A lifetime spent practising medicine is unlikely to be error free, but there are steps you can take to reduce risks and prevent clinical incidents. In this article we discuss six common risk areas for new doctors: Clinical records, Consent, Confidentiality, Communication, Competency and Careful prescribing.
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1. Clinical Records
Accurate clinical documentation is one of the strongest defences against complaints and claims. A well-kept medical record allows another clinician to understand and continue care safely. It should be clear, accurate, legible and, wherever possible, contemporaneous, allowing a colleague to carry on where you left off.
Good record keeping is also essential in defending any potential complaints or claims that are brought against you.
Imagine if you were unable to defend yourself because of a lack of notes.
What should a medical record include?
- Discussions around consent, including chaperone arrangements.
- Relevant medical history.
- Details of the examination.
- Details of any investigations requested.
- Details of any treatment provided or advised.
- Clinical findings.
- Your professional opinion, for example a differential diagnosis.
- Information provided to the patient.
- Any decisions made by the patient.
- Follow up arrangements and referrals, including any safety netting advice given.
- Details of whether the consultation was face-to-face or remote, and the reason why.
Good record-keeping practices need to be supported by strong clerical processes and systems. Doctors can avoid clerical errors by:
- Reviewing all investigations, acting on the outcome and communicating results.
- Following up missed appointments.
- Taking care with prescription reviews and renewals.
- Filing, tracking and maintaining the security of medical records.
- Making and following up any referrals.
Survival Tips…
- All entries should be dated, timed and signed, or entered using your own specific log in password, if the entries are electronic.
- Any correction must be clearly shown as an alteration, complete with the date the amendment was made, your name and the reason for the addition. Never delete the original entry – just run a single line through it.
- Write assuming the patient may one day read the notes - only include information relevant to the health record.
2. Consent
Consent is founded on the principle of autonomy – it must be given freely by a competent patient, on a voluntary basis, after making an informed decision.
In Ireland, consent is guided by Medical Council ethical guidance and the Assisted Decision-Making (Capacity) Act 2015, which provides guidance for doctors on the consent process, assessing capacity and the treatment of patients who lack capacity.
For consent to be legally valid, the patient must be:
- Capable of giving consent – They must understand what decision they need to make and why, be able to retain, use and weigh up all the relevant information, and have the capacity to communicate their decision, with assistance if necessary.
- Sufficiently informed to make a considered decision – They must be given an explanation of the investigation, diagnosis or treatment, an explanation of the probabilities of success, and the risk of failure or any harm associated with the different options for treatment, and no treatment.
- Giving consent voluntarily – They should also always be given sufficient time to ask questions and to make a decision. Consent is invalid if it is obtained under duress.
It is ultimately the responsibility of the doctor taking consent to assess the patient’s mental capacity. Unless there is reason to think otherwise, all adults are presumed to have the capacity to make decisions about their own health care.
Patients should not be assumed to lack capacity due to communication problems, their age, appearance or assumptions you make about their condition. Even if a patient does lack capacity, the onus is on you to include them as much as possible in decisions that affect their lives.
3. Confidentiality
Confidentiality in healthcare is both an ethical obligation and a legal requirement. Even the fact that a patient is registered with your practice is confidential. Breaches of confidentiality are a common source of complaints and regulatory referrals.
A doctor’s duty of confidentiality extends beyond medical records and includes all patient-identifiable information. You should take care to avoid unintentional disclosure – for example, by ensuring that any consultations with patients cannot be overheard.
Disclosures
Express consent from the patient is usually required before you disclose information about them to a third party. However, there are some situations where disclosure is required by law, for example:
- When ordered by a judge in a court of law, or by a tribunal or body established by an Act of the Oireachtas.
- Where required by infectious disease regulations.
- Where you know or have reasonable grounds for believing that a crime involving sexual assault or other violence has been committed against a child or other vulnerable person. If the coroner requests information about the deceased that is required by their investigation into the circumstances of a death. There are also situations where it may be justifiable to disclose information about a patient without their express consent, for example:
- If it is in the public interest to disclose the information in order to protect the patient, other people or the community more widely. You must satisfy yourself that the possible harm the disclosure may cause is outweighed by the benefits that may arise for the patient or others.
- If a patient lacks capacity to give consent and is unlikely to regain capacity, disclosure may be justified if it is in the patient’s best interests.
- When there is a claim arising out of the death of a patient.
You should ensure the disclosure is proportional – anonymised if possible – and includes only the minimum information necessary for the purpose.
Survival Tips...
- Except in exceptional circumstances, you must always obtain consent from a patient before releasing confidential information.
- Give cause of death accurately on death certificates, even where this might be embarrassing or distressing to relatives.
- Be aware of high-risk items and places where confidentiality is easily breached: computer screens, printers, memory sticks, handover sheets, emergency departments, corridors, lifts.
4. Communication
Good communication is key to an effective doctor–patient relationship and is important for all aspects of a patient’s care. Understandably patients may experience difficulties in assessing the technical competency of a doctor, so will frequently judge the quality of clinical competence by their interpersonal interactions. Developing good communication skills will therefore improve clinical effectiveness and reduce medicolegal risk.
Beyond doctor-patient interactions, it is also essential to communicate clearly and appropriately with all clinical and administrative colleagues you work with directly, as well as doctors who refer to you and to whom you refer.
Survival Tips...
- Be patient, observant and curious.
- Show respect and self-awareness (posture, eye contact, first impression).
- Assess patients’ moods and respond accordingly.
- Show empathy but be aware that physical contact is not always appropriate (outside of an examination).
- Interact professionally with other colleagues.
5. Competency
Competency, in professional terms, is defined as the ability to perform the tasks and roles required to the expected standard. It can be applied to a doctor at any stage in their career.
Competency encompasses the need to keep up to date with changes in practice and systems that can impact on it. Continued professional development (CPD) is a prerequisite of many jobs, but no more so than in medicine which is constantly evolving. Doctors effectively never stop learning, so a heavy focus is placed on CPD whatever speciality a doctor may work in.
Recognising your own limitations is the key principle behind competency. When providing care, you must work within your own competencies, and ask for advice when you feel out of your depth.
Survival Tips...
- Recognise and work within the limits of your competence.
- Keep your professional knowledge and skills up to date.
- In an emergency, wherever it arises, you have a professional duty to offer assistance, taking account of your own safety and competence, and the availability of other options for care.
6. Careful Prescribing
Prescribing errors are a major source of preventable harm and litigation - the financial costs associated with adverse events and inappropriate prescribing amount to hundreds of millions of euros every year. Careful prescribing reduces risk to patients and protects doctors professionally.
Prescribing risks include:
- Transferring information to new charts.
- Transcribing medication onto GMS prescriptions.
- Team handovers.
- Over-prescribing.
- Forged prescriptions.
- Prescribing for the wrong patient
Survival Tips...
- Prescriptions should clearly identify the patient, drug, dose, frequency and start/finish dates.
- Be aware of a patient’s drug allergies and any interactions with medications they may already be taking.
- Only prescribe drugs to meet the identified need of the patient.
- Refer to the relevant prescribing formulary.
Conclusion
Understanding and managing medicolegal risk is an essential skill for every doctor. By maintaining high standards in documentation, consent, confidentiality, communication, competence, and prescribing, doctors can significantly reduce clinical incidents and protect both patients and their professional careers.