Section 4: A potpourri of advice on avoiding errors

We have discussed what is involved in the diagnostic process and where the errors occur. We have discussed systematic methods of trying to overcome cognitive errors. We have discussed where Bayesian reasoning can inform our understanding of the clinical process of diagnosis. In Part 2 we will deal with the main purpose of the book – applying these principles to real life clinical scenarios.

However, we still need to cover a few more areas in which errors commonly occur such as clinical skills, communication problems, telephone consultations, the unexpectedly abnormal result, prescribing errors, drug monitoring errors, issues around consent, record keeping and the crucial aspect of ‘safety netting’.

History and examination

Doctors, in general, are now far better at listening to patients then they were 20 years ago. When consultation techniques were first being analyzed and videotaped it became clear that doctors frequently interrupt a patient less than 30 seconds into their narrative. Clearly this is unwise because, in primary care, 90% of the diagnostic information is usually in the history. As the nineteenth-century clinician Sir William Osler who effectively created the modern clinical assessment said: ‘Listen to the patient. He is telling you the diagnosis.’

The difficulty, of course, is that listening, like any observation, is not a passive business. It is necessary to concentrate and navigate what may be a blizzard of information. Patients vary greatly in their ability to describe their symptoms and concerns. The polysymptomatic middle-aged or elderly patient who is worried about everything is a particular concern. Many of the symptoms will be unlikely to signify serious disease but some will. It is difficult to walk the tightrope between over- and under-investigation in such patients. It is probably wise, if possible, to listen to their symptoms as it serves two purposes: first, it can be useful to look back some years later and see that the patient had those symptoms at that time too. Secondly, it potentially gives a more realistic picture of the difficulties of diagnosis if something is missed.

Examination skills have probably deteriorated since the time of Osler. One recent US book, Lisa Saunders’ Diagnosis (Saunders, 2009) described how newly qualified doctors rapidly give up on examination and ‘just do the tests’. Neurological examinations seems to cause general practitioners particular problems. In fact, an enormous amount of information can be gained by simple examinations such as watching swallowing, watching the gait and manual dexterity. Many medico-legal cases are brought because the general practitioner has not felt for pedal pulses, checked visual acuity or pupillary reflexes, has not watched the patient walk or swallow, failed to feel the abdominal mass or visualize and feel the cervix in a woman with abnormal vaginal bleeding.

The telephone consultation

The telephone consultation has become a much commoner process since general practitioners in the UK gave up the requirement to do their own on call. Many patients contacting Out of Hours services are ‘triaged’ by telephone. These cases figure prominently in negligence.

A particular difficulty about the assessment of the patient Out of Hours or in any emergency setting is that the first role of the general practitioner is essentially to determine whether the patient is seriously ill and needs to be admitted to hospital. Much of the information that determines that assessment is usually visual. The patient looks unwell. He may be sweaty, have a poor colour or appear to have laboured breathing.

For the Court, and for good clinical practice, it is necessary to consider that the default standard of assessment required of a general practitioner is the standard that is possible when the patient is seen and examined. Anything less is a short cut which may or may not be justified. In a high profile case a few years ago a relatively young woman died of septicaemia after receiving telephone advice on five separate occasions over an Easter weekend. She was not seen or examined before her death.

When assessing the patient over the telephone it is necessary to try and envisage what is the range of possible scenarios on the other end of the phone. Are you confident that the patient with diarrhoea and vomiting is unlikely to be dehydrated (when did they last pass urine) or to have an acute surgical abdomen (if they have abdominal pain they need to be seen and examined)? How sure are you that the patient has a normal respiratory rate and colour? It is not enough that the patient does not request to be seen, or seems to be happy with advice. Usually in medico-legal cases concerning Out of Hours services there is a recording of the telephone consultation. Sometimes there are large gaps in the clinical information elicited. Sometimes the doctor gives advice before eliciting that the dizzy patient is on lithium, or that the vomiting patient is diabetic. Before hanging up on a telephone consultation it is necessary to ask yourself whether the clinical picture is absolutely clear, whether you can visualize that patient and have all the necessary information, whether the information from an abdominal examination or seeing the patient’s breathing rate would be useful and whether all necessary ‘safety netting’ has been done.

