Number % Death 422 32.0 Unnecessary pain 247 18.7 Fractures 207 15.7 Pressure sores 93 6.8 Psychiatric 31 2.4 Bruising/extravasation 24 1.8 Healthcare associated infection 14 1.1 Brain damage 14 1.1 Burns 13 1.0 Venous thromboembolism 9 0.7 Anaphylaxis 8 0.6

The NHSLA was also able to provide a breakdown of the primary cause of the alleged errors that led to successful litigation in these cases. These are summarized in Table 1.2.

Table 1.2 Primary cause of incidents leading to successful litigation 1/4/2005 to 31/3/2011, n = 1319

The damages awarded in each of the cases (excluding legal costs) ranged from £200 to £2.5m (mean £39 291). The total damages awarded over this six-year timeframe – in relation to adult medicine – amounted to £52m, with an additional £33m in legal costs.

Not surprisingly, the study shows that the commonest cause of errors lie in a failure or a delay in diagnosis and treatment. Prescribing errors also come high up the list.

Most errors in clinical practice result in little or no harm. However, the NHSLA data show that the commonest outcome in the cases analysed was death. Looking a little further down that list, unnecessary pain, fractures and pressure sores feature prominently. It is likely that some of these fractures occurred following inpatient falls.

The physical and psychological consequences to the patient and his family of these adverse incidents can be very severe. The financial cost to the NHS, especially in this age of budgetary pressure, is considerable. The largest claims resulted from cases that had led to brain damage and paraplegia. NHS Trusts do not pay the compensation to patients directly. They make monthly subscription payments to CNST that are calculated on their claims history, size of Trust and type of clinical specialities in the Trust. If a Trust can demonstrate that it meets specified NHSLA standards it can obtain a discount in its CNST subscription payments (at level 1, 2 or 3 – 10%, 20% or 30% respectively).

Pulling all this research together, we believe that there are certain key areas where doctors would benefit from advice. We aim to provide such advice in the following sections. This will include advice on making the correct diagnosis promptly, avoiding prescribing errors, checking test results and acting on abnormal findings, avoiding errors in practical procedures, supervising or coordinating care and discharging patients effectively. We shall start by looking at the patient consultation and how to identify the sick patient.

The patient consultation

The patient consultation is, in a very practical sense, at the heart of the doctor–patient relationship. It gives an opportunity for face-to-face communication and for the doctor to build up a rapport with the patient and to win his trust. If it is handled correctly, at the end of the consultation, the doctor should be armed with the information that he needs to reach a diagnosis or at least to start considering differential diagnoses. And of all consultations, it is the first that is perhaps the most important; that first consultation will strongly influence all that follows. How should it be conducted?

A good medical history is essential in making a correct diagnosis. The medical history on its own is said to lead to the diagnosis in over half of all cases. Once a patient has given his account of his presenting complaint, the doctor should ask questions to clarify his understanding of the complaint and the patient’s symptoms. All this is perhaps obvious, but it all comes down to communication. Good communication should aid diagnosis; poor communication will hamper it. Thus a doctor must listen carefully to patients and their carers. In the words of Sir William Osler, Regius Professor of Medicine in Oxford in the early twentieth century, ‘Listen to the patient. He is telling you the diagnosis.’ This requires skill and patience and can be difficult if time is short.

Doctors often see patients who speak poor English. Where this gets in the way of understanding, the doctor should find a translator who can speak the mother tongue of the patient. If a translator is not on site, most hospitals have telephone access to translators 24 hours a day. A judge is unlikely to excuse a mistake caused by a failure to find and use a translator.

After the medical history comes the patient examination. If the examination is a limited one, the doctor should make that clear in the patient’s notes together with the reason why.

Once the medical history and patient examination have been completed, it is important to make a diagnosis or to consider the differential diagnoses in order of probability. The doctor should list the investigations required to clarify the diagnosis and to provide further details about the illness. A management plan should then be constructed. Following this pathway encourages a doctor to rigorously analyse the ailment afflicting the patient.

The medical history, patient examination, diagnosis, investigations and management plan should be clearly documented. It is also very important to note negative findings in the medical history and patient examination. The investigation results should be obtained and documented promptly. The importance of clear and thorough documentation cannot be overemphasized.

The requirement in the NHS to see all patients who present to the ED within four hours can sometimes cause doctors to prioritize patients inappropriately. Thus a doctor may find himself rushing the medical history and patient examination in order to meet this deadline. Errors may occur as a result. But it is no defence for a doctor to argue this in court. This, along with factors such as the stress, tiredness and depression, are issues which may adversely affect the outcome of the patient consultation. If the doctor has concerns about the systems in place at his hospital, he should discuss them with his superiors.

