Making Mistakes

Question 1

Why do errors happen?

Answer 1

• Stress
• Fatigue
• Covering for collegues
• Professional culture (unwilling to seek support)
• Feeling decisions must be made alone
• unable to admit uncertainity

Question 2

What is the importance of minimising errors?

Answer 2

Clinicians must put themselves in the best position to competent nowithstanding the inherent risks of healthcare: the moral difference between avoidable and unavoidable mistakes

Question 3

What was the Francis Report?

Answer 3

• Feb 2013
• Public inquiry into stafford hospital
• Reasons for death had been covered up
• 290 recommendations made; including the Duty of Candour

Question 4

What is the duty of candour?

Answer 4

A statutory obligation on doctors and nurses fro a duty of candour so they are open with patients about mistakes

Question 5

What are the GMC recommendations regarding the professional Duty of Candour?

Answer 5

• Tell the patients when something has gone wrong
• Apologise to patient
• Offer an appropraite remedy or support to put matters right
• Explain fully to the patient the short and long term effects of what happened

Question 6

What might happen in response to errors or inadequete health care?

Answer 6

• Negligence; legal action
• NHS complaints procedure
• GMC hearing; professional body disciplinary action

Question 7

What must a claimant establish to prove there is negligance?

Answer 7

• They were owed a duty of care by the defendant
• The defendant breaches that duty by failing to provide resonable care
• Breach of duty of care caused the claimant’s injuries (causation) and those injuries are not too remote (proximity)

Question 8

What is the Bolam Test (1957)?

Answer 8

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

Question 9

What is the Bolitho test (1997)?

Answer 9

Modified Bolam to add - the professional opinion must be capable of withstanding logical analysis (dealt with the problem of inexperience and alternative practitioners)

Question 10

What was the impact of Montgomery (2015)

Answer 10

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 alterative or variant treatments

Question 11

What is causation?

Answer 11

There must be a clear link between the action of a doctor and the harm the patient experienced

Question 12

What is a key factor in causation?

Answer 12

proximity

Question 13

What are the strategies used to learn from mistakes

Answer 13

• Person-centered approach - focuses on the individual doctor
• Systems-based approach - considered the environment and seeks to minimise opportunties for error

Question 14

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

Answer 14

• Dedicated centres for less common and complex procedures
• Requirement to retain
• Data collection of incidents
• Improved instrument design
• Protocols and guidelines
• Checklists