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Semester 1 Year 2 > Making Mistakes > Flashcards

Making Mistakes Flashcards

1
Q

Learnig outcomes

A

Explain why ‘whistleblowing’ in medicine can be difficult
Name common factors that contribute to basic error-making in medical practice, and understand the actions doctors can take to combat them
Contrast a person-centred approach and a systems-based approach to addressing medical errors, and give examples of each
Explain what is meant by ‘human factors’ and identify ways of reducing errors through a systems-based approach
Describe the Duty of Candour introduced in the Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill, 2015
Describe the 4 steps involved in the Professional Duty of Candour (GMC & RMC Guidance, 2015)
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 (p2, point 4, GMC & RMC Guidance, 2015)
Describe the three elements that comprise an action in negligence
Define the Bolam test and the Bolitho amendment and understand the implication of the ruling in Montgomery v Lanarkshire Health Board (2015) on the issue of consent
Identify weaknesses in the current clinical negligence system

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2
Q

State some stats on errors in medicine

A

Scientific American report, 2009 (Harmon, Aug 10th)
200 000 deaths/yr in US due to preventable mistakes and infections

And in the UK?
(all from Jackson-quoted studies, p154)
• 10% of hospital inpatients suffer an adverse event
• One study estimated that nearly a third of all adverse events
led to moderate or great disability or death
• 10 000 serious adverse reactions to drugs are reported/year

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3
Q

Why do basic errors happen?

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
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4
Q

Why is it difficult to admit andreport errors in medicine

A
  • Consequences:
  • Does error = incompetence? (after all, everyone makes mistakes…)
  • Whistle-blowing is not without risk (far from it in fact…)
  • Medicine is not an exact science
  • Some argue that there is a “norm of non-criticism”

Prof Don Berwick: “Climate of fear” in the NHS is the single biggest barrier to patient safety

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5
Q

What is the Francis Report?

A

• Published February 2013
• Robert Francis, QC – public inquiry (£13 million)
• Stafford Hospital
• “They (Stafford Hospital patients) were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.“
• 290 recommendations including:
– Duty of Candour: A statutory obligation on doctors and nurses for a duty of candour so they are open with patients about mistakes

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6
Q

Discuss the duty of candour

A

Law: organisational Duty of Candour
• ‘To place a duty of candour on health and social care organisations. This would create a legal requirement for health and social care organisations to inform people when they have been harmed as a result of the care or treatment they have received.
• To establish new criminal offences of ill-treatment or wilful neglect in
health and social care settings; one offence applying to individual health and social care workers, managers and supervisors, and another applying to organisations’
• RCPE – supportive of both the above (written evidence, August 2015)

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7
Q

What is the Duty of Candour (2015)’s stance on apologising

A

An apology is a statement of sorrow or regret in respect for the unintended or unexpected incident
And apology or other step taken in accordance with the duty of candour procedure […] does not itself amount to an admission of negligence or a brach of statutory duty

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8
Q

What must a healthcare professional do in regards to the Duty of Candour (2015)

A
  • 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.
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9
Q

What might happen in response to errors or inadequate care?

A
  • Negligence (legal approach): patient might take legal action
  • NHS Complaints Procedure: patient might make a complaint
  • GMC (professional body): disciplinary action or removal from register
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10
Q

What are the four outcomes from a GMC investigation

A
  • Case concluded, no further action
  • Issue a warning
  • Agree undertakings

-Refer to MPTS (Medical Practitioners Tribunal Service)
E.g. sexual assault or indecency, violence, improper sexual or emotional relationships, knowingly practising without a licence, unlawfully discrimination, dishonest and gross negligence, recklessness about a risk of serious harm to patients, custodial or non-custodial conviction, caution or a determination from another regulatory body, refuses to agree undertakings.

-No action/Undertakings/Conditions/Suspension/Erasure

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11
Q

Discuss the legal basis of negligence

A

The claimant must establish:
1. He/she is owed a duty of care by the defendant
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).
(p104, Medical Law – Emily Jackson)

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12
Q

What is reasonable care?

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.” Judge McNair (p113,
Ibid)
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)

NB: Problem of inexperience

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13
Q

What is the impact of Montgomery (2015) (SoC in informed consent)

A

Daniel Sokol (BMJ, 2015):
“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?
• 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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14
Q

What is the Montgomery (2015) case?

A

“Nadine Montgomery, a woman with diabetes and of small stature, delivered her son vaginally; he experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby’s size was a potential problem.” From: https://doi.org/10.1136/bmj.j2224

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15
Q

What is causation in negligence?