Communication problems

In most medico-legal cases the patient has been seen by several doctors. Often there will be two or three general practitioners involved and an ED attendance. The patient may have seen the in house physiotherapist or district nurse. Sometimes one doctor may have requested a test and another sees the result. Each of these contacts is fraught with the difficulty that communication between the professionals may be unsatisfactory and key bits of information may be lost or not communicated. The physiotherapist may tell the patient to see the general practitioner because of urinary problems with back pain but the patient may fail to do so or may contact the general practitioner and not mention the detail that concerned the physiotherapist. Sometimes the problem is that the second general practitioner did not look back at the notes of the first and consequently missed a key clinical detail. He may not have checked the past medical history and missed that the patient had breast cancer 13 years earlier. The practice nurse may have noted that an ulcer that is failing to heal should be biopsied but this was never read or acted upon. In most cases there are several communication breakdowns.

To try and minimize this risk it is wise to always check the content of the past two or three consultation notes and have at least a cursory look at the past medical history and drug therapy before deciding on a management plan. Clear notes, which we will discuss in a moment, also make practice much safer.

When lack of knowledge plays a part

It is not possible for a general practitioner to know all that is necessary about all conditions and drugs. But in the modern information age it is very easy to look things up very quickly. A general practitioner should really be consulting the British National Formulary very regularly through the day. That episode of angio-oedema may be drug related. If you prescribe an angiotensin receptor blocker to a woman of child-bearing age it is necessary to be clear that they are teratogenic. There is extensive detailed and expert knowledge available on the web about conditions that general practitioners do not routinely look after, such as ulcerative colitis. It is always reasonable to look things up in a consultation, seek advice or revert to a patient later when you have found out more. It is often the over-confident general practitioner who ends up in court.

The unexpectedly abnormal result

A general practitioner will often see hundreds of separate results in a day. She may have only wanted a serum creatinine but she will get a sodium anyway. She may have requested an ALT and obtained a serum calcium anyway. A single request with ten numerical results has a nearly 50% statistical chance of having at least one result that is more than two standard deviations from the mean. Consequently, there will frequently be abnormal results. The sodium is only 129 mmol/l, the ALT is 86 UI/l, the platelets are 90.

Investigations can potentially lead to what Deyo describes as the ‘cascade of technology’ (Deyo, 2002). The routine ECG for a BUPA medical shows some inverted T waves, the echo is equivocal and the patient ends up having a coronary angiogram which is normal and a serious thigh haematoma.

However, failure to act on the unexpectedly abnormal result is a common cause of medico-legal cases. The raised ESR ends up being due to myeloma, the iron deficiency anaemia to cancer and high voltages on the ECG to aortic stenosis. The raised random glucose in 1997 is missed and leads to advanced retinopathy and nephropathy in 2009.

The general practitioner needs to adopt a careful and vigilant approach to abnormal results. Some can clearly be routinely ignored. The marginal abnormalities in subfractions of white cells, the sodium of 131 mmol/l. But most need to be treated with caution. A statistically freak result will normalize when it is repeated because of the statistical phenomenon of ‘reversion to the mean’. Often that is all that is required. However, when a result is persistently abnormal it needs explaining. Often the explanation is relatively anodyne and requires no action. The patient with the sodium of 130 mmol/l is taking carbamazepine for epilepsy. But it is important to be aware that the abnormal result ticked as ‘OK’ may be a problem in the future. Even the instruction ‘please repeat’ may be a problem when it does not occur.

The standard of notes

General practice notes have historically been rather poor. When paediatric cases from the 1990s come to trial now (see the section on Limitations in Part 1, Section 1) it is necessary that the Court is aware that the average (and therefore Bolam defendable) standard of note keeping then would not be acceptable now.

Some general practitioners consider that detailed note taking is only necessary as part of medico-legally defensive practice. But this is not the case.

The standard of detail in consultation notes required by the General Medical Council is such that a subsequent clinician, reading the notes, would be able to reconstruct the clinical essentials of the consultation. In fact this standard is required for good clinical care, irrespective of any medico-legal considerations. The problems outlined in the section on communication between clinicians above are significantly amplified when the notes are poor. The patient is at greater risk of errors. It is also difficult to escape the conclusion that, although there are exceptions, poor notes often reflect poor clinical practice.

There are some basic details that are quite commonly omitted. It is good practice to record the duration of the symptom. ‘Cough’ is unacceptable. All that is required is ‘cough 4/7’ or whatever. Sometimes it is helpful to record key relevant negatives. The fact that the patient with a chronic cough has not lost weight is useful, particularly if she ends up having lymphoma. It is surprising how often general practitioners do not record the temperature, pulse and blood pressure in the febrile patient. It would not be possible to argue that a reasonable assessment was recorded when the patient subsequently dies of septicaemia.

