Some of the most important and best lessons in a doctor’s career are learnt from mistakes. However, an awareness of the common causes of medical errors and developing positive behaviours can reduce the risk of mistakes and litigation.
Written for Foundation Year doctors, trainees and general practitioners, and unlike any other clinical management title available, Avoiding Errors in General Practice identifies and explains the most common errors likely to occur in an outpatient setting - so that you won’t make them.
The first section in this brand new guide discusses the causes of errors in general practice. The second and largest section consists of case scenarios and includes expert and legal comment as well as clinical teaching points and strategies to help you engage in safer practice throughout your career. The final section discusses how to deal with complaints and the subsequent potential medico-legal consequences, helping to reduce your anxiety when dealing with the consequences of an error.
Invaluable during the Foundation Years, Specialty Training and for Consultants, Avoiding Errors in General Practice is the perfect guide to help tackle the professional and emotional challenges of life as a GP.
Review
“My experience as an expert witness in clinical negligence cases, MPTS Panel chairman, medical adviser to a Public Inquiry and as a sometimes commissioned independent reporter on adverse incidents tells me that these are excellent books, valuable for all clinicians, not just those in high-risk specialties; and all NHS managers involved in maintaining or improving the quality of care. The case vignettes, alone, are useful source material for teaching medical trainees on what can go wrong and how to deal with it when it does.” (Harvey Marcovitch, Clinical Risk journal)
“This is a tremendous exercise in critical thinking skills, i.e. the ability to think through differential diagnoses and longer-term consequences beyond the simple facts presented. This book has great learning value for young and midcareer clinicians to help them hone their diagnostic skills.” (Doody’s, 5 July 2013)
"This excellent 182-page book is designed for general practitioners in their early years. It will be a very useful source for all involved in teaching and mentoring those in general practice, and should, I think, be compulsory reading for all practice managers. It is so packed with information, concepts and case studies written in decent English that I found it difficult to put down.
The first section gives a resume of the law concerning breach of medical duty, including the Bolam test. Causation, damages and time limits for litigation are discussed. Protocols, guidelines and communications are considered followed by a heart felt appeal to learn from system failures. This is what I want practice managers to read.
The next section looks at how an initial diagnosis is reached, and then refined. Avoiding being misled by first impressions by testing against a differential diagnosis, excluding diagnoses that must not be missed, considering non-fitting facts, and follow up review all help. Making arrangements to review the case if the illness does not follow the expected course can retrieve the situation, and a record of this can save a reputation.
Communication is recognised as the core of safe practice. I like the simple concept “Ask yourself whether a colleague could work out from your notes the essential details of the consultation.”
Then follows the real meat of the book. This consists of forty recent clinical cases, each demonstrating a particular mishap. These forty cases bring up 95% of causes of complaints against general practitioners. Each describes a case in a few well-chosen sentences, and asks the reader what they think, and might do next. For example, make a differential diagnosis, or perform further simple examinations. An expert opinion is then given on what good practice would involve. This is followed by a legal opinion of the case, including the likely range of damages or settlement. Some of the sums are unnerving! Each case takes up just two pages.
The book ends with the various enquiries and courts that may be faced, and practical advice on addressing them.
I sincerely hope that other practitioners and practice managers will find this little book as thought provoking as I have." (Daniel Haines, FRCGP, MFFLM.)
Author(s): Kevin Barraclough, Jenny du Toit, Jeremy Budd, Joseph E. Raine, Kate Williams, Jonathan Bonser
Series: AVE - Avoiding Errors Series
Edition: 1
Publisher: Wiley-Blackwell
Year: 2013
Language: English
Tags: General Practice; Family Practice Medicine
Avoiding Errors in General Practice
Contents
Contributors
Preface
Abbreviations
Introduction
PART 1
Section 1: The legal structure of negligence
A few words about error
Medical negligence
Negligence
Has there been a breach of duty?
Causation
Damages
The limitation period
Jurisdictions
Learning from system failures – the vincristine example
Failure to follow protocols or guidelines
Inadequate communication
Reference
Section 2: Causes of diagnostic errors in general practice and how they can be avoided
How do general practitioners reach diagnoses?
Initiation of the diagnosis
Refinement
Defining the final ‘diagnosis’
Where do errors occur in diagnosis?
How can we minimize the risks of these errors?
