Intro to Practice of Medicine + Making Mistakes

Question 1

Define the basis of deontology.

Answer 1

it is in accord with a moral rule or principle.

Question 2

Define the basis of consequentialism.

Answer 2

it promotes best consequences.

Question 3

Define the basis of virtue ethics.

Answer 3

it is what a virtuous agent would do in the circumstances

Question 4

What are the main principles of medical ethics ?

Answer 4

Non-maleficience
Beneficience
Justice
Respect for autonomy

Question 5

State and explain the topics of the four quadrant approach.

Answer 5

1) Medical indications:
Consider each medical condition and its proposed treatment:
i.Does it fulfill any of the goals of medicine?
ii.With what likelihood?
iii.If not, is the proposed treatment futile?

2) Patient preferences:
What does the patient want? Does the patient have the capacity to decide? If not, can anyone advocate for the patient? Do the patient’s wishes reflect a process that is: informed? understood? voluntary? continuing?

3) Qualify of Life:
Describe the patient’s quality of life in the patient’s terms and from the care providers’ perspectives.

4) Contextual Features:
Circumstances that can either influence the decision or be influenced by the decision (Religious, legal, cultural factors).

Question 6

Identify the steps involved in a structured case analysis.

Answer 6

• Summarise the case or problem
• State the moral dilemma
• State the assumptions that are being made
• Analyse the case
• Acknowledge other approaches and state the preferred approach with explanation

Question 7

Name common factors that contribute to basic error-making in medical practice, and understand the actions doctors can take to combat them.

Answer 7

• Stress
• Fatigue
• Covering for colleagues (too little locum support)
• Professional culture (unwillingness to use support structures)
• Feeling that decisions must be made alone •Unable to admit to uncertainty

How they can combat them:
Rest more, make decisions using support structures.

Question 8

Explain why ‘whistleblowing’ in medicine can be difficult.

Answer 8

• Consequences (whistleblowing not without risk, and does error really equal incompetence?)
• Norm of non-criticism
• Medicine is NOT an exact science (dealing with things we don’t full understand in some cases)
• Lack of support from their organisation

Question 9

Describe the Duty of Candour. When/how was this introduced in Scotland ?

Answer 9

A statutory obligation on doctors and nurses for a duty of candour so they are open with patients about mistakes. Specifically, professional Duty of Candour Healthcare professionals must:
• tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong
• apologise to the patient (or, where appropriate, the patient’s advocate, carer or family)
• offer an appropriate remedy or support to put matters right (if possible)
• explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.
HOWEVER, an apology or other step taken in accordance with the duty of candour procedure under section 22 does not of itself amount to an admission of negligence or a breach of a statutory duty.

One of the recommendation of the Francis Report (about the Stafford Hospital)
Introduced in Scotland as part of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill, 2015

Question 10

Outline a doctor’s duty to the their patient and to their organisation when something goes wrong, as stated in the Professional Duty of Candour.

Answer 10

-Your duty to be open and honest with
patients in your care, or those close to
them, if something goes wrong. This
includes advice on apologising (paragraphs
6–21).
-Your duty to be open and honest with your
organisation, and to encourage a learning
culture by reporting adverse incidents
that lead to harm, as well as near misses
(paragraphs 22–33).

Question 11

Describe the elements that comprise an action in negligence.

Answer 11

The claimant must establish:

1. He/she is owed a duty of care by the defendant (Duty of care: assumed when the doctor has taken responsibility for patient’s care)
2. That the defendant breached that duty by failing to provide reasonable care; and
3. That the breach of duty caused the claimant’s injuries (causation), and that those injuries are not too remote (proximity).

Question 12

What might happen in response to errors or inadequate care ?

Answer 12

• Negligence (legal approach): patient might take legal action (Not usually the doctor himself but the NHS, with the aim to put patient in situation financially that they would be in if error hadn’t happened)
• NHS Complaints Procedure: patient might make a complaint
• GMC (professional body): disciplinary action or removal from register

Question 13

Define the Bolam test and the Bolitho amendment.