It is necessary in the modern era to record some management plan and ‘safety netting’ advice unless it is truly self-evident from the consultation.

Some trainee general practitioners used to be embarrassed because they would come out of hospital practice and write long structured notes, only to see their senior colleagues writing one sentence.

Although brevity is to be valued, it is good practice to keep some semblance of the old SOAP (Subject, Object, Assessment, Plan), or ‘history, examination, diagnosis, plan’ structure and to second guess yourself. Ask yourself whether a colleague could work out from your notes the essential details of the consultation.

Drug errors or prescribing errors

It does appear that in general practice, because of the computerized prescribing systems, errors in doses are less common, though it is clearly more of a risk with paediatric dosing.

The more common allegations are inappropriate prescribing, inappropriate monitoring or failing to recognize drug side effects. Prolonged benzodiazepine prescribing remains a common cause of litigation. Inadequate monitoring of drugs such as azathioprine, lithium, phenytoin or prednisolone are relatively common causes of litigation.

Consent

The aspect of consent that features sometimes in negligence cases against general practitioners is when the patient initially decides not to be referred into hospital with an acute medical condition. The general practitioner may record ‘patient not keen on admission’. The patient then dies from a pulmonary embolism.

If a competent general practitioner would have sought to admit the patient, the patient’s decision not to go to hospital only absolves the general practitioner if it was a fully informed decision. The general practitioner needs to have explained all the material risks in making such a decision. The risks it is necessary to explain are those that a reasonable general practitioner would advise to their patient. In other words, the standard is based on the Bolam test. Usually it would be necessary to explain any diagnostic uncertainty (‘I think you have a chest infection but it may be a pulmonary embolism’) and the range of possible outcomes (‘if you do not go into hospital you may die’). Sometimes an elderly patient, or a patient with terminal disease, may elect not to be admitted into hospital. But ‘patient not keen on admission’ is only likely to be a defence if the patient made a fully informed decision.

Consent features are more straightforward in cases about minor procedures carried out in general practice. Was the young woman informed of the risk of keloid if she had the lesion excised from the necklace area on her chest? Again, the duty is to inform of all material risks that might inform a reasonable person’s decision.

If a general practitioner handles the above examples with insufficient care, he may find himself facing a negligence claim. The last issue of consent we will cover is more likely to arise in a complaint against a general practitioner rather than a negligence case. It is the question of the competence of a child or an adult with diminished capacity to consent to treatment.

It is important to understand that the test is whether the person has the capacity to consent to that particular decision. It is not a global assessment of whether the patient has the capacity to make any decision. A person may have the capacity to consent to have a minor operation to remove a mole, but may not have the capacity to make a complicated life and death decision about whether to be admitted into hospital or not.

A person is competent, if he can:

• understand and retain information pertinent to the decision about his care, i.e. the nature, purpose and possible consequences of the proposed investigations or treatment, as well as the consequences of not having treatment;
  
• use this information to consider whether or not he should consent to the intervention offered;
  
• communicate his/her wishes.

Children aged 16 and over are presumed to have the same capacity as an adult to consent to medical treatment (Family Law Reform Act, 1969).

Except in emergencies, the consent of a parent or, more accurately, someone with parental responsibility will be required for children under 16 who lack the capacity to understand the nature of the treatment being offered.

A child under the age of 16 may have capacity, provided she is capable of understanding the nature of the proposed course of treatment and is capable of expressing that wish. Such a child is referred to as Fraser (or Gillick. The two terms can be used interchangeably) competent. There is no fixed age at which a child becomes Fraser competent. It depends on the maturity of each individual child. Usually, the Fraser test will cause few difficulties, as both parent and child will agree on the treatment and be involved in the decision-making process. The problem typically arises when a young girl turns up at the surgery asking for contraception or a termination of pregnancy, determined to keep her treatment or condition from her parents. Then the doctor will have to carefully assess the capacity of this child, to determine whether she is competent to understand.

Confidentiality

‘Whatever I see or hear, professionally or privately, which ought not to be divulged, I will keep secret and tell no one.’ The words are those of Hippocrates. They form part of his oath and are still an important article of the doctor/patient relationship. Hippocrates simply gives voice to the fact that a full history is an essential requirement for diagnosis and treatment and the patient must feel able to tell his doctor everything relevant to his condition, even the most embarrassing and personal details, without fear that those details will be divulged to others. Updating the words of Hippocrates and putting them in legal terms, a doctor owes a duty of confidence regarding information about his patient or others acquired in his capacity as a doctor. This duty applies whether the information comes from other people or from the patient himself.

