Avoiding trouble – the Six Cs
Your practice is in its early days but you will already know that the future holds a potential minefield. Gareth Gillespie shows how following the “Six Cs” guide can help you to stay safe
It will no doubt be clear to any newly-graduated medic that your fledgling career presents many potential opportunities to make mistakes and be accused of clinical negligence. The very nature of the profession means that lives are in your hands and the consequences of errors are grave indeed.
This is ominous enough without even mentioning the stress and anxiety associated with claims, complaints and inquests that the HPCSA may be drawn into investigating you for.1 But staying safe need not be such a complicated matter; following the guide to the “Six Cs” – which cover the main areas for making mistakes – ccan ensure that your medical career proves to be a long, fruitful and honourable one.
1. Clinical records
An adequate clinical record is one that enables the doctor to reconstruct a consultation without reference to memory. There are four crucial components to a good clinical record: legibility, the accurate date and time, a signature and being kept up-to-date.
A clinical record is also vital in ensuring good continuity of care, so it is essential that they are as clear and complete as possible. On the first occasion that a patient is seen, the record should include:
- Relevant details of the history, including important negatives
- Examination findings, including important negatives
- Differential diagnosis
- Details of any investigations requested and any treatment provided
- Follow-up arrangements
- What you have told or discussed with the patient.
Subsequent consultations should include the patient’s progress, findings on examination, monitoring and follow-up arrangements, details of telephone consultations, details about chaperones present, and any instance in which the patient has refused to be examined or comply with treatment. It is also important to record your opinion at the time regarding, for example, diagnosis.
Any investigation into clinical negligence will inevitably call on the relevant medical records as a source of facts and evidence, and therefore they will become absolutely central as the investigation wears on. Imagine if your defence case was to collapse because of abysmal handwriting, illegible scribbles and unclear, vague references.
Uncertainty over the reliability of a clinical record is not going to do you any favours during an investigation. This uncertainty can be caused by alterations or late additions that cannot be sufficiently explained. It is perhaps only human for a doctor, panicking amid a looming negligence claim, to realise his/her error is fully documented in the clinical record – and be tempted into making a late alteration, embellishing an action here or inserting a procedure there. If you do have to make an alteration, make sure you enter the date of it and also your name, so there can be no unwarranted suspicion.
To continue the theme of legibility, you should also try and avoid abbreviations unless absolutely necessary. This avoidance includes any personal comments made about a patient.
2. Consent
“Healthcare practitioners must work on the presumption that every adult has the capacity to decide whether to consent to, or refuse, proposed medical intervention, unless it is shown that they cannot understand information presented in a clear way.”2
All patients have the right to information about their treatment, including the options open to them. This means that they must always be given, for example, an explanation of the investigation, diagnosis or treatment; an explanation of the probabilities of success, or the risk of failure; or harm associated with options for treatment. The patient should always be given sufficient time to ask questions and, when the time comes for them to make a decision, they should not feel pressured into consenting to treatment – this invalidates the consent.
But what happens if you suspect the patient is not capable of evaluating the information and making the decision over consent? To be considered capable of giving consent, a patient must be able to comprehend the information and then believe it, and be able to retain the information for long enough to consider it and make a decision. It is ultimately your responsibility to assess capacity, keeping in mind that the following should not automatically be assumed to lack capacity: patients with communication problems, or those of a low intellect.
The HPCSA has rigorous guidance on consent and this should be consulted when attempting to make a decision on assessing capacity. In cases where a patient is mentally ill and therefore unable to consent to treatment, the Mental Health Care Act (Act No. 17 of 2002) should be consulted; whereas the National Health Act makes provisions for certain people to make decisions on behalf of those who are mentally incapacitated. These include: a person authorised by the court, such as a carer; or, in order of priority, the patient’s spouse, partner, parent, grandparent, major child or brother or sister.
The failure to obtain valid consent is the reason that a significant number of clinical negligence cases have been settled, and any disregarding of official guidance on the matter can lead to accusations of serious professional misconduct. Furthermore, it could attract allegations of assault and battery or, in extreme cases, criminal charges; while such cases are rare, the risk does exist if a patient has befallen harm and valid consent was not obtained.
3. Confidentiality
Any profession that deals with people’s sensitive personal information is bound by the same expectations of confidentiality and healthcare is no different. However, your duty of confidentiality relates not only to sensitive health information but to all information you hold about your patients. This includes demographic data and the dates and times of any appointments your patients may have made, or consultations they may have attended. The fact that an individual may be a patient of yours or registered with your practice is also confidential.
You are only permitted to reveal confidential information about a patient in certain circumstances – the most obvious of which is with the permission of the patient in question, assuming that they have sufficient capacity to consent to this. According to the HPCSA, the other appropriate scenarios are:
- In the terms of a Statutory provision
- At the instruction of a court
- When it is in the public interest
- With the written consent of a parent or guardian of a minor under the age of 12 years
- In the case of a deceased patient with the written consent of the next of kin or the executor of the deceased’s estate.3
Another set of valid circumstances includes the risk of death or serious harm to the patient or others, which could be avoided through the disclosure of appropriate information. You should still seek the consent of the patient if possible – or at least inform them of the imminent disclosure. Such a situation may arise if you feel you may be able to help prevent, detect or prosecute for a serious crime.
The risk of unintentional disclosure can appear if you discuss patients where you can be heard, or if medical records – paper or electronic – are left in a place where they can easily be seen by members of the public.
4. Communication
Good communication with your patients may seem like an obvious demand of the profession, but it is here where ambiguities and misunderstandings can take root, causing problems later down the avenue of care. It is a vital foundation on which to discuss and obtain consent, for example, and is central to the doctor–patient relationship’s key component: trust.
It is achieved by listening to patients and respecting their views and beliefs; giving patients the information they ask for or need about their condition, its treatment and prognosis, in a way they can understand – this includes any drug you prescribe, information about any serious side effects and, where appropriate, dosage; and sharing information with patients’ partners, close relatives or carers, if they ask you to do so.
5. Competency
Recognising your own limitations is the key principle behind competency. When providing care, you are duty-bound to work within your own professional competence, taking the time to ask for assistance when needed; you must also feel thoroughly competent when diagnosing and giving or arranging treatment.
6. Careful prescribing
Much the same as with clinical records, utmost care should be taken when prescribing, in terms of accuracy and legibility. The consequences of prescribing errors are as dire as can be expected in a situation that could see patients taking the wrong drugs.
The path to a long and negligence-free career doesn’t have to be an arduous one, and by following this guide – and taking on board the supplementary sources of advice that are mentioned – you can help your practice to stay safe and risk-free.
In addition to all of the above, remember to stay indemnified. The cost of defending a clinical negligence claim without appropriate cover is extremely high and MPS can be there to help. As always, MPS is also on hand to prevent mistakes happening in the first place – contact us through your local medicolegal consultant for further advice.