accord with a moral rule or principle.

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2
Q

Define the basis of consequentialism.

A

it promotes best consequences.

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3
Q

Define the basis of virtue ethics.

A

it is what a virtuous agent would do in the circumstances

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4
Q

What are the main principles of medical ethics ?

A

Non-maleficience
Beneficience
Justice
Respect for autonomy

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5
Q

State and explain the topics of the four quadrant approach.

A

1) Medical indications:
Consider each medical condition and its proposed treatment:
i.Does it fulfill any of the goals of medicine?
ii.With what likelihood?
iii.If not, is the proposed treatment futile?

2) Patient preferences:
What does the patient want? Does the patient have the capacity to decide? If not, can anyone advocate for the patient? Do the patient’s wishes reflect a process that is: informed? understood? voluntary? continuing?

3) Qualify of Life:
Describe the patient’s quality of life in the patient’s terms and from the care providers’ perspectives.

4) Contextual Features:
Circumstances that can either influence the decision or be influenced by the decision (Religious, legal, cultural factors).

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6
Q

Identify the steps involved in a structured case analysis.

A
  • Summarise the case or problem
  • State the moral dilemma
  • State the assumptions that are being made
  • Analyse the case
  • Acknowledge other approaches and state the preferred approach with explanation
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7
Q

Name common factors that contribute to basic error-making in medical practice, and understand the actions doctors can take to combat them.

A
  • Stress
  • Fatigue
  • Covering for colleagues (too little locum support)
  • Professional culture (unwillingness to use support structures)
  • Feeling that decisions must be made alone •Unable to admit to uncertainty

How they can combat them:
Rest more, make decisions using support structures.

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8
Q

Explain why ‘whistleblowing’ in medicine can be difficult.

A
  • Consequences (whistleblowing not without risk, and does error really equal incompetence?)
  • Norm of non-criticism
  • Medicine is NOT an exact science (dealing with things we don’t full understand in some cases)
  • Lack of support from their organisation
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9
Q

Describe the Duty of Candour. When/how was this introduced in Scotland ?

A

A statutory obligation on doctors and nurses for a duty of candour so they are open with patients about mistakes. Specifically, professional Duty of Candour Healthcare professionals must:
• tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong
• apologise to the patient (or, where appropriate, the patient’s advocate, carer or family)
• offer an appropriate remedy or support to put matters right (if possible)
• explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.
HOWEVER, an apology or other step taken in accordance with the duty of candour procedure under section 22 does not of itself amount to an admission of negligence or a breach of a statutory duty.

One of the recommendation of the Francis Report (about the Stafford Hospital)
Introduced in Scotland as part of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill, 2015

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10
Q

Outline a doctor’s duty to the their patient and to their organisation when something goes wrong, as stated in the Professional Duty of Candour.

A

-Your duty to be open and honest with
patients in your care, or those close to
them, if something goes wrong. This
includes advice on apologising (paragraphs
6–21).
-Your duty to be open and honest with your
organisation, and to encourage a learning
culture by reporting adverse incidents
that lead to harm, as well as near misses
(paragraphs 22–33).

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11
Q

Describe the elements that comprise an action in negligence.

A

The claimant must establish:

  1. He/she is owed a duty of care by the defendant (Duty of care: assumed when the doctor has taken responsibility for patient’s care)
  2. That the defendant breached that duty by failing to provide reasonable care; and
  3. That the breach of duty caused the claimant’s injuries (causation), and that those injuries are not too remote (proximity).
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12
Q

What might happen in response to errors or inadequate care ?

A
  • Negligence (legal approach): patient might take legal action (Not usually the doctor himself but the NHS, with the aim to put patient in situation financially that they would be in if error hadn’t happened)
  • NHS Complaints Procedure: patient might make a complaint
  • GMC (professional body): disciplinary action or removal from register
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13
Q

Define the Bolam test and the Bolitho amendment.

