Some simple processes can reduce the risk of adverse events in primary care so practices should ensure they have adequate systems in place, says Dr Gerard Panting
There is no mystique about risk management just a number of myths and misconceptions. Risk management is simply the business of putting mechanisms into place to prevent problems arising in practice.
However, it is impossible to cover all conceivable risks, just as it is impossible to eliminate all harm that may befall patients. Practice resources are not infinite, so decisions must be made about which risks should be addressed and which are so improbable or trivial as not to warrant the same degree of attention.
So what does go wrong in general practice? A study of 1000 consecutive claims against GPs gives a clear picture.1,2 Some 631 could be described as a delay in arriving at the correct diagnosis, most of which were delays in the diagnosis of malignancy, with carcinoma of the breast and of the cervix being the most common.
With carcinoma of the breast, the most frequent error was categorising a breast lump as benign, either on clinical or mammographic grounds, when it later turned out to be malignant, and there were grounds to justify taking further action.
A further 29 claims stemmed from delayed diagnosis of carcinoma of the digestive tract. In these cases, a misdiagnosis such as irritable bowel syndrome, colitis or haemorrhoids had generally been made on history alone with no reassessment when the symptom complex changed in a way that should have cast doubt on the original diagnosis.
Diabetes mellitus featured in a further 40 claims. In 19 of these, the patients were either very young or very old and the true diagnosis did not even cross the doctor’s mind. The remainder of the claims stemmed from inadequate monitoring resulting in peripheral neuropathies, visual problems and vascular complications.
Some 193 cases were linked to medication and prescribing errors, the largest single category being drug side-effects, when the GP failed either to warn patients of the possibility or to recognise a side-effect when it occurred. Top of the list were steroids – oral steroids giving rise to osteoporosis in some cases causing vertebral collapse and depot injections typically resulting in atrophy of subcutaneous fat.
Why do things go wrong?
Although no two complaints or claims are identical, analysis reveals a number of recurrent themes, which include, on the clinical front:
- Failure to obtain sufficient information to reach an informed opinion;
- Failure to organise appropriate investigations;
- Failure to reassess when symptoms and signs change;
- Failure to follow-up;
- Failure to refer.
Medication errors stem from:
- Prescribing the wrong drug;
- Prescribing the wrong dose;
- Providing the wrong instructions;
- Administering drugs via the wrong route;
- Failing to warn of side-effects;
- Failing to warn of interactions;
- Failing to warn about or recognise significant adverse effects;
- Failing to monitor or review allowing repeat prescriptions to continue indefinitely.
Administrative problems may contribute to, or be the sole cause of, many adverse events. The most common are:
- Failing to pass on important information;
- Failing to arrange appointments, investigations or referrals with the appropriate degree of urgency;
- Failing to review results of investigations;
- Failing to arrange follow-up and monitoring;
- Mislabelling, misfiling and failing to check labels.
To add to this communication difficulties, resulting in a lack of continuity of care, might mean a degree of double counting but it is a big issue and so deserves to be singled out for special attention. The doctor-patient relationship is not the sole province of communication problems, particularly where care is being delivered by multidisciplinary teams or shared between general practice and hospital, and it is vital that all relevant information is recorded and accessible to team members who need it.
Avoiding clinical errors
The key to avoiding clinical errors includes taking an adequate history, conducting a relevant examination and managing the patient appropriately thereafter, always acting (especially when it comes to procedures) within the limits of your own expertise. Consequently, it is up to individual clinicians to apply the correct standards. The RCGP’s circular In Safer Hands looks at ways of reducing episodes of misdiagnosis in general practice.3 It suggests:
- Use algorithms and ‘red flags’ (significant clinical signs and/or symptoms) to aid the diagnosis process
- Raise the standard of clinical communication skills
- Keep up to date and learn from significant events
- Work with and seek help from colleagues
- Report diagnostic errors so that trends can be detected both locally and nationally. This helps identify solutions
- Improve access to investigations, including imaging and consultant support. Earlier access to a wider range of investigations can lead to earlier diagnosis
- Improve clinical risk management systems. Better information communication technology solutions are needed. Building tracking functionality into primary care systems would be one way of supporting practices in managing test results.
Analysing significant events within a practice, conducting regular audit and discussing cases informally are all means of enhancing the insight required to identify educational needs and build personal development plans.
Significant event audit
Significant event audit (SEA) can be defined as a system whereby individual episodes in which there has been a significant occurrence (either beneficial or deleterious) are analysed in a systematic and detailed way. The purpose is to ascertain what can be learnt about the overall quality of the care and to indicate what improvements, if any, can be made.
Significant event audit is said to have considerable advantages over other techniques because it focuses on outcomes, is relevant to practice and practical problems, is flexible and capable of being applied to a wide range of situations, contributes to team building and has emotional appeal.
So how does it work in practice? The format is flexible but should involve the entire practice team and usually a meeting to discuss the events in question. First, the event needs to be described so that everyone knows what is being discussed before deciding the key issues to be addressed.
For each issue raised, key questions will include (in the case of adverse events): Could it have been avoided? And how can a recurrence be prevented? When discussing a significant success, the key issues will be what went well and why.
The next phase is to identify the learning needs of individuals, practices and patients. However, significant event audit is of no use unless it gives rise to an action plan. This should enable the lessons learnt to be applied in practice and a review should be carried out at an appropriate time, often six or 12 months later.4
Medication errors can be prevented to some extent by alert systems.
However, the prescriber must be sufficiently knowledgeable to ensure that it is the correct drug in the correct dose, and give the right directions and administer it via the correct route for that patient. He or she must also ensure that there are no contraindications, such as allergy or severe interactions, and that the patient is given sufficient information to be alert to potential adverse effects.
Information leaflets can be a useful adjunct to verbal information during the consultation and, particularly where complex dosage regimens are in place, they should be clearly written down and in terms the patient can understand. However, not all adverse effects will be self-evident to patients. Some will require specific examination or investigations and it is imperative that repeat prescriptions are not given ad infinitum, particularly when patients do not attend for whatever monitoring is required.
Administrative issues are really about putting appropriate processes in place to ensure that results of investigations are reviewed and necessary arrangements have been made for follow-up and monitoring – in short, to ensure that what needs to be done is done.
Doctors and other healthcare professionals are not infallible, and it is folly to suggest that all errors can be eliminated.
Equally, however, sensible risk management measures can and do reduce exposure to adverse incidents. According to In Safer Hands you can get an idea of how you are doing on the risk management front by asking the questions in Box 1 (below).
|Box 1: How good is your practice at risk management?|
- Findings from 1,000 negligence claims – Part One. Health Care Risk Report, 7, November 2000.
- Findings from 1,000 negligence claims – Part Two. Health Care Risk Report, 7, February 2001.
- Royal College of General Practitioners. In Safer Hands. Issue 6. London: RCGP.
- Significant event auditing in primary healthcare. Health Care Risk Report, 10, September 2004.