A delay or failure in making a diagnosis and a delay or failure of treatment are the two commonest causes of errors. The reasons behind these delays and failures are many; they include poor training, a lack of knowledge, failure to recognize when help is required and a more senior opinion is needed, and an inadequate hospital Trust and departmental induction to the job.

Hospital Trust protocols and national protocols on different conditions provide information on the symptoms that need to be asked about, the signs that need to be checked, the differential diagnoses in a given set of circumstances and the appropriate treatment plan. Likewise, various courses such as the Advanced Life Support Course or the ALERT (Acute Life threatening Events – Recognition and Treatment) Course provide very useful training in important areas of Adult Medicine, encouraging doctors to make use of standardized procedures, particularly at times of stress and urgency.

Failure to identify a sick patient

It is easy to identify a severely unwell patient. The challenge is to spot the patient who is not yet severely unwell but who may deteriorate rapidly if he does not receive the right treatment. Such patients present alongside hundreds of other patients with self-limiting conditions.

Where a sick patient is not identified, this is usually because early warning signs of a critical illness were missed or ignored. Therefore, when an essential physiological parameter (heart rate, blood pressure, respiratory rate, SaO2 or GCS) is abnormal, this needs to be carefully explored to see if it is a sign of an impending deterioration.

When cases involving sick patients who were not correctly identified are reviewed, it is often found that the patient had a single abnormal parameter and that this was not acted upon. All too often, the journey to cardiovascular shock is evident in retrospect from looking at observation charts with blood pressure falling and heart rate increasing in tandem. Reviewers generally conclude that the doctor did not act on this finding because:

• he attributed the abnormal parameter to some cause other than illness e.g. the doctor considered that the patient’s tachycardia was caused by anxiety; or
  
• he chose to ignore a single abnormal parameter because everything else was normal; or
  
• he failed to recognize that the parameter was abnormal.

To try and prevent these common mistakes, various Early Warning Scores (EWS) were developed. These provide a range of defined triggers for review by a clinician and escalation where required.

On occasion, a patient can re-present to the ED critically ill after attending the ED for the first time just a few days earlier. It is natural to assume that ‘something was missed’ at the first attendance. In many cases this is true, but it is also true that patients can deteriorate suddenly and rapidly. While all such cases should be explored to see if lessons can be learned, it can equally be that sometimes, when patients are seen very early in the course of a critical illness, there are no early warning signs of a severe illness to identify.

This only serves to reinforce the need to give patients clear ‘safety net’ advice, when they are discharged from medical care: that is advice about when they should re-attend the ED or the GP, if the patient fails to get better. Such advice should be given no matter how trivial the presenting complaint may appear to be.

Inability to competently perform practical procedures

The phrase ‘Practice and Planning Prevents Poor Performance’ is often used in military basic training and could be equally applied to medical procedures. Assiduously following the simple guidance below should help avoid errors whilst carrying out practical procedures.

Practical procedures require good communication skills, manual dexterity, patience, a calm and gentle touch, and supervised practice. The doctor should be aware of the limits of his competence and should not exceed them without experienced supervision (GMC – Good Medical Practice, sections 3 and 12).

The use of an assistant is also important in many scenarios. The objective should be to perform the correct procedure on the correct patient, on the correct side, competently and with appropriate consent. Plan the procedure where possible, and give adequate analgesia or sedation, in an appropriate environment.

Prepare the trolley and instrument pack. Watch a good scrub nurse at work – a doctor can learn much from a scrub nurse about safe and ergonomic methods of preparing his own kit. Ensure all the necessary instruments are present. Keep sharp instruments, needles and blades inside a tray to reduce the risk of a needlestick injury. Keep a count of needles and swabs.

Ensure that the patient is adequately monitored. An assistant should take primary responsibility for the safety and comfort of the patient whilst the doctor performs the procedure. If indicated, the doctor should check that life support equipment is present and working, and that he knows how to use it if necessary.

Good aseptic technique reduces the chance of infective complications. Empower the assistant to notice lapses and tell him to point out if gloves or instruments become contaminated.

Prevent the external surfaces of cannulae and catheters from becoming contaminated with cotton wool fibres – these can cause thrombosis if inadvertently inserted into blood vessels.

A doctor should ensure that he understands the anatomy of the procedure, and use instruments for the purposes for which they were designed. Practise using the instruments. Most commonly-used instruments are designed to be used by a right-handed operator and may not work optimally if used left-handed. Read the product inserts and instructions, especially if using a new type of catheter. Thin-walled catheters may become cracked if manipulated with metallic instruments. Examine distance markers carefully. The doctor should ensure that he knows what length of a tube or catheter will protrude from the patient at the end of the procedure.

At the end of the procedure, document the process carefully, retaining a note of the batch number and catheter type inserted. Obtain radiological confirmation of line positions if needed, record the findings and take remedial action if necessary.

Remember to talk to the patient at the end of the procedure. The doctor should explain what he has done, what should happen next, and make patients aware of potential complications.

