It is important that not only should the clinical assessment and any procedure be adequately documented, but also the discussion behind any decision made regarding treatment. It is, of course, a matter of judgment regarding how much to write in the notes and, inevitably, time pressures will contribute to that consideration.
“The elusive diagnosis” for Mr M turned out to be diabetes in a patient who had repeatedly attended the GP surgery for several infections. While MPS successfully defended this case, it reminds us of the importance of reconsidering the diagnosis in patients who represent with recurring symptoms or signs. There can be a temptation when a patient returns with no improvement to keep adjusting the treatment, whereas sometimes what is needed is a review of the original diagnosis and adjustment of the treatment to match the reviewed diagnosis.
The system errors of Mrs Y and the blood transfusion (“Transfusion confusion”) highlight the importance of someone taking responsibility when the patient has suffered an adverse outcome and, following an apology, having an open and honest discussion with the patient, explaining what has happened. It is always appropriate to say that you are sorry for what the patient has experienced. It also shows how patients themselves can make a valuable contribution to patient safety.
I hope that you find reading the cases to be interesting and informative. Our range of education risk management products can help you address some of these challenges, and I encourage you to go to the Events & E-learning section of our site for more information.