Poor communcitaion + malpractice Flashcards
What is Martha’s rule
Patient safety initiate that allows patients and families to request urgent independent clinical reviews, if they feel their cocnerns are not being listened to
-aims to improve detection a d treatment of acute Deteriortaion
Implemented in April 2024
Benefits of Martha’s rule
patient autonomy and irmopved communcitaionm, doctor pateint relationships
-relatives can recognize things doctors may not
-prevents extreme cases, can be a safeguard if doctor si feeling overworked
How did Martha’s rule come about, and what were mistakes of doctors
-Martha mills healthy 13 year old had a bike accident causing a laceration in her pancreas
-but when admitted to hospital developed sepsis and died
(Bc doctors failed to acknowledge signs of sepsis(heavy bleeding) even tho mother was concerned)
Mistakes of the doctors;
Undermined the GMC;
-ARROGANCE AND OFFICE POLITCS doctors must, take immediate action if believe pateint is unsafe and respect pateint concerns
(Liver consultants saw as sign of weakness brining in junior colleagues in ICU, soDid not immediately transfer her to ITU when first identified,
-lack of trust between doctord and nurses,
Bc nurses had cocnerns
-doctors must provide good quality of care and stay up to date
(Misdiagnosis of sepsis)
Sepsis training was not compulsory
Drawbacks of Martha’s rule
-cost implications, for excessive reviews and resource allocation
-Uneccesray exploitation by patients, eg alerting team when not needed
-don’t want oevrrelainc of fmaily mebers esp if does not have a support scheme
What did Harold shipman do and what changes did it lead to
Forged opioid prescriptions and forged medical records, to kill patients
-killed at;east 250
-changes from single doctor to multiple doctor parties
Increased regulation of opioids and Paine medications
-changes to REVALIDTAION process so that could’ve recognized opioid misuse earlier on
What happens in dr barwa case
death of jack adcock who had down syndrome and died as a result of cardiac arrest from sepsis
What mistakes made by doctors in dr barwa case
-CONFUSION;temporally called off his cpr during the cardiac arrest, however confused him with another DNACPR patient
LACK OF COMMUNICTAION
-DID NOT INFORM MOTHER, that he had to stop taking enalpiril, specific medication, so she continued to give it to him,
-DID NOT SEEK ADVICE FROM CONSULATANT when he was available later
What were the systematic mistakes in dr barwa garba
Systematic mistakes;
OVERTSRTECHED
-was covering entire unit and the work of other two doctors
LITTLE TRAINIGN
-recently returned form maternity leave and given no induction abt the hospital
-IT FAILURE
Delayed patients test results
What r key messages from dr barwa
idea is not to blame, but instead to reflect and improve
-a;though systematic failures do not absolve her from her mistakes, doctors in these conditions need to raise awareness of their conditions
(And to go down WHISTLEBLOWING PATHWAYS- to investigate risks in a timely manner to prevent damage)
-unnecessary culture of blame created by the GMC, instead of using as a learning opportunity, they scapegoated onto an individual
-lessons;
-more effective communication in multidisciplinary team
-system has repsonbsilty that individuals feel empowered to raise concerns
-individual need to have responsibility to raise concerns
