Making Mistakes

Question 1

Learning outcomes

Answer 1

• Explain why ‘whistleblowing’ in medicine can be difficult
• Name common factors that contribute to basic error-making in medical practice, and understand the actions doctors can take to combat them
• Contrast a person-centred approach and a systems-based approach to addressing medical errors, and give examples of each
• Explain what is meant by ‘human factors’ and identify ways of reducing errors through a systems-based approach
• Describe the Duty of Candour introduced in the Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill, 2015
• Describe the 4 steps involved in the Professional Duty of Candour (GMC & RMC Guidance, 2015)
• Outline a doctor’s duty to their patient and to their organisation when something goes wrong, as stated in the Professional Duty of Candour (p2, point 4, GMC & RMC Guidance, 2015)
• Describe the three elements that comprise an action in negligence
• Define the Bolam test and the Bolitho amendment and understand the implication of the ruling in Montgomery v Lanarkshire Health Board (2015) on the issue of consent
• Identify weaknesses in the current clinical negligence system

Question 2

Why do basic errors happen?

Answer 2

• Sokol & Bergson, list the following
• Basic errors happen due to:
  1) Stress
  2) Fatigue
  3) Covering for colleagues (too little locum support)
  4) Professional culture (unwillingness to use support structures)
  5) Feeling that decisions must be made alone
  6) Unable to admit to uncertainty

Question 3

Why is it difficult to admit and report errors in medicine

Answer 3

• Bowman highlights several areas
• It is difficult to admit and report errors in medicine due to:
  1) Consequences:
  2) Does error = incompetence? (after all, everyone makes mistakes…)
  3) Whistle-blowing is not without risk (far from it in fact…)
  4) Medicine is not an exact science
  5) Some argue that there is a “norm of non-criticism”

Question 4

Why is it difficult to admit and report errors in medicine

Answer 4

• Bowman highlights several areas
• It is difficult to admit and report errors in medicine due to:
  1) Consequences:
  2) Does error = incompetence? (after all, everyone makes mistakes…)
  3) Whistle-blowing is not without risk (far from it in fact…)
  4) Medicine is not an exact science
  5) Some argue that there is a “norm of non-criticism”

Question 5

What does the Francis report cover?

Answer 5

• The Francis Report was published based on a public inquiry into poor care at the Mid Staffordshire NHS Foundation Trust.
• The report examined what led to poor standards of care at the hospital, unnecessary patient deaths and why the warning signs of serious failings were not recognised.

Question 6

What does the GCM duty of Candour (2015) state that healthcare professionals must do?

Answer 6

• The GCM duty of Candour (2015) state that healthcare professionals must:
  1) Tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong
  2) Apologise to the patient (or, where appropriate, the patient’s advocate, carer or family)
  3) Offer an appropriate remedy or support to put matters right (if possible)
  4) Explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short- and long-term effects of what has happened.

Question 7

What 3 things might happen in response to errors or inadequate care?

Answer 7

• 3 things that might happen in response to errors or inadequate care:
  1) Negligence (legal approach): patient might take legal action
  2) NHS Complaints Procedure: patient might make a complaint
  3) GMC (professional body): disciplinary action or removal from register

Question 8

What does the GMC do when reported with error?

What are four outcomes from GMC investigation?

Answer 8

• What the GMC does when faced with complaints:
• “We receive complaints or concerns about many doctors throughout their careers. But we only investigate when these raise issues about a doctor’s ability to practise safely or threaten public confidence in the profession”
• Four outcomes from GMC investigation:
  1) Case concluded, no further action
  2) Issue a warning
  3) Agree undertakings
  4) Refer to MPTS (Medical Practitioners Tribunal Service)
• E.g. sexual assault or indecency, violence, improper sexual or emotional relationships, knowingly practising without a licence, unlawfully discrimination, dishonest and gross negligence, recklessness about a risk of serious harm to patients, custodial or non-custodial conviction, caution or a determination from another regulatory body, refuses to agree undertakings.
• No action/Undertakings/Conditions/Suspension/Erasure

Question 9

What 3 things must a claimant a establish for there to be a case of negligence?

