Mistakes, Negligence and Patient Safety

Question 1

Which situations are mistakes more likely to be made in?

Answer 1

• Elderly
• Polypharmacy
• Multiple co-morbidities

Question 2

Findings of the Francis Report (2013)

Answer 2

• Culture of blame
• Staff felt unable to speak out
• Problems with systems of staff training, recruitment + retention –> understaffing

Question 3

Allan Johnson’s (2003) path of least resistance

Answer 3

In any system, people will follow the ‘rules of the game’ - even if it means doing things they would not do outside the system

Question 4

Principles of system ethics

Answer 4

• The system makes the channels
• People’s behaviour flows along them

Question 5

Iris Bohnet’s (2016) outcome of system ethics

Answer 5

Systems will only do what you have designed them to do

Question 6

Sorts of mistakes

Answer 6

• Medication related
• Diagnostic
• Clinical management
• Invasive procedures
• Hospital-acquired infections
• Surgical procedures
• System-related

Question 7

NHS ‘5 whys’ approach

Answer 7

If you ask why 5 times, you will get down to the systemic cause of the problem

Question 8

Near miss vs never event

Answer 8

• NM = potential harm avoided but weaknesses still revealed
• NE = serious incident that is wholly preventable

Question 9

2 core elements of the patient safety strategy

Answer 9

• Culture of safety
• System of safety

Question 10

Aspects of a culture of safety

Answer 10

• Avoiding individual blame
• Psychological safety for staff
• Role of trust
• Inclusivity
• Kindness + civility

Question 11

What must a doctor do after something goes wrong according to the duty of candour?

Answer 11

• Tell the patient
• Apologise
• Offer appropriate support
• Explain fully the short-/long-term effects

Question 12

What does the duty of candour say regarding near misses?

Answer 12

• Obliges doctors to inform their organisation
• Organisation decides if appropriate to tell patient

Question 13

Civil wrong vs criminal wrong

Answer 13

• Civil = wrong against the individual
• Criminal = wrong against society as a whole

Question 14

3 criteria for clinical negligence

Answer 14

• Did you have a duty to to the patient?
• Did you breach that duty?
• Did you breach cause the patient harm?

Question 15

What is a material risk?

Answer 15

• Reasonable person in the patient’s position would attach significance to the risk
• Doctor knows that specific patient would attach significance

Question 16

What is criminal negligence?

Answer 16

• Harm result of ‘gross’ carelessness –> beyond medical practice
• Requirement to establish ‘beyond reasonable doubt’ instead of ‘balance of probabilities’ (civil negligence)