Delays in diagnosis, referral or treatment top the list of claims made against GPs, as Dr Gerard Panting of the Medical Protection Society explains
Just about anything can go wrong in general medical practice. However, the majority of claims stem from a small number of recurrent problems, with infinite variations upon the general theme.
Most problems in clinical management can broadly be categorised into:
- Delays in diagnosis, referral or treatment
- Failure to monitor and follow up patients adequately
- Medication errors
- Lack of technical expertise or skill
- Administrative failures.
The number of claims resulting from failure to visit has fallen over recent years, probably due to the advent of co-ops and easier access to medical care out of hours. Nevertheless, by far the largest single category of claim against GPs remains delayed diagnosis, referral or treatment. Many of these cases arise quite simply from inadequate assessment or failure to spot an obvious alarm signal.
For example, a man in his fifties was seen seven times in 15 months complaining of changes in bowel habit and occasional rectal bleeding. On the first occasion, he was diagnosed as suffering from irritable bowel syndrome and given anti-spasmodics. Each time he returned he was given a repeat prescription without reassessment. Finally, weight loss triggered a referral, following which the true diagnosis of colonic cancer was made.
Failure to monitor and follow up patients adequately is a common problem. Frequently occurring situations in this category include poor control of diabetes mellitus leading to ophthalmic and CNS complications, and poor control of blood pressure resulting in cardiovascular, CNS and renal problems.
Medication errors account for 20-25% of all claims against GPs. The four most common errors are giving the wrong dosage, use of inappropriate medication, failure to monitor treatment for side-effects and toxicity, and failure to provide the patient with important information.
Use of inappropriate medication includes the prescription of drugs to which the patient is allergic or which interact with his or her current medication. A particularly common problem is the use of non-steroidal anti-inflammatory drugs and other drugs which displace warfarin. This has led to catastrophic bleeding and death in a number of patients.
Simple administrative errors can have disastrous consequences. The most common administrative problems 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
- Failure to arrange follow-up and monitoring
- Mislabelling, misfiling and failure to check labels.
In one case, the mother of a young man telephoned the surgery asking for the doctor to visit. Her son had been suffering from severe abdominal pain for approximately 24 hours and appeared to be getting worse. The receptionist undertook to pass the message on and said that the doctor would visit as soon as he had finished at the surgery. She wrote the patient’s name but nothing else in the telephone message book.
Soon afterward, her own son’s school telephoned to ask her to take him home as he was unwell. Diverted by concerns about her child, she left the surgery without telling anybody else about the house call she had accepted on behalf of the doctor. Later that day the patient was admitted to hospital via accident and emergency with a perforated appendix.
On another case, a new receptionist at a general medical practice had not been told that all incoming pathology reports were to be left with the patient’s records in the relevant doctor’s tray each day. Instead she filed all results in the records as they arrived and put them neatly away.
Unfortunately, when the doctors commented on the dearth of reports received over the past few days, there was no way of identifying the patients whose results had been filed away unseen. The practice staff had to check laboriously through every set of notes looking for reports that had not been signed by the doctor.
Another recurring theme is poor communication, not just between doctor and patient but also between GPs and specialists and sometimes between members of the same practice.
For example, penicillamine was prescribed for a patient attending a rheumatology clinic. The GP was asked to issue repeat prescriptions and did so for 7 years. However, unbeknown to the GP, the patient defaulted from the clinic after just a few consultations and did not therefore undergo regular blood screening. In the absence of any communication to the contrary, the GP assumed that no problems had been identified. The patient was eventually admitted to hospital in end-stage renal failure.
In another case, a specialist telephoned a GP’s surgery asking for Losec to be prescribed for one of his patients. The message was taken by a receptionist who had not heard of Losec. She thought the specialist had said ‘Lasix’ and duly completed a prescription for the GP to sign. The Lasix caused some short-term distress to the patient but no lasting harm.
When care is delivered by several different people, continuity of care is vital. All relevant information must be included in the records so that a doctor new to the patient can pick up where the last doctor left off, as illustrated by the following example from secondary care.
A consultant with admitting rights to a number of hospitals filed the notes of his patients in a cardboard box locked in the boot of his car for safekeeping. While he was away for the weekend, a patient developed pneumonia. The resident medical officer immediately commenced treatment with antibiotics. Unfortunately, the only record of the patient’s allergy to the prescribed drug was in the consultant’s private records.
Reducing the risk
Many of these problems can be avoided by identifying the potential problems and rectifying them before something goes wrong. This is the business of risk management. There is considerable scope in general practice to institute small changes that may prevent major problems, particularly in relation to administrative procedures.
Even where systems are in place, it is worth reviewing them regularly to see if they are working as well as planned or if they can be improved. The prime candidates for review are systems for repeat prescribing, systems for receiving laboratory reports and acting on identified abnormalities, and methods of recording and relaying messages.