Risk Management in General Practice

1. Risk ManagementinGeneral Practice Professor Carol A Seymour MA (Oxon) MA (Cantab) PhD FRCPath FRCP FFFLM Barrister Medicolegal Adviser 19 January 2010

2. Aims of this Session • Principles of professional practice • Identification of risk • Risk assessment and management • Medicolegal implications of risk management

3. Doctors and Society • Doctors – Patient relationship • Environment – doctor’s training / practice • Public trust in medicine • Challenge to traditional work / behaviour of doctors Doctors in Society, Clin Med [2005] : 5 ; 53

4. Clinical Governance • A First Class Service 1998 – Framework for quality of care and monitoring • Health Act 1999 – Duty of care of each Trust • Organisation with a Memory 2000 – complaints, adverse incidents • High Quality Care for Patients 2008 • Patient Safety First 2009 – “The how to guide” for implementing human factors in healthcare

5. Clinical Governance “A First Class Service” – 1998 “Framework through which NHS organisations are accountable for continuously improving the quality of the services, and safeguarding high standards of care by creating an environment in which excellence in clinical care still flourish”

6. NPSA Guidance: Seven Pillars • Safety culture • Lead/support staff • Integrate risk management activity • Promote risk/incident reporting • Involve public/patients • Lean/share lessons • Implement solutions to avert harm

7. Risk Factors: Precipitating • Adverse Events • Iatrogenic • Failure to Provide Care • Incorrect Care • System Errors • Mistakes

8. Risk Factors: Predisposing • Rudeness; Judgemental • Conduct • Delays • Mis or Lack of Communication • Perceived Apathy

9. Risk Management: Why Bother? • Professional • Clinical Governance • Patient Safety • Reduce Complaints, Litigation

10. Systems of Accountability • Complaint • Claim • Disciplinary action - GMC procedures • Ombudsman Inquiry • Coroner’s Inquest • Criminal Investigation A single clinical incident may give rise to:

11. Non-Claim Conduct ; Attitude Communication Delays/Cancellation Clinical Record Missed Diagnosis/Result Prescribing Errors Subject of Complaint

12. Top key risks in UK general practice • 95% Confidentiality • 92% Prescribing • 90% Health and safety • 85% Communication • 84% Record keeping • 84% Test results MPS Risk Consulting 2006 MPS Risk Consulting August 2006

13. Keys to a peaceful life The Important C’s • Confidentiality • Communication; Clinical records • Complex Professional Processes • Clinical negligence • Cognisance

14. Confidentiality

15. Enquiries • Police • Social Worker • Insurance/ Employer • Divorced father Disclosure

16. Confidentiality and Disclosure Hippocrates: “Whatsoever things seen/ heard in the course of medical practice – right not to be spoken of ”

17. General Medical Council “Patients have a right to expect that information about them will be held in confidence by their doctors” “Confidentiality is central to trust between doctors and patients” Confidentiality GMC 2004

18. Law on Professional Confidence • Common law duty of confidence • Data Protection Act 1998 • Human Rights Act 1998 • Health and Social Care Act 2001 • Access to Health Records Act 1990 (Limitation)

19. Statutory Disclosure • Public Health legislation – notifiable diseases • Health and Safety legislation • Deaths and major injuries • Accidents (>3/12 off work) • Contagious diseases • Abortions legislation – standard form to CMO • PACE 1984; Road Traffic Act 1988 • Health Commissioner’s Act 1996 • Terrorism Act 2002

20. What is Confidential Information? • All information about a patient • Any information which identifies the patient • medical records • current illness, investigations, treatment • personal details • record of appointments • audio/audio visual recording(s) • fact of person being your patient

21. Disclosure of information • Patients have a right to information regarding their care • Patient consent before releasing information to third parties • Only release relevant information

22. When to disclose • With consent - patient ; not the patient • Required by law - Statutes; Court order; Regulation • Protected by law - Permitted disclosure - DVLA - Child abuse • Directed disclosure - Public Interest

23. Some tips • Consent • Minimum necessary • Anonymised where possible • Statutes Disclosure

24. Communication “ Man invented language to satisfy his deep need to complain” Lily Tomlin

25. Pitfalls Communication Working relationships Documentation Clinical skills

26. Pitfalls

27. Re: Learners “In my view, the law requires the trainee or learner to be judged by the same standard as his more experienced colleagues. If it did not, inexperience would frequently be urged as a defence to an action for professional negligence.” Wilsher v Essex AHA 1987 - LJ Glidewell

28. Communication • Timely and appropriate explanation • Offer patient information, answer questions • Recognise cultural differences • Timely appropriate handover • Written communication of information

29. Good Medical Records • Relevant history – important negatives • Examination – important negatives • Working/differential diagnosis • Details of investigations • Follow-up arrangements • What d/w “patient” • Window on clinical judgement