Failure to check test results or act on abnormal findings

It is stating the obvious to say that if tests are requested, the results have to be looked at (ideally by the doctor who ordered them). They have to be considered with the care to be expected of a competent doctor.

Life at the coalface is always more complicated. Circumstances may intervene: the doctor who actually requested the test may finish his shift before the results are available, leaving another doctor to deal with them. The handover to that doctor may have been inadequate. Alternatively, he may simply be too busy to give them proper attention, with the result that an abnormality is overlooked. While those circumstances might point to weaknesses in the system, they do not absolve the responsible doctor (or his employing hospital Trust) from a charge of negligence.

That is why it is so important that clear notes are made, pointing out the need to follow up the results of investigations.

When it comes to interpreting the results, however, the situation is different. A misinterpretation obviously might be negligent: the inexperienced doctor may not appreciate the significance of an abnormal finding, or the incompetent doctor may realize it but just not act on it. However, a competent doctor is allowed to make errors of judgement without necessarily being labelled negligent. So, in a subtle case, with confusing symptoms and signs, an independent expert may take the view that the notional competent doctor might well have made the same mistake as the one accused of negligence.

Another, not uncommon scenario is a fluctuating situation where an abnormal result comes and goes. At the time, a considered judgement may be made to ‘watch and wait’. Later, with the benefit of hindsight, an independent expert may be able to pinpoint exactly when that policy ceased to be appropriate, with a clarity which was unavailable at the time, but that is with the benefit of hindsight.

Prescribing errors

Prescribing errors are very common. The EQUIP study (2009), a prospective observational analysis of hospital prescribing showed that in the UK prescribing errors are made in disturbingly high numbers. 8.4% of prescriptions written by FY1 doctors contain errors and this increases to 10.3% amongst FY2 doctors. Consultants do slightly better but still get it wrong in 5.9% of prescriptions. Although many of these errors are minor and most are picked up in checking processes (usually by pharmacists), 1.74% of all prescribing errors are potentially lethal. If you think about the millions of prescriptions written every day in the UK, it is easy to see that in absolute terms the scale of the problem is immense.

A doctor should always refer to The British National Formulary or approved local guidelines when prescribing a medication unless he is fully familiar with the medicine, dose, route, side effects, interactions, duration of therapy and indication. Doctors should be aware that the responsibility for a mistake lies with the person who has signed the prescription. The following principles should be adhered to when prescribing medication:

• Write prescriptions legibly, ideally in capitals.
  
• The generic names of drugs should be used whenever possible.
  
• Beware of drugs with similar sounding names or which look similar when written down.
  
• Always double check the prescription. This is particularly important when using unfamiliar drugs, or familiar drugs in an unfamiliar setting. If calculations are involved, try to get a medical or nursing colleague to check the arithmetic. If someone questions the prescription, the prescription should be checked carefully. During working hours a pharmacist may be available to check the prescription.
  
• The strength or quantity to be contained in tablets or liquids should be stated (e.g. 125 mg/5ml).
  
• Dose frequency, and also specific times, should be stated and in the case of drugs to be taken ‘as required’ a minimum dose interval should be specified.
  
• Great care needs to be taken with the decimal point. The unnecessary use of decimal points should be avoided (e.g. 5 mg, not 5.0 mg). The zero should be written in front of the decimal point where there is no other figure (e.g. 0.5 mg, not .5 mg). To avoid confusion over the placing of decimal points, amounts less than 1 milligram should be prescribed in micrograms (e.g. 500 micrograms, not 0.5 mg).
  
• The correct units should always be used. Avoid abbreviations. In particular, do not abbreviate the terms micrograms and nanograms.
  
• The term ‘Units’ should always be spelt out in full when prescribing (e.g. insulin or heparin) in order to reduce the chance of ‘U’ being interpreted as ‘0’ leading to a tenfold error.
  
• Ensure that the correct route of administration has been specified. See, for example, the vincristine example above, when the chemotherapy was administered intrathecally instead of intravenously.
  
• Clear plans should be in place for the necessary monitoring of drugs. For example, gentamicin levels.
  
• Ask about allergies, and the nature of the reaction. Document the reply that the patient has given.
  
• Careful consideration should be given to the information that is provided to patients concerning side effects. Some doctors believe that it is only necessary to tell patients of risks that have more than a 1% chance of occurring (the Electronic Medicines Compendium quantifies the incidence of side effects of many drugs). This is not an accurate reflection of the law. A doctor should always consider what would be reasonable to tell the patient. For example, in many circumstances it is right to mention rare but potentially serious side effects.
  
• Doctors should ensure that the medication is not contraindicated. For example, beta blockers in asthma. Changes in pathophysiology are important. A drug which was appropriate at one stage in an illness may not be as the disease progresses. For example, metformin may be the drug of choice for a Type 2 diabetic early in their disease, but some years down the line when glomerular filtration rate has fallen it may become more hazardous.
  
