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As part of my training as an Expert Witness, I took part in a `pretend court` along with some other trainees. A real barrister questioned us for 10 minutes each about an anonymised case we had each brought along and it became competitive as to how long we could last before becoming a gibbering wreck. We learned what it was like to be in a situation where the gloves were truly off and we were in an aggressive environment. One of my fellow defendants was a lovely man, an experienced paediatric consultant and part time professor, he lasted six minutes before he actually started crying. Yes, real tears and this was only a test.
As professionals, we are used to being in situations where we are in control and our judgement is not questioned. It is extremely uncomfortable to lose that ability to control a conversation and not even be able to run away. Well, many more of you are going find yourselves in this situation. The Medical Defence Union has found that legal claims against GPs for medication errors have risen 60% in recent years. They have reviewed 371 claims and reported on the 86 which have been settled (177 remained active). More about the results later in the article.
The MDU has paid out £5 million in compensation since 2008, together with £400,000 in legal costs. The largest payout on behalf of a GP was £1.2 million to a patient who was left severely disabled after a failure to monitor levels of a long-term prescription for lithium, resulting in lithium toxicity, while the average compensation awarded to successful claimants came in a just over £58,500. The Medical Protection Society has also found that claims against GPs rose by 40% in 2012 alone and is now at record levels. The MPS also warned the value of claims has increased, with catastrophic injury cases, such as brain damage from a missed diagnosis of meningitis, being settled for £6m. However, the money apart, each of these claims represents months and even years of stress and unhappiness for the doctors involved. The last thing you want is `your day in court`!
Dr Chris Godeseth, MPS medical risk manager, said: “This may not come as such a surprise to some GPs, who have perhaps themselves observed more complaints and issues being raised by patients, but it will still cause concern among many who are juggling challenges around funding, resources and commissioning.” The MDU also said the rise was likely driven by an increase in GPs’ prescribing workloads, it said there were a range of things GPs can do to reduce the risk of claims for medication errors. It’s important that GPs have an understanding of the current claims climate but the challenge, of course, is not adopting a ‘defensive’ approach. There are a number of practical steps that GPs and their practices can take to avoid the risk of receiving a claim or complaint, such as ensuring prescribing and test result systems are robust, and being open and honest with patients when things go wrong. This transparency is really important, as patients like to feel that raising their own concerns will make a difference as to what will happen to other people in the future. Lastly, there is nothing wrong with saying `sorry` and this alone can stop a simple complaint becoming litigation.
GPs should also be wary of remote prescribing. The GMC is clear that remote prescribing should not be a matter of routine and should only be done if you have "adequate knowledge of the patient's health and are satisfied that the medicines serve the patient's needs." You are also expected to consider the limitations of communicating with a patient via the telephone or other technology; whether a physical examination is required and whether you have access to the patient's medical records. Also, be aware that remote consultations, such as telephone conversations and emails, form part of the patient's records and should be stored securely.
Now, what about those settled cases and this means cases that were agreed to be a fault from the doctors` end? You can believe that this will never happen to you, but here are 86 people who thought the same and are now wondering how they could have lost focus in such a big way. The biggest group, thirty three, concerned prescribing the wrong or inappropriate drug and eleven of these were a result of a mix-up and the wrong drug name or formulation being prescribed to a patient. For example, prescribing quinine instead of the antipsychotic quetiapine. In several cases, a prescribed drug interacted with the patient’s existing medication causing a severe adverse reaction. For example, one patient was prescribed the antibiotic clarithromycin when they were already taking digoxin for a heart problem.
The next most popular mistake was in long-term administration of medication. The claims in this category related to a failure to monitor patients on long-term repeat prescriptions which meant that they experienced harmful side-effects, including renal failure or becoming addicted to the drug they were taking. Drug types included NSAIDs, benzodiazepines, steroids and antibiotics.
Next came `dose error`. These claims followed incidents where patients had taken too high a dose of a drug either because it had been prescribed wrongly or there was confusion about the dose frequency. Drugs involved included antidepressants and dopamine agonists. I am personally familiar with an incident in which a doctor placed a decimal point two places out – one hundred times the recommended dose. Fortunately, the pharmacy noticed the unusual circumstances and referred back to the practice before dispensing. Unfortunately, the patient wanted to know why they had to return to their doctor!
Lastly, fourteen cases involved prescribing to a patient with a known allergy (usually penicillin). This may have been because the allergy had been identified in a hospital setting and the patient’s record had not been updated or because the GP had not checked or asked the patient if they were allergic to the drug.
Momentary loss of focus, or a feeling of being rushed, can result in upsetting circumstances for both patient and practitioner. The defence organisations are very good at supporting you through the process, but that doesn`t stop you going through months of guilt, anger and frustration. Risk management should be an everyday part of practice because you do not want to risk that court appearance. In case anyone is wondering, I lasted seven minutes.
Dr John Shapter – QCS Expert GP Contributor