30. Case Notes (2) Remember your notes are disclosable “ I’ve met the patient, the wife, his children and the pet rabbit. Of the lot of them, the rabbit is the most intelligent.” • Keep a copy

31. Complex professional process • 1∙3% population consult GP each day • 50 – 60% patients receive a prescription • GPs issue 1∙8 million prescriptions each day DoH: Building a Safer NHS for patients: Improving Medication Safety, 2004 In 2005 • NHS spent nearly £8 billion on medicines • 720 million prescription items dispensed http://www.ic.nhs.uk/primary-care-2007/community-pharmacy

32. Definition “A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of health professional, patient or consumer.” National Patient Safety Agency adopted from US National Co-ordinating Council for Medication Error Reporting and Prevention

33. MPS study Main reason for the notified claims include: • Failure to warn or recognise drug side effects • Adverse outcome from the procedure , including errors in administration • Drug reaction or interaction • Incorrect or inappropriate medication • Failure to monitor • Wrong dose Silk N, Healthcare Risk Report 7 (3) 2000

34. Size of the Problem - GP 2150 reports from April 2007 to March 2008 from general practice, England: • 26% Medication errors • 14% Documentation • 11% Consent/communication/ confidentiality • 10% Access/admission/transfer/discharge • 0.27% of all reports received NPSA National Reporting and Learning Data Summary Issue 9 August 2008

35. Commonly implicated drugs • Steroids 20.7% • Hormonal preparations 15.5% • Antibiotics 6% • Antipsychotic 5% • Anti-epileptics 4% • Opiates 3% • Warfarin 3% • NSAIDs 2.5% Silk N, Healthcare Risk Report 7 (3) 2000

36. Risk Areas - Prescribing • No repeat prescribing protocol • No designated receptionist to record or generate repeat prescriptions • Reception staff are allowed to add medication to the computer • Medication reviews are undertaken on an ad hoc basis. • No system for recalling patients on long-term medication • Uncollected prescriptions are destroyed

37. Predisposing Factors • More rapid throughput of patients • Increasing complexity of care • New drug developments • Increased use of medicines • Patient expectation • Older population, more vulnerable to adverse events

38. Human factors • Fatigue – sleep deprivation • Hunger • Concentration • Stress • Lack of training • Lack of access to information • Other factors: alcohol, drugs, illness

39. Special Situations • Repeat prescribing • Secondary/primary interface • Prescribing for children • Computer prescribing

40. High risk groups • Elderly and housebound patients • Patients in nursing homes or residential care • Those on four or more drugs • Patients with disabilities • Patients recently discharged from secondary care • Patients taking certain medications • Patients with mental illness

41. Other problem areas • Controlled drugs • Unlicensed drugs • Nurse prescribing • Dispensing • Patient compliance and concordance • Wholesale generic switches

42. The ABC of Safe Prescribing • Is this the right person? • Do they need it? • Have I prescribed the right agent? • Are the formulation, dose, frequency and route of administration correct? • Is my prescription legible and understandable? • Are there any reasons why this might not be a good idea? • Does the patient know what’s going on? • Do I need to monitor anything as a result of this prescription? Kavanagh S February 2005

43. Risk Management • Review practice systems • Refine computer alerts • Remove the hazard • Packaging • Computer • Storage • Improved communication between health professionals

44. Risk Management • Address human factors • Stress • Distractions • Workload • Conventional audit • Good patient records • Staff awareness and training • Include and educate patients

45. Clinical Negligence Elements of medical negligence: • Duty of Care • Breach of Duty • Causation (loss) - harm flows from breach - harm not to remote

46. Standard - Bolam Test “The test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill at the risk of being found negligent. It is well-established law that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art.” McNair J Bolam v Friern Hospital Management Committee 1957

47. Bolam Test “A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. … a doctor is not negligent if he is acting in accordance with such a practice, merely because there is a body of opinion taking a contrary view.” McNair J Bolam v Friern Hospital Management Committee 1957

48. Further Test “…before accepting a body of opinion as being responsible, reasonable or respectable, [the judge] will need to be satisfied that, in forming their views, the experts have directed their minds to the question of comparative risks and benefits and have reached a defensible conclusion on the matter.” Bolitho v City and Hackney Health Authority 1997 - Browne-Wilkinson LJ

49. Indemnity/Insurance (1) • Crown Indemnity - NHS Litigation Authority (NHSLA) - Clinical negligence scheme for Trusts (CNST) • Medical defence organisation (MDO) - GP - Private practice

50. Indemnity/Insurance (2) • Role of MDO - Support and advice - Complaint responses - Reports - Inquests - Assist in disciplinary representation/negotiation - GMC Fitness to Practise - Criminal charges – professional issues