In April 2001 the Department of Health published Building a Safer NHS for Patients,1setting out the Government's plans to promote safer care by 'harnessing learning throughout the NHS when something goes wrong'.
The cost of critical events is horrifying in both human and financial terms. It is estimated that approximately 850 000 critical events occur in hospitals each year. That is 10% of all admissions, resulting in additional expenditure of £3 billion.
In May 2001, the National Audit Office issued its annual report.2 This revealed that the current cost of outstanding clinical negligence claims is £3.9 billion, and that NHS trusts in England paid out nearly £400 million in compensation in 2000 to patients harmed as a result of negligence.
Complaints and claims are not confined to the hospital sector. A review of 1000 consecutive claims against GPs revealed a number of recurrent problems,3 many of which can be prevented by instigating simple checks and processes (see Figure 1, below).
|Figure 1: Recurrent problems resulting in complaints and claims against GPs3|
Reducing the number of critical events
One approach to reducing the number of critical events is critical event auditing. This involves careful documentation of events so that the steps needed to prevent recurrence can be identified and implemented. A critical event is defined as an incident that has in some way resulted in harm or threatened harm to patients or staff.
How can this be established in practice? First, a reporting system must be designed and all staff within the practice informed about what it is and how to use it. Someone within the practice should be nominated to act as a coordinator, i.e. the person to whom critical events and near misses are reported.
Next, the details of the event must be recorded:
- What happened
- Why it was important
- Who was involved
- Contributing factors
- Most importantly – what should be done in future to prevent the same thing happening again.
A typical case
On your last working day before your summer holiday, Mrs Jones attends without an appointment. She is 48 years old, and is usually in good health. But recently she has been feeling tired and becomes breathless whenever she exerts herself. There is no other history of note and nothing is found on examination.
You decide to do a few routine tests and suggest that she comes back in a fortnight, when you will be back at work. Unfortunately, as you are in a rush, your records are brief.
The blood test reveals a haemoglobin level of 7.8g/100ml. The result is returned to the surgery. It is very busy while you are away and, although your partners would normally keep an eye on your incoming mail, they simply do not get round to it during the first week that you are away.
Mrs Jones collapses and is admitted to hospital as an emergency at the end of that week. Her haemoglobin level has fallen to 4.0g/100ml. She is transfused and recovers.
Auditing the event
What happened and why it is important are self-evident. But what is the underlying problem? As happens during many critical events, a sequence of unusual or even unique events exposed a patient to potential harm. However, this is unlikely to be any consolation to the patient.
The main problem in this example was the failure to review test results received at the practice and to act appropriately in response to identified abnormalities. This would normally be achieved by the other partners mucking in, but because they were all hard-pressed they did not get round to it.
What must be done to prevent a recurrence of the same situation is equally obvious. A system must be developed to ensure that all results are reviewed, whether or not the doctor who ordered the test is away from the practice, and that whoever reviews the result takes responsibility for further action.
Simple stuff – all self-evident – but many complaints arise from simple mistakes that could easily have been avoided.
Most medication errors occur because a drug is given in the wrong dose or prescribed despite an absolute or comparative contraindication (including known allergy), because side-effects and toxicity are not monitored, or because of a communication failure so that the patient is not informed of side-effects or which symptoms to report to the doctor.
The most common administrative errors are:
- Failure to pass on important information
- Failure to arrange appointments, investigations or referrals with the appropriate degree of urgency
- Failure to review the results of investigations (as in the case of the unfortunate Mrs Jones)
- Failure to arrange follow-up and monitoring
- Failure to check labels.
Critical event reporting
In Building a Safer NHS for Patients the Government anticipates a mandatory reporting system for all critical events in both primary and secondary care.1 Such a proposal is likely to fill many doctors with horror, particularly in the current finger-pointing culture. Many will wonder whether recording critical events in this way is not simply laying doctors open to more complaints, more claims, more adverse findings and potential disciplinary action.
Any documentation compiled in relation to a critical event will be discoverable in relation to any legal proceedings, including negligence claims or General Medical Council (GMC) proceedings. But should that discourage doctors from analysing critical events and modifying their practice as a result? I hope not.
When something has gone wrong, the doctor has a duty to answer the patient fully and honestly. This is required by the GMC (see Figure 2,below) and is the basis of the NHS complaints procedure.
|Figure 2: If things go wrong – GMC requirements for GPs dealing with patient complaints. Source: Good Medical Practice4|
|"Patients who complain about the care or treatment they have received have a right to expect a prompt and appropriate response. As a doctor you have a professional responsibility to deal with complaints constructively and honestly. You should co-operate with any complaints procedure which applies to your work. You must not allow a patient's complaint to prejudice the care or treatment you provide or arrange for that patient.
"If a patient under your care has suffered serious harm, through misadventure or for any other reason, you should act immediately to put matters right, if that is possible. You should explain fully to the patient what has happened and the likely long- and short-term effects. When appropriate, you should offer an apology. If the patient is under 16 and lacks the maturity to consent to treatment, you should explain the situation honestly to those with parental responsibility for the child."
Obfuscation and stonewalling are sure ways to spur a complainant on to discover the true facts. Some may attempt to sue or press for disciplinary action, but the doctor who can demonstrate that the whole episode was dealt with openly and professionally is in a far stronger position if hauled before a disciplinary tribunal.
Even if we were able to achieve, in general, a blame-free culture, individual accountability for culpable acts and omissions must remain.
Critical event reporting is a valuable tool to identify shortcomings in practice procedures. The fact that a critical event occurred should, in itself, convince everyone within the practice that the need for review is beyond question.
- DoH. Building a Safer NHS for Patients. London: DoH, April 2001. Available from DoH, PO Box 777, London SE1 6XH, or to download from: http://www.doh.gov.uk/buildsafenhs/index.htm
- National Audit Office. Annual Report. London, HMSO, April 2001.
- Health Care Risk Report. London, Eclipse, February 2001.
- General Medical Council. Good Medical Practice. London, GMC, 1998.