Communication with colleagues in primary care
The divide between primary and secondary care is an area where communication can easily break down, particularly when patients are receiving long-term treatment.
If the patient is being given ongoing care as an outpatient it is particularly important to keep the GP informed about his or her progress and treatment, as they may have a bearing on the GP’s own treatment of the patient.
Delays in mailing discharge summaries to GPs are another common cause of adverse incidents. Patients’ GPs should be notified whenever their patients are seen in secondary care, and especially if they’ve referred the patient themselves. As the GP is often familiar both with the patient’s past medical history and with relevant family history, their concerns and suggestions should be taken seriously, as the following case report illustrates.
Delays in mailing discharge summaries to GPs are a common cause of adverse incidents
Case report: GP’s concerns ignored with fatal consequences
Had the GP been aware that the child had been sent home he would probably have contacted the parents or visited the patient
In a serious incident a few years ago, a GP referred a nine-year-old girl urgently to A&E, sending her and her parents 30 miles in a taxi and telling them to pack an overnight bag for the child.
The girl had recently been discharged home following an appendicectomy and her GP feared that she’d developed a bowel obstruction. He was right, but her symptoms had eased by the time she arrived at the hospital, so the A&E doctor concluded that there was no serious abnormality and sent the girl home.
The GP wasn’t notified, so he didn’t know that the patient was at home. Her symptoms continued and her parents coped as best they could without the benefit of medical advice. Had the GP been aware that the child had been sent home he would probably have contacted the parents or visited the patient, in which case the outcome of this story might have been different.
As it was, the child was taken back to A&E by ambulance two days later, having inhaled gastric contents due to a small bowel obstruction. Sadly, attempts to resuscitate her failed and she died shortly after arrival at the hospital.
Source: North Eastern Health Board, Review of the Circumstances Pertaining to the Death of Frances Sheridan (nd)
Case report: Poor communication with blinding results
A diabetic clinic in a teaching hospital diagnosed TB in a diabetic patient with a history of weight loss. He was admitted to hospital and, on discharge, was prescribed three months’ supply of ethambutol, rifampicin, pyrazinamide, isoniazid and pyridoxine.
Three months after starting TB treatment, the patient began to complain of deteriorating vision and his GP made an urgent referral to the eye clinic
A month later, he was seen in the diabetic clinic but there was no discussion of his TB treatment. He failed to attend his next appointment. Three months after starting TB treatment, the patient began to complain of deteriorating vision and his GP made an urgent referral to the eye clinic.
The GP had not yet received a discharge letter about the patient’s last hospital admission for the treatment of TB, nor had the diabetic clinic informed her of the diagnosis, so her referral letter to the eye clinic made no mention of the fact that the patient was taking ethambutol.
The patient attended the eye clinic several times over a month, but no history of TB or treatment for TB was obtained – his visual loss being attributed to diabetes. However, his vision continued to deteriorate and by the end of this period he was only capable of counting fingers. A week later, the patient attended the diabetic clinic. Only then was the diagnosis of ethambutol eye toxicity raised.
The patient was seen immediately in the eye clinic where the diagnosis was confirmed and the ethambutol stopped, but by then he had sustained a permanent loss of 90% of his vision.
Communicating with patients
Patients who are kept informed about their condition and are involved in deciding on the appropriate treatment are more likely to comply with the treatment you suggest, and less likely to complain if things go wrong.
It is particularly important that you tell patients about the possible side-effects of drugs or treatment you are ordering, and that they know what complications to look out for and what to do if they develop.
Warn patients about the risks before carrying out any procedures or prescribing medication. "Informed" consent is dealt with in more detail in the MPS booklet, Consent to Medical Treatment in Ireland – An MPS Guide.
Tell patients about the possible side-effects of drugs or treatment you are ordering, and that they know what complications to look out for
When you are discharging patients from your care, tell them about arrangements you have made for follow-up care and given them appropriate advice about what to do if symptoms recur or complications develop. It they are receiving long-term therapy, tell them when to return for review and what symptoms or signs of adverse effects or changes in their condition to report. If possible, give them an indication of when they might expect to see an improvement in their condition, and when to seek medical advice if no progress is made within a certain timescale.
Document any advice you have given the patient. It is useful to document in the record any supporting literature or written information given to the patient.