Answer 9

• 3 things a claimant must establish for there to be a case of negligence:
  1) He/she is owed a duty of care by the defendant
  2) That the defendant breached that duty by failing to provide reasonable care
  3) That the breach of duty caused the claimant’s injuries (causation), and that those injuries are not too remote (proximity) (e.g injuries cause from 6 months after the treatment may be too remote)

Question 10

What is reasonable care according to The Bolam test (1957) and updated Bolam test (1997)?

Answer 10

• What is reasonable care according to The Bolam test (1957) and updated Bolam test (1997):

1) The Bolam (1957) 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.”

2) The Bolitho (1997) test:
* Modified Bolam to add: the professional opinion must be capable of withstanding logical analysis (note: a move away from the deferential approach of Bolam)

Question 11

What was the ‘impact of Montgomery case’ (2015)?

How did this case alter the laws regarding informed consent?

What 3 questions must be answered by medical professionals when treating patients?

Answer 11

• The impact of Montgomery: (2015)
• “Nadine Montgomery, a woman with diabetes and of small stature, delivered her son vaginally; he experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby’s size was a potential problem.”
• After this case:
• “The law now requires a doctor to take ‘reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.’ …
• 3 questions that must be answered by medical professionals when treating patients:
• Three questions:
  1) Does the patient know about the material risks of the treatment I’m proposing?
  2) Does the patient know about reasonable alternatives to this treatment?
  3) Have I taken reasonable care to ensure that the patient actually knows this?”

Question 12

What is causation? What must be established for there to be a case of negligence?

When does negligence most commonly fail?

If negligence fails, what can the patient do if they are not happy with their care?

What are the 2 stages of NHS Scotland’s complaints procedure?

Answer 12

• Causation is the act of causing something
• For a case of negligence to be established, there must be a clear link between the action (or inaction) of a doctor, and the harm the patient experienced
• Often causation is where a patient’s case may fail
• If not eligible for negligence, but not happy with care – NHS complaints procedure
• 2 stages of NHS Scotland’s complaints procedure:
  1) Local resolution
  2) Scottish public services ombudsman

Question 13

What occurred in the Doctor Bawa Garba Case?

What was the outcome?

What were the legal outcomes?

What were the professional outcomes?

Answer 13

• The Dr Baw Garba case:
• “An inquest was promptly convened and expert evidence suggested the care given to Jack by both Bawa-Garba and a nurse was inadequate and complacent. But it was apparent from the outset there were many systemic issues that had contributed to what had happened.” – Ian Freckleton, QC
• Legally outcomes - guilty of gross negligence manslaughter
• Professionally outcomes : suspended for 12 months, GMC appealed for erasure, Bawa- Garba appealed, suspension put in place. Qualified as a consultant in 2022.

Question 14

What is not a good way to learn from errors?

What is a person-centred approach to learning from errors?

What is a systems based approach to learning from errors?

Answer 14

• Negligence is not an effective way to learn from errors as outcome bias exists (culpability (responsibility for a fault) does not depend on blameworthiness but on consequences)
• Person-centred approach to learning from errors – focusses on the individual doctor
• Systems based approach to learning from errors - Considers the environment, and seeks to minimise opportunities for error

Question 15

How has medicine sought to address some of the failures in the current system?

Answer 15

• How medicine has sought to address some of the failures in the current system?

1) Dedicated centres
* Beneficial for less common and uncommon procedures
* E.g National Patients Safety Agency from 2001 to 2012 in England and Whales, a lot of which has been transferred to NHS Commissioning Board Special Health Authority
* Key part: National Reporting and Learning System (NRLS), the “world’s most comprehensive database of patient safety information, to identify and tackle important patient safety issues at their root cause.”
* In Scotland, Scottish Patient Safety Research Network

2) Requirement to retrain
* New procedures and techniques

3) Data collection of incidents

4) Improved instrument design

5) Protocols & guidelines

6) Checklists