References and further reading
Section 3: Bayesian reasoning and avoiding diagnostic errors
References and further reading
Section 4: A potpourri of advice on avoiding errors
History and examination
The telephone consultation
Communication problems
When lack of knowledge plays a part
The unexpectedly abnormal result
The standard of notes
Drug errors or prescribing errors
Consent
Confidentiality
Data Protection Act, 1998
Disclosure without consent
Caldicott Guardians
Conditions that are ‘frequent flyers’ in negligence cases
Safety netting
References and further reading
PART 2
Clinical cases
Introduction
Case 1 A man with iron deficiency
What would you have done with the results?
What would you do now? What is your differential diagnosis?
Expert opinion
Legal comment
References and further reading
Case 2 When is a headache abrupt?
What would you have done?
What would you do now? What is your differential diagnosis?
Do you think their claim will succeed?
Expert opinion
Legal comment
References and further reading
Case 3 A woman with chest pain
What other information would you obtain?
What would be your differential diagnosis and how would you discriminate between them?
Do you think her claim will succeed?
Expert opinion
Legal comment
References and further reading
Case 4 A dizzy man
What would you do now?
What would be your differential diagnosis and how would you discriminate between them?
Do you think his claim will succeed?
Expert opinion
Legal comment
References and further reading
Case 5 Rectal bleeding in a pregnant woman
If you had been her GP what would you have done?
Would you have done anything differently?
Expert opinion
Legal comment
References and further reading
Case 6 A pulled calf muscle
What are the clinical features that you would consider discriminatory when assessing a possible DVT?
What would you do now?
Do you think her claim will succeed?
Expert opinion
Legal comment
References and further reading
Case 7 A woman with hemiplegic migraine
What would you do now?
What would be your differential diagnosis and how would you discriminate between them?
Do you think his claim will succeed?
Expert opinion
Legal comment
References and further reading
Online resources
Case 8 Irritable bowel syndrome after sickness in Goa
What would be your differential diagnosis?
What would you have done differently?
Expert opinion
Legal comment
References and further reading
Case 9 A young man with back pain
Do you think his claim will succeed?
Expert opinion
Should Dr Mitchell have insisted on admission?
Should Dr Murphy have sought admission?
Legal comment
References and further reading
Case 10 Irregular intermenstrual bleeding in a woman on the pill
What would you do?
Would you have done anything differently?
Expert opinion
Legal comment
References and further reading
Case 11 A boy with a limp
What is the differential diagnosis and what would you do now?
Do you agree with the diagnosis? Would you have managed the case differently?
Do you think his claim will succeed?
Expert opinion
Legal comment
References and further reading
Case 12 A runner with a cough
What would you do now?
What would be your differential diagnosis and how would you discriminate between them?
Do you think her claim will succeed?
Expert opinion
Legal comment
Further reading
Case 13 A woman with classical migraine
What would you do now? What bits of information would you want to elicit?
What would be your differential diagnosis and how would you discriminate between them?
Do you think her claim will succeed?
Expert comment
Legal comment
Further reading
Case 14 A young woman with diarrhoea and vomiting
Why was the diagnosis of appendicitis missed?
Expert comment
Legal comment
References and further reading
Case 15 Ill-fitting dentures in an elderly man
What would you do now?
What would be your differential diagnosis and how would you discriminate between them?
Do you think his claim will succeed?
Expert comment
Legal comment
References and further reading
Case 16 Back pain in a middle-aged woman
What would you do now? Are any particular features on examination likely to be helpful?
What would be your differential diagnosis and how would you discriminate between them?
Do you think her claim will succeed?
Expert comment
Legal comment
References and further reading
Case 17 Cellulitis in a man’s foot
Would you have done anything differently?
Would this result have reassured you?
Expert opinion
Legal comment
References and further reading
Case 18 A flare-up of ulcerative colitis
What would you do now?
What would be your differential diagnosis and how would you discriminate between them?
Do you think her claim will succeed?
Expert comment
Legal comment
References
Case 19 A woman with a skin lump on her leg
Do you think a claim against Dr Welch will succeed?
Expert comment
Legal comment
References and further reading
Case 20 A woman with microscopic haematuria
What would you do now?
What would be your differential diagnosis and how would you discriminate between them?
Do you think her claim will succeed?
Expert comment
Legal comment
References
Case 21 A limping young girl
What would you do now?
Do you think her claim will succeed?
