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Avoiding Errors in General Practice

Kevin Barraclough, Jenny du Toit, Jeremy Budd, Joseph E. Raine, Kate Williams, Jonathan Bonser

ISBN: 978-1-118-50889-3 December 2012 Wiley-Blackwell 200 Pages


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.

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

“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.)