If a doctor breaches this duty of confidence, then he could be sued for damages, but more likely he will be reported to the GMC. As far as it affects clinicians, the law concerning confidentiality is fashioned from a number of different sources. Primarily, there is the common law duty of confidence (constructed from court judgements). In the last few decades, this has been supplemented by a number of Acts of Parliament: namely, The Access to Health Records Act (1990), The Data Protection Act (1998) and The Human Rights Act (1998). These different elements combine to create a more or less coherent whole. What we have set out below represents a basic outline of this legal framework.

Starting with the basics, a doctor can disclose information to others, if he has the patient’s consent. But consent can be implied. Most patients understand that a doctor will share information about them with other members of the health team. In other words, the doctor can assume that he has the patient’s implied consent to do this.

This may seem obvious, but a doctor should, where appropriate, consider just how far this implied consent extends for any given course of treatment. It may not extend to highly personal details about the patient that he has learned in treating some other, previous illness. The doctor should consider what information it is necessary to disclose to other members of the healthcare team, when treating the child. If he discloses information of a highly personal nature, then he should make it clear that the information is disclosed to them in confidence. He should also tell the patient that the information has been shared with other members of the team.

Data Protection Act, 1998

Generally speaking, patients seek disclosure of their records under the Data Protection Act. It is most frequently ‘used’ for this purpose. However, disclosure of records represents only a small part of its purpose.

The Act requires every practice to have in place a number of protocols to safeguard the confidentiality of patient information. For example, the physical paper records should be carefully stored in a secure environment. Any electronic data (e.g. radiographs) should be protected with access only allowed to those with passwords.

Disclosure without consent

There are a number of circumstances in which a doctor can legitimately disclose patient information to another without the consent of the patient:

• Abuse or neglect: Where the doctor believes that a child may be the victim of abuse or neglect and he is unable to give or withhold consent for disclosure, then the child’s health is of paramount importance and he may disclose his belief to an appropriate, responsible person.
  
• Statutory obligation: A doctor is required to notify the appropriate authorities, if he attends upon someone suffering from an infectious disease or someone who is known or suspected to be addicted to controlled drugs.
  
• Public interest: A doctor may disclose patient information, if he believes that the patient presents a real risk of danger or serious harm to the public.
  
• When ordered by the court to do so: A doctor should not assume that simply because a lawyer or some figure of authority, such as a police officer, asks for disclosure of the patient’s records, they are entitled to see the medical records. He should only disclose the records, if the patient has consented or the court has ordered disclosure.

Caldicott Guardians

Each health service body, including GP practices, should employ a Caldicott Guardian. His role is to ensure that patient information is dealt with in an appropriate fashion and that there are systems in place to ensure that all doctors generally respect the duty of confidentiality that exists between them and the patients that they serve. Therefore, he should be a first port of call, if an issue arises concerning the use of confidential information.

Conditions that are ‘frequent flyers’ in negligence cases

There are some conditions that are very over-represented in medical negligence cases. It is worth keeping them at the back of your mind when assessing patients. ‘Could this patient have…?’ Here are a few:

• Subarachnoid haemorrhage. Always ask about the onset of the headache. Was it abrupt? Bear in mind that the headache can take minutes to reach full severity in 50% of cases. Beware the headache at the back of the neck.
  
• Pulmonary embolism. 22% do not have features of pulmonary infarction or collapse and present with breathlessness alone. Always consider it with unexplained breathlessness.
  
• Cauda equina syndrome. Very rare in normal practice and very common in medico-legal cases. Always ask about urinary symptoms and abnormal sensation in the saddle area. Ideally, warn about the significance of the same.
  
• Acute appendicitis. Be aware that a significant proportion do not present in the classical way. There may be urinary symptoms or diarrhoea that misleads the general practitioner. Signs of right lower quadrant tenderness may be absent if the appendix is retrocaecal.
  
• Ischaemic feet. Beware of ‘gout’ or ‘cellulitis’ in a pulseless foot. The red painful foot may be critically ischaemic. Always check for pulses, with a Doppler if impalpable. It is good practice to do an ABPI (Ankle Brachial Pressure Index), especially if there is an ulcer. Refer diabetics with an ulcer to a ‘multi-disciplinary diabetic foot team’ within 24 hours (required under NICE, 2004).
  
