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Avoiding Errors in General Practice

ISBN: 978-0-470-67357-7
198 pages
March 2013, Wiley-Blackwell
Avoiding Errors in General Practice (0470673575) cover image

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.

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Contributors, viii

Preface, ix

Abbreviations, x

Introduction, xii

Part 1

Section 1: The legal structure of negligence, 1

A few words about error, 1

Medical negligence, 1

Learning from system failures – the vincristine example, 6

Reference, 10

Section 2: Causes of diagnostic errors in general practice and how they can be avoided, 11

How do general practitioners reach diagnoses?, 11

Where do errors occur in diagnosis?, 15

How can we minimize the risks of these errors?, 17

References and further reading, 18

Section 3: Bayesian reasoning and avoiding diagnostic errors, 20

References and further reading, 25

Section 4: A potpourri of advice on avoiding errors, 26

History and examination, 26

The telephone consultation, 27

Communication problems, 28

When lack of knowledge plays a part, 28

The unexpectedly abnormal result, 28

The standard of notes, 29

Drug errors or prescribing errors, 30

Consent, 30

Confidentiality, 32

Conditions that are 'frequent flyers' in negligence cases, 33

Safety netting, 34

References and further reading, 36

Part 2 Clinical cases

Introduction, 37

Case 1 A man with iron deficiency, 38

Case 2 When is a headache abrupt?, 41

Case 3 A woman with chest pain, 44

Case 4 A dizzy man, 48

Case 5 Rectal bleeding in a pregnant woman, 51

Case 6 A pulled calf muscle, 54

Case 7 A woman with hemiplegic migraine, 57

Case 8 Irritable bowel syndrome after sickness in Goa, 60

Case 9 A young man with back pain, 64

Case 10 Irregular intermenstrual bleeding in a woman on the pill, 67

Case 11 A boy with a limp, 70

Case 12 A runner with a cough, 72

Case 13 A woman with classical migraine, 74

Case 14 A young woman with diarrhoea and vomiting, 77

Case 15 Ill-fitting dentures in an elderly man, 79

Case 16 Back pain in a middle-aged woman, 82

Case 17 Cellulitis in a man’s foot, 85

Case 18 A flare-up of ulcerative colitis, 88

Case 19 A woman with a skin lump on her leg, 91

Case 20 A woman with microscopic haematuria, 93

Case 21 A limping young girl, 96

Case 22 A builder tripping over his feet, 98

Case 23 An anxious young woman with hyperventilation, 101

Case 24 A slightly raised AST in an Asian woman, 103

Case 25 Cough and fever in a 42-year-old accountant, 105

Case 26 Lost prescription: Benzodiazepine addiction, 108

Case 27 A febrile baby, 110

Case 28 A limping elderly woman after a fall, 113

Case 29 Indigestion in a stressed executive, 116

Case 30 A hoped-for pregnancy, 119

Case 31 A breast lump that disappears, 122

Case 32 Fever and cough after an ankle fusion, 125

Case 33 Urinary problem in a welder, 128

Case 34 A hypertensive 38-year-old woman, 130

Case 35 A swollen lip in a 56-year-old man, 133

Case 36 A woman with fatigue and weight gain, 135

Case 37 A woman told off for ignoring her friends, 137

Case 38 A man with a headache: Swine flu or meningitis?, 140

Case 39 A woman suffering dizziness, 142

Case 40 A middle-aged man with an ankle injury, 144

Part 3 Investigating and dealing with errors

1 Introduction, 147

2 How errors and their recurrence are prevented in primary care, 147

3 The role of the primary care trusts, 150

4 Other investigations, 152

5 Legal advice – where to get it and how to pay, 155

6 External inquiries, 157

7 The role of the doctor, 172

8 Emotional repercussions, 175

9 Conclusion, 175

Reference, 176

Index, 177

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Kevin Barraclough is General Practitioner, Painswick Surgery, Painswick, Gloucestershire

Jenny du Toit is General Practitioner, Painswick Surgery, Painswick, Gloucestershire

Jeremy Budd is General Practitioner, East Quay Medical Centre, Bridgwater, Somerset

Joseph E. Raine is Consultant Paediatrician, Whittington Hospital, London

Kate Williams is Partner, RadcliffesLeBrasseur Solicitors, Leeds

Jonathan Bonser is Consultant in the Healthcare Department of Fishburns LLP, Solicitors, London, and former Head of the Claims and Legal Services, Department of the Leeds office of the Medical Protection Society

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“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.)

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