Making Mistakes

Question 1

Why is medicine a difficult environment in which to report or admit errors?

Answer 1

• 70% doctors said they received no or little support from their organisation when something went wrong
• 49% fear of consequences is why whistleblowing is ineffective
• 60% not even consider whistleblowing because of the doubts of the process
• 18% who blew the whistle felt isolated
• just less than 40% of doctors who raised concerns felt they had been addressed

Question 2

What are the common causes of basic-error making in clinical practice?

Answer 2

• stress
• fatigue
• covering for colleagues
• professional structure
• feeling that decisions must be made alone
• unable to admit to uncertainty

Question 3

What is a person-centred approach in terms of dealing with medical errors?

Answer 3

focused on dealing with the individual doctor

Question 4

What is a system-based approach to dealing with medical errors?

Answer 4

considers the environment and seeks to minimise opportunities for error

Question 5

Give an example of a person centred approach.

Answer 5

individual doctors have to just accept responsibility where it falls to them, just as they accept the accolades . People run systems, they do not run themselves.

Question 6

give an example of a systems based approach.

Answer 6

human error is anticipated and there are non-punitive reporting systems. Produce an organisation with a memory.

Question 7

What are ways of reducing error through a systems based approach?

Answer 7

• dedicated centres, beneficial for less common and uncommon procedures
• requirement to retrain, new procedures and new techniques
• data collection of incidents
• improved instrument design
• protocols and guidelines
• checklists

Question 8

what is the duty of candour? which was introduced in the 2015 health bill

Answer 8

A legal requirement for for health and social care organisations to inform people when they have been harmed are a result of the care or treatment they have received

Question 9

What are the four steps involved in the professional duty of candour?

Answer 9

• tell the patient (advocate, family member) when something has gone wrong
• apologising to the patient
• offer an appropriate remedy or support to put matters right
• explain full to the patient the short and long term effects of what has happened

Question 10

What are the three elements which comprise action in negligence?

Answer 10

• he/she is owed a duty of care by the defendant
• that the defendant breached that duty by failing to provide reasonable care
• that the breach of duty caused the claimant those injuries and that those injuries are not too remote

Question 11

Explain the Bolam test 1957.

Answer 11

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 art

Question 12

what is the Bolitho amendment 1997?

Answer 12

added to Bolam: the professional opinion must be capable of withstanding logical analysis

Question 13

The impact of Montgomery. What 3 questions which should be addressed when dealing with consent?

Answer 13

• Does the patient know about the material risks of the treatment I am proposing?
• does the patient know of the alternatives to this treatment?
• Have I taken responsible care to ensure the patient actually knows this?

Question 14

Why is the current system for clinical negligence not an effective way to learn from errors?

Answer 14

outcome bias exists.
culpability does not depend on blameworthiness but on consequences.
a point misunderstood is that human error being by definition unintentional, is to easily deterred.