Expert comment
Legal comment
References and further reading
Case 22 A builder tripping over his feet
What would be your differential diagnosis and how would you discriminate between them?
Do you think his claim will succeed?
Expert comment
Legal comment
References and further reading
Case 23 An anxious young woman with hyperventilation
What would you do now?
What would be your differential diagnosis and how would you discriminate between them?
Do you think her claim will succeed?
Expert comment
What went wrong in this case?
Legal comment
Further reading and references
Case 24 A slightly raised AST in an Asian woman
What would you do now?
What would be your differential diagnosis and how would you discriminate between them?
Do you think her claim will succeed?
Expert comment
Legal comment
References and further reading
Case 25 Cough and fever in a 42-year-old accountant
Would you have done anything else?
Do you think his claim will succeed?
Expert comment
Legal comment
References
Case 26 Lost prescription: Benzodiazepine addiction
What options were open to the GP?
Should she speak to the police?
Expert comment
Legal comment
Further reading
Case 27 A febrile baby
What features would you have specifically noted?
Would you have done anything differently?
Do you think his claim will succeed?
Expert comment
Legal comment
Further reading and references
Case 28 A limping elderly woman after a fall
Would you have done anything differently?
Do you think her claim will succeed?
Expert comment
Legal comment
References and further reading
Case 29 Indigestion in a stressed executive
What would you do now?
What would be your differential diagnosis have been and how would you discriminate between them?
Do you think his claim will succeed?
Expert comment
Legal comment
References and further reading
Case 30 A hoped-for pregnancy
What would you do now?
What would be your differential diagnosis and what would you do?
Do you think her claim will succeed?
Expert comment
Legal comment
References and further reading
Case 31 A breast lump that disappears
What would you do now?
Do you think her claim will succeed?
Expert comment
Legal comment
References
Case 32 Fever and cough after an ankle fusion
Would you have done anything differently?
Do you think the claim will succeed?
Expert comment
Legal comment
References
Case 33 Urinary problem in a welder
What would you do now?
Do you think his claim will succeed?
Expert comment
Legal comment
References
Case 34 A hypertensive 38-year-old woman
What would you do now?
Expert comment
Legal comment
References
Case 35 A swollen lip in a 56-year-old man
What would you do now?
What would be your differential diagnosis and how would you discriminate between them?
Do you think his claim will succeed?
Expert comment
Legal comment
Reference
Case 36 A woman with fatigue and weight gain
What would you do now?
Would you have done the same?
Expert comment
Legal comment
References
Case 37 A woman told off for ignoring her friends
What would you do now?
What would be your differential diagnosis and how would you discriminate between them? Would you have done anything else?
Do you think the claim will succeed?
Expert comment
Legal comment
Further reading and references
Case 38 A man with a headache: Swine flu or meningitis?
What would you do now?
Was it reasonable to diagnosis swine flu and authorize Tamiflu?
What would be your differential diagnosis and how would you discriminate between them?
Can Dr Craig be criticized for his initial diagnosis of flu? Headache is relatively common with influenza. How does one avoid admitting everyone with flu?
Expert comment
Legal comment
References and further reading
Case 39 A woman suffering dizziness
Was there anything else you would have checked?
What would be your differential diagnosis and what would you have done?
Do you think her claim will succeed?
Expert comment
Legal comment
References and further reading
Case 40 A middle-aged man with an ankle injury
What other information would you obtain in a case such as this?
Do you think a claim against the GP will succeed?
Expert comment
Legal comment
Further reading
PART 3
Investigating and dealing with errors
1 Introduction
2 How errors and their recurrence are prevented in primary care
Guidelines and protocols
Audit
Appraisals
Complaints management
Significant Event Analysis
3 The role of the Primary Care Trusts
Performers’ Lists
4 Other investigations
National Clinical Assessment Service (NCAS)
Partnership issues arising from errors
The Care Quality Commission
5 Legal advice – where to get it and how to pay
Medical Defence Organizations
6 External inquiries
The Health Service Ombudsman
Negligence claims and the litigation process
Coroner’s Court
Fatal Accident Inquiries
Criminal matters
Public inquiry
General Medical Council in practice
An example from general practice
The GMC in future
7 The role of the doctor
Witness statements
Formal requirements
Content
Presenting oral evidence
8 Emotional repercussions
9 Conclusion
Reference
Index