A
The Bolam (1957) test:
“A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art.” (i.e. If you can find another three or four people who can agree with you, you’re fine  )
The Bolitho (1997) test:
Modified Bolam to add: the professional opinion must be capable of withstanding logical analysis (note: a move away from the deferential approach of Bolam) (p115, Ibid)
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14
Q

Explain the implication of the ruling in Montgomery v Lanarkshire Health Board (2015) on the issue of consent.

A

THE CASE:
“Ms. Montgomery gave birth to a baby boy. As a result of complications during the
delivery, the baby was born with severe disabilities. In these proceedings Mrs
Montgomery seeks damages on behalf of her son for the injuries which he
sustained. She attributes those injuries to negligence on the part of Dr Dina
McLellan, a consultant obstetrician and gynaecologist employed by
Lanarkshire Health Board, who was responsible for Mrs Montgomery’s care
during her pregnancy and labour. She is diabetic and diabetics are likely to have babies that are larger than normal, and there can be a particular concentration of
weight on the babies’ shoulders. She was told that she was having a larger than usual baby but she was not told about the risks of her experiencing mechanical problems
during labour. In particular she was not told about the risk of shoulder dystocia. “

“The law now requires a doctor to take ‘reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.’

Three questions:

  • Does the patient know about the material risks of the treatment I’m proposing? (and do they know about their ability to refuse any treatment ?)
  • Does the patient know about reasonable alternatives to this treatment?
  • Have I taken reasonable care to ensure that the patient actually knows this?”
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15
Q

Identify weaknesses in the current clinical negligence system.

A

The problem of inexperience & alternative practitioners (mainly applied when Bolam Test was in place) + is the standard of care fixed?)

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16
Q

Explain how causation (or lack thereof) is established in NHS negligence enquiries.

A

There must be a clear link between the action (or inaction) of a doctor, and the harm the patient experienced (the ‘but for’ test)
•a key factor is proximity (must not have too many links in the chain)

I.e. f patient’s health deteriorates, is it due to their condition, or the treatment? (must show probability, not just possibility)

17
Q

What steps can patients who are not eligible for negligence, but unhappy with care, take ?

A

NHS complaints procedure

18
Q

Identify the steps of an NHS complaints procedure.

A
  • Stage 1: Local resolution
  • Stage 2: Scottish Public Services Ombudsman
  • Judicial review
19
Q

Contrast a person-centred approach and a systems-based approach to addressing medical errors, and give examples of each.

A

• Person-centered approach
– Focussed on the individual doctor
Negligence NOT an effective way to learn from errors as outcome bias exists (culpability does not depend on blameworthiness but on consequences)
E.g. more rest, more use of support structures when making decisions

• Systems-based approach
– Considers the environment, and seeks to minimize opportunities for error (Errors are not random but rather often fit into a pattern – hence it’s wise to build in processes to decrease error-making opportunities) (through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organization on human behavior and abilities and application of that knowledge in clinical settings)
E.g. checklists, requirement to retrain, dedicated centers, data collection of incidents, protocols & guidelines, Improved instrument design

20
Q

Is negligence an effective way to learn from errors ? Why or why not ?

A

Negligence is not an effective way to learn from errors as outcome bias exists (culpability does not depend on blameworthiness but on consequences).

21
Q

Identify ways of reducing errors through a systems-based approach

A

• Dedicated centres
– Beneficial for less common and uncommon procedures

• Requirement to retrain
– New procedures and techniques

Ways which take into consideration growing understanding of importance of ‘human factors’ approach:

  • Data collection of incidents (e.g. National Patient Safety Agency, National Reporting and Learning System both of which collect information on patient safety incidents)
  • Improved instrument design
  • Protocols & guidelines
  • Checklists
22
Q

Explain what is meant by ‘human factors’ and identify ways of reducing it through a systems-based approach.

A

“Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of
that knowledge in clinical settings”

Effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities

Ways of reducing it: 
• Data collection of incidents
• Improved instrument design
• Protocols & guidelines
• Checklists