A

There must be a clear link between the action (or inaction) of a
doctor, and the harm the patient experienced
• a key factor is also proximity

Often causation is where a patient’s case may fail

If not eligible for negligence, but not happy with care – NHS
complaints procedure

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16
Q

What is the NHS Complaints Procedure (Scotland)

A

2012 Charter of Patient Rights and Responsibilities
• Stage 1: Local resolution
• Stage 2: Scottish Public Services Ombudsman
• Judicial review

17
Q

Can an honest mistake amount to serious professional misconduct?

A 
“[The] possible penalties available to the committee, which used to be
confined to the ultimate sanction of erasure, have been extended to include suspension and the imposition of conditions upon practise. This suggests that the offence was intended to include serious cases of negligence… [T]he public has higher expectations of doctors and members than of other self-governing professions. Their governing bodies are under a corresponding duty to protect the public against the genial incompetent as well as the deliberate wrongdoer.”
Lord Hoffman (quoted in Medical Law: Text, Cases, and Materials p154– Emily Jackson, 2013)
18
Q

Discuss the case of Dr Hadiza Bawa-Garba

A

“An inquest was promptly convened and expert evidence suggested the care given to Jack by both Bawa-Garba and a nurse was inadequate and complacent. But it was apparent from the outset there were many systemic issues that had contributed to what had happened.” – Ian Freckleton, QC

Legally: guilty of gross negligence manslaughter
Professionally: suspended for 12 months, GMC appealed for erasure, Bawa- Garba appealed, suspension put in place

19
Q

How can one learn from negligence?

A
  • Negligence is not an effective way to learn from errors as outcome bias exists (culpability does not depend on blameworthiness but on consequences)
  • “A point which is often misunderstood is that human error, being by definition unintentional, is not easily deterred” (p2, Merry & McCall Smith)
20
Q

How can one learn best from errors?

A

• Person-centred approach
– Focussed on the individual doctor
• Systems-based approach
– Considers the environment, and seeks to minimise 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

“[Human factors in healthcare]: Enhancing clinical performance through an 	understanding of the effects of teamwork, tasks, equipment, workspace, culture and 	organisation on human behaviour and abilitiesand application of that knowledge in 	clinical settings” (cited in NHS England Concordat, 2013)

Cf. aviation industry (“human error is anticipated” and there are non-punitive reporting systems, p155, Jackson, 2nd Ed)

Move from person-centred approach to systems-based: D of H produced “An 	organisation with a memory”.
21
Q

What is Sir Donald Irvine’s take on candour and blame?

A

• “I think the term ‘no blame’ is actually unhelpful. It can become
so easily associated with the abrogation of responsibility. It might be better to seek a ‘fair culture’ that attributes responsibility appropriately. … Individual doctors have to accept responsibility where it falls to them, just as they accept the accolades. …People run systems, they do not run themselves. The bottom line is doctors’ individual accountability. We should expect no less.”

22
Q

How has medicine sought to address some of the failures in the current system?

A 
• Dedicated centres
	– Beneficial for less common and uncommon procedures
• Requirement to retrain
	– New procedures and techniques
• Data collection of incidents
• Improved instrument design
• Protocols & guidelines
• Checklists
23
Q

What is the National Patient Safety Agency

A

Established in 2001; abolished in 2012 (England & Wales)
• Set up to improve patient safety through collecting data on patient safety incidents (& also providing confidential services to manage concerns with the performance of practitioners).
• Now all of this has transferred to NHS Commissioning Board Special Health Authority
• Key part: National Reporting and Learning System (NRLS), the “world’s
most comprehensive database of patient safety information, to identify
and tackle important patient safety issues at their root cause.”
• In Scotland, Scottish Patient Safety Research Network
(http://www.spsrn.ac.uk/)

24
Q

Summary

A

Explain why ‘whistleblowing’ in medicine can be difficult
Name common factors that contribute to basic error-making in medical practice, and understand the actions doctors can take to combat them
Contrast a person-centred approach and a systems-based approach to addressing medical errors, and give examples of each
Explain what is meant by ‘human factors’ and identify ways of reducing errors through a systems-based approach
Describe the Duty of Candour introduced in the Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill, 2015
Describe the 4 steps involved in the Professional Duty of Candour (GMC & RMC Guidance, 2015)
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 (p2, point 4, GMC & RMC Guidance, 2015)
Describe the three elements that comprise an action in negligence
Define the Bolam test and the Bolitho amendment and understand the implication of the ruling in Montgomery v Lanarkshire Health Board (2015) on the issue of consent
Identify weaknesses in the current clinical negligence system

Semester 1 Year 2 (69 decks)

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