PPS Patient Safety, Clinical Risk and Errors Flashcards
(39 cards)
Medical errors vs adverse events
Medical errors: do something you shouldnt do or not doing something you should have when treating a patient
-near misses (errors that do not result in adverse events)
Adverse events: unwanted outcome
-non-preventable adverse events
these intersect: preventable adverse events (errors that result in adverse events)
What are the 3 basic error types?
- Slips/lapses- good plan poor execution SKILL/TECHNIQUE PROBLEM
- Mistakes- bad plan executed well KNOWLEDGE PROBLEM
- Violations- deliberate deviation from what’s accepted ATTITUDE/BEHAVIOUR PROBLEM
What are the 2 categories of error?
PERSONAL
Identifies individuals at fault
Allows blame, retraining
Mirrors legal process
SYSTEMIC
Acknowledges human fallibility
Identifies promoting factors
Builds systemic safety
Swiss cheese model (James Reason)
From medical error to patient harm there are multiple layers- training, policies, teamworking, automation, supervision and auditing. All of these can together prevent the error from causing patient harm, but they all have potential holes in them. (eg, not everyone attends the training, not enough team members etc)
Yin Yang model
Two sides- reducing medical error and preventing patient harm from occurring due to medical error
Systems and culture- how is the system aiding or not aiding this, and what is the culture like?
System reflects culture
How has the view of medical errors changed over time?
Ignorance -> denial -> personal -> systemic
What are switch points?
Where you are making a decision to do something different- a point where things can go either way for the patient
The 10 deadly errors
Sloth Fixation- stuck on an idea or plan even when we get info that challenges that Communication Team working Playing the odds- we expect common diseases more than rare Bravado Ignorance- don't know what's needed Mis-triage- do things in wrong order Lack of skill System error
Reporting to affect system design
Datix incident -> identify underlying mindsets, behaviours, processes -> what is the opposite to this? -> route to new position
Best solution for medical error
Systemic improvement (eg, clinical governance, reporting to agencies) as errors usually systemic problems and rarely ‘one offs’
How can patients have recourse if an error occurs?
NHS Complaints Procedure
General Medical Council General Medical Council
The Law
If the complaints procedure ends in dissatisfaction, what is the final option for patients?
Parliamentary and Health Service Ombudsman
GMC fitness to practice panel:
If they conclude that the doctor’s fitness to practice is impaired the following sanctions are available:
to take no action
to accept undertakings offered by the doctor provided the panel is satisfied that such undertakings protect patients and the wider public interest
to place conditions on the doctor’s registration
to suspend the doctor’s registration
to erase the doctor’s name from the Medical Register, so that they can no longer practise.
Duty of candour GMC
Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that 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.
ALSO be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. They must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest, and not stop someone from raising concerns.
3 sources for duty of candour
Ethics
Professional guidance
Law
Contractual duty of candour
NHS organisations whose services are commissioned under a post-April 2013 standard NHS contract, with the exception of primary care services, have a contractual duty of candour
Statutory duty of candour
The new statutory duty of candour was introduced for NHS bodies in England (e.g. trusts, foundation trusts and special health authorities) and all other care providers registered with CQC.
Notifiable Patient Safety Incident (NPSI)
As soon as is reasonably practicable after a Notifiable Patient Safety Incident (NPSI) occurs, the organisation must tell the patient (or their representative) about it in person.
A NPSI has a specific statutory meaning: it applies to incidents where a patient suffered (or could have suffered) unintended harm that results in death, severe or moderate harm, or prolonged psychological harm.
If someone takes action against a doctor, what are the legal options?
- A criminal action [rare]:
e. g. Gross negligence manslaughter [v. rare] - A civil action:
The patient could sue for damages using:
-tort of negligence (NHS or private patient)
-breach of contract (private patients only)
In order to prove negligence in a civil suit the plaintiff must prove what three things?
- The doctor had a duty of care
- The duty of care was breached
- The breach of the duty of care caused harm
Basics in duty of care
Doctors have a duty of care towards anyone with whom they have a doctor-patient relationship
It is easy to establish that a doctor had a duty of care to establish that a doctor had a duty of care
NHS trusts have a duty of care to provide a comprehensive service to their service users and can be sued if such care is not forthcoming
The NHS also has vicarious liability for the errors that doctors employed by the NHS make
Duty of care grey areas
No Good Samaritan law in UK
Good Samaritan laws offer legal protection to people who give reasonable assistance to those who are, or whom they believe to be injured, ill, in peril, or otherwise incapacitated.[1] The protection is intended to reduce bystanders’ hesitation to assist, for fear of being sued or prosecuted for unintentional injury or wrongful death.
GMC requires doctors to help if they are able (and it is safe)
If you do not help then you can be found negligent:
“If a person holds himself out as a possessing special skill & knowledge…he owes a duty to the patient” R v Bateman (1925)
How to know if there was a breach of duty of care?
In order to know whether the duty of care was breached, we need to know what the duty of care amounts to:
This means that we need to know what the expected standard of care is.
According to Bolam 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”
Bolam v Friern Barnet Hospital Management [1957] 2 All ER 118
According to Bolitho a doctor is not guilty of negligence if his actions have a “logical basis”
Bolitho v City of Hackney Health Authority [1996] 7 Med LR 1
Bolitho test
The Bolitho test ensures that, although medical experts will still play a vital role in determining the standard of care, judges are now much more willing to scrutinise the rationale behind doctors decisions.
