Mistakes in General Practice

1. Mistakes in General Practice Dr Sunil Gupta August 2009

2. Ten real cases of mistakes made in General Practice 1 � A GP prescribed a beta blocker to an asthmatic and the patient died. 2 � A GP prescribed Penicillin to a patient who had a past history of severe allergic reaction to Penicillin. 3 � A clerk filling a blood result filed it in the notes of a wrong patient who had the same name but different date of birth. This resulted in incorrect treatment being given.

3. Ten real cases of mistakes made in General Practice 4 � A GP printed out a prescription from the computer of the correct drug but for the wrong patient. 5 � A GP printed out a prescription from the computer for 1000 Ibuprofen tablets instead of 100. 6 � A Practice Nurse gave several patients a tetanus vaccine rather than the flu vaccine.

4. Ten real cases of mistakes made in General Practice 7 � A elderly man presented with increased wind PR but no other symptoms. The examination was normal. The patient was reassured. But 3 months later the patient presented with metastatic bowel cancer. 8 � A GP wrote a prescription fro Depo-medrone rather than Depo-provera.

5. Ten real cases of mistakes made in General Practice 9 � A GP arranged an ECG for a patient with mild chest pain for the last few weeks. On looking at the ECG the GP missed the Q waves and wrongly reassured the patient. 10 � A GP gave a patient a letter for a private referral to see a Dermatologist about a probable Melanoma. The patient did not make the appointment and the GP only realised when the patient came back to see the GP nine months later.

6. Communication Mistakes Doctor not knowing patient was asthmatic (case 1). Doctor not knowing patient was allergic to Penicillin (case 2). Doctor not telling patient clearly what symptoms to look out for (case 7). Doctor not telling patient clearly the importance of the referral (case 10).

7. Prescribing Mistakes Wrong drug because contraindicated (case 1). Wrong drug because allergy (case 2). Wrong Patient (case 4). Wrong quantity (case 5). Wrong drug because sound similar (case 8).

8. Causes of Mistakes (1) System Errors Allergies not clearly marked. Similar names of patients not highlighted. Diagnosis e.g. asthma not cleared marked. Injections look similar. Culture of blame � mistakes not learnt from. People scared to question the action of their � superiors�.

9. Causes of Mistakes (2) Patient Factors Poor communication skills Not reading patient information leaflets. Afraid to question the action of doctor.

10. Causes of Mistakes (3) Health Professional Factors Lack of knowledge. Poor communication skills. Tiredness / lack of sleep / stress. Physical or mental illness. Poor handwriting. Consultation time too short. Afraid to admit when out of depth. Not willing to seek or listen to advice of others.

11. How to reduce the number of mistakes in General Practice 1 - Make all staff aware of common mistakes. 2 - No longer have a culture of blame. 3 - Ensure important diagnosis and allergies clearly visible. 4 - Make medicines easier to distinguish from each other. 5 - GP to have a system to track patients they are concerned about.

12. How to reduce the number of mistakes in General Practice 6 � Check the prescriptions you print out. 7 � Do one thing at a time. 8 � Ensure regular maintenance of equipment. 9 � Do regular significant event audits. 10 � Avoid working excessive hours. 11 � Communications skills training.