• Malignant melanoma. With pigmented lesions, even if they appear benign, measure them and see them again in 6 weeks if there is an uncertain history of possible change.
  
• Breast cancer. Re examine in 6 weeks if you cannot feel the lump the patient felt. Be aware that even a competent clinical breast examination misses many cancers that are less than 2 cm in diameter.
  
• Colorectal cancer. Be aware of the significance of asymptomatic mild, iron deficiency anaemia, rectal bleeding and a change in bowel habit to loose stools. Always do a digital rectal examination and feel the abdomen.
  
• Cervical cancer. A young woman on the pill may have breakthrough bleeding, but once it persists despite a pill change the cervix needs examining. A recent normal smear is not a SnOUT.
  
• Diabetic ketoacidosis. Always check the urine for ketones in an unwell patient with Type 1 diabetes. Admit if more than 1+ ketones.
  
• Achilles tendon rupture. With the ankle injury ask about any ‘snap’, check they can stand on tip toe and do the ‘calf squeeze test’.
  
• Septicaemia. Always measure and record a temperature, pulse and blood pressure in a febrile patient.
  
• The unexpectedly abnormal result. The default is usually to repeat it.

Safety netting

The last issue in this section is of crucial importance in general practice.

The general practitioner is in the unenviable task of making assessments and decisions in an environment when there is usually considerable diagnostic uncertainty and the patient is not supervised as they would be in hospital.

It is neither practical nor good medicine to investigate all patients to the degree that they will be investigated in secondary care. An important part of the role of the general practitioner is to protect the patient against the iatrogenic harm that comes about if the patient is unnecessarily exposed to a ‘cascade’ of medical technology inherent in searching for an elusive diagnosis.

In addition, the illness may evolve in an unpredictable way. A two year old with an unremarkable upper respiratory tract infection may abruptly deteriorate. Most adults with community acquired pneumonia can be managed at home, but one may unexpectedly develop septicaemia or respiratory failure. The teenager with the abdominal pain may have no features of acute appendicitis when assessed but may then start vomiting and developing right lower quadrant peritonism.

The general practitioner’s powerful magic weapon is ‘safety netting’.

Twenty years ago the safety net involved saying ‘come back if you don’t get better’ and recording ‘SOS’. Safety netting is now a more evolved beast. It extends from, at one end, the advice above. Most minor illness in primary care is self-limiting and the patient does not routinely need to be reviewed. If the patient’s course deviates from the expected natural history (they still have diarrhoea in 7 days) then they need review but otherwise they do not.

A more elaborate form of safety netting is the planned review, together with advice about what to do if the situation deteriorates in the interim. ‘You have no signs of acute appendicitis now but I would like to see you again tomorrow after morning surgery. If things get worse overnight then you should call the Out of Hours service and this is the number.’

A more elaborate form still is to specify the symptoms that should prompt the patient to seek review. Most patients with acute low back pain will not appreciate the significance of having difficulty passing urine or abnormal sensation in the saddle area. Warning them of the significance of this may mean that they seek help at an early stage rather than having a complete cauda equina syndrome and having a neuropathic bladder for 48 hours before seeking advice.

The gold standard is a written advice sheet. ‘Your febrile 2 year old does not seem to have any serious illness at the moment but very rarely a child can become very unwell very quickly. If you are at all concerned ring this number. We would be particularly concerned about fast breathing, unreasonable distress, unrousable drowsiness, poor fluid intake, wet nappies spaced by more than 4 hours, cold or mottled hands or feet or a rash that doesn’t blanch. This sheet outlines the things that would worry us and instructions of what to do.’

It would not be reasonable to be critical of a general practitioner who carried out a careful assessment and safety netted carefully, merely because the child later developed signs of a serious illness. Documenting advice given is clearly also good practice.

Safety netting is a very powerful weapon with which to deal safely with uncertainty in general practice.

References and further reading

Almond S, Mant D, Thompson M (2009) Diagnostic safety-netting. British Journal of General Practice 59: 872–4.

Deyo RA (2002) Cascade effects of medical technology. Annual Review of Public Health 23: 23–44.

General Medical Council (2008) Consent Guidance: Patients and Doctors Making Decisions Together. GMC.

NICE (2004) NICE guideline to Type 2 diabetes – footcare. CG10.

Saunders L (2009) Diagnosis: Dispatches from the Frontlines of Medical Mysteries. Icon Books Ltd.