Answer 13

The Bolam (1957) test:
“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.” (i.e. If you can find another three or four people who can agree with you, you’re fine  )

The Bolitho (1997) test:
Modified Bolam to add: the professional opinion must be capable of withstanding logical analysis (note: a move away from the deferential approach of Bolam) (p115, Ibid)

Question 14

Explain the implication of the ruling in Montgomery v Lanarkshire Health Board (2015) on the issue of consent.

Answer 14

THE CASE:
“Ms. Montgomery gave birth to a baby boy. As a result of complications during the
delivery, the baby was born with severe disabilities. In these proceedings Mrs
Montgomery seeks damages on behalf of her son for the injuries which he
sustained. She attributes those injuries to negligence on the part of Dr Dina
McLellan, a consultant obstetrician and gynaecologist employed by
Lanarkshire Health Board, who was responsible for Mrs Montgomery’s care
during her pregnancy and labour. She is diabetic and diabetics are likely to have babies that are larger than normal, and there can be a particular concentration of
weight on the babies’ shoulders. She was told that she was having a larger than usual baby but she was not told about the risks of her experiencing mechanical problems
during labour. In particular she was not told about the risk of shoulder dystocia. “

“The 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 alternative or variant treatments.’

Three questions:

• Does the patient know about the material risks of the treatment I’m proposing? (and do they know about their ability to refuse any treatment ?)
• Does the patient know about reasonable alternatives to this treatment?
• Have I taken reasonable care to ensure that the patient actually knows this?”

Question 15

Identify weaknesses in the current clinical negligence system.

Answer 15

The problem of inexperience & alternative practitioners (mainly applied when Bolam Test was in place) + is the standard of care fixed?)

Question 16

Explain how causation (or lack thereof) is established in NHS negligence enquiries.

Answer 16

There must be a clear link between the action (or inaction) of a doctor, and the harm the patient experienced (the ‘but for’ test)
•a key factor is proximity (must not have too many links in the chain)

I.e. f patient’s health deteriorates, is it due to their condition, or the treatment? (must show probability, not just possibility)

Question 17

What steps can patients who are not eligible for negligence, but unhappy with care, take ?

Answer 17

NHS complaints procedure

Question 18

Identify the steps of an NHS complaints procedure.

Answer 18

• Stage 1: Local resolution
• Stage 2: Scottish Public Services Ombudsman
• Judicial review

Question 19

Contrast a person-centred approach and a systems-based approach to addressing medical errors, and give examples of each.

Answer 19

• Person-centered approach
– Focussed on the individual doctor
Negligence NOT an effective way to learn from errors as outcome bias exists (culpability does not depend on blameworthiness but on consequences)
E.g. more rest, more use of support structures when making decisions

• Systems-based approach
– Considers the environment, and seeks to minimize opportunities for error (Errors are not random but rather often fit into a pattern – hence it’s wise to build in processes to decrease error-making opportunities) (through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organization on human behavior and abilities and application of that knowledge in clinical settings)
E.g. checklists, requirement to retrain, dedicated centers, data collection of incidents, protocols & guidelines, Improved instrument design

Question 20

Is negligence an effective way to learn from errors ? Why or why not ?

Answer 20

Negligence is not an effective way to learn from errors as outcome bias exists (culpability does not depend on blameworthiness but on consequences).

Question 21

Identify ways of reducing errors through a systems-based approach

Answer 21

• Dedicated centres
– Beneficial for less common and uncommon procedures

• Requirement to retrain
– New procedures and techniques

Ways which take into consideration growing understanding of importance of ‘human factors’ approach:

• Data collection of incidents (e.g. National Patient Safety Agency, National Reporting and Learning System both of which collect information on patient safety incidents)
• Improved instrument design
• Protocols & guidelines
• Checklists

Question 22

Explain what is meant by ‘human factors’ and identify ways of reducing it through a systems-based approach.

Answer 22

“Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of
that knowledge in clinical settings”

Effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities

Ways of reducing it: 
• Data collection of incidents
• Improved instrument design
• Protocols & guidelines
• Checklists