• The doctor should ensure that potential interactions with other medicines that the patient is taking are identified and warn the patient about possible interactions with over the counter medicines. Where interactions may be anticipated dosage alteration may often be needed and close monitoring is obligatory. Some combinations should never be used (for example azathiaprine and allopurinol).
  
• Repeat prescriptions should be regularly reviewed to ensure that they are still necessary.
  
• The administration of medicines should be carefully documented to ensure that drugs are not given twice.
  
• Mistakes in the calculation and conversion of doses of opiates are a common serious prescription error. So, too, are errors in the prescription of anticonvulsants, calcium channel antagonists and antibiotics. In time, computer packages and online prescribing should become available and facilitate the correct calculation of drug doses, help with drug interactions and diminish the incidence of medication errors. However, the first error-prone element of the prescription process – a doctor making an active decision that a prescription is indeed necessary – will not be directly affected by this technology. Safe prescribing modules are part of the undergraduate curriculum and are also incorporated into several Foundation year training programmes.

Sources of error in the case of vulnerable adults

Failure to recognize vulnerability and abuse

Vulnerable adults do not necessarily come with a label. They may not be small in stature or physically weak. A large number of adults, some of them with learning difficulties or cognitive impairment, are vulnerable. It is imperative that all professionals involved in patient care maintain a high index of suspicion with regards to the signs and symptoms of abuse, and an open enquiring mind with respect to the risk factors associated with abuse. Paediatricians are now well versed in identifying the victims of abuse. In adult medicine, we are perhaps too quick to explain away the possible signs of abuse and to be reassured about a patient’s home environment and care. Rather than being reassured, we should always seek solid evidence (assurance) of well-being and good care, triangulating different streams of information where appropriate. All NHS Trusts have a Vulnerable Adult Lead who can be contacted for advice.

Failure to act

If a doctor has a gut feeling that something is not right, he should act on it. Action might involve consulting with seniors, involving social services or obtaining information from other sources. The care of the vulnerable adult operates in a protective jurisdiction. That is to say, professionals can and must act upon suspicion or concern, rather than requiring absolute proof. False alarms are sadly necessary if the majority of true cases of abuse are to be uncovered and tackled.

Failure to document

During the course of a patient’s involvement with the health services, a number of professionals may experience their own fleeting moment of questioning or doubt as to a vulnerable individual’s safety. Unless those professionals communicate with one another effectively and appropriately, the true nature of the patient’s situation may never be realized. It is imperative that the multidisciplinary team including social services and primary care is brought in to the conversation.

Common pitfalls

• Not being suspicious enough when things don’t add up – ‘Think the unthinkable.’
  
• Failure to recognize the impact of alcohol abuse in the household.
  
• Failure to put the vulnerable patient’s needs first. The best interests of a vulnerable patient and his relatives or carers normally go hand in hand but when there is any suspicion of maltreatment the patient’s interests are paramount, above those of the carer.
  
• Not referring upwards at an early stage.
  
• Sloppy or inadequate history.
  
• Not admitting a vulnerable patient to hospital when abuse has not been excluded and it is not clear that home is a safe place.
  
• Not discussing with other agencies.
  
• Not checking if the patient is on a vulnerable adult register.
  
• Poor communication between doctors, social workers and police – ‘not speaking the same language’. Doctors may often think that they have fully explained the medical findings, but actually these may not have been clearly understood by non-health professionals.
  
• Not documenting all discussions including telephone calls with other agencies.
  
• Being drawn by social workers or the police to give a definitive opinion on the cause or age of injuries when this is not possible.

References and further reading

1. Department of Health (2000) An Organisation with a Memory, the report of an expert group on learning from adverse events in the NHS, chaired by the Chief Medical Officer (2000). http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4065083

2. Dornan T, Ashcroft D, Heathfield H, et al. (2009) An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. Available at http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf

3. GMC (2008) Consent: Patients and Doctors Making Decisions Together.

4. GMC (2009) Good Medical Practice. www.gmc-uk.org/guidance/good_medical_practice.asp

5. Hampton JR, Harrison  MJG, Mitchell JRA et al. (1975) Relative contribution of history taking, physical examination and laboratory investigation to diagnosis and management of medical outpatients. BMJ 2: 486–9.

6. Markert RJ, Haist SA, Hillson SD et al. (2004) Comparative value of clinical information in making a diagnosis. MedGenMed 6(2): 64.

7. Office of the Public Guardian, Department of Health and Welsh Assembly Government (2005) Mental Capacity Act 2005 – Summary. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_080403.pdf

8. Reynard J, Reynolds J, Stevenson P (2009) Practical Patient Safety. Oxford University Press.

9. Vincent C (2005) Patient Safety. Churchill Livingstone.

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