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:
and Careful Prescribing
1. CLINICAL RECORDS
A good medical record summarises the key details of every patient contact and should enable the doctor to reconstruct a consultation without reference to memory. 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.
A patient’s medical record should 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
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
• All entries should be dated, timed and signed.
• 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.
Dr P sees Mrs G, a patient referred from the emergency department (ED) after a sudden collapse. She takes a comprehensive history and does a complete examination. She sees that some blood samples were taken in the ED and checks the results, but the samples “have clotted” and new ones need to be sent. The nurses agree to do it as soon as possible. Dr P finishes her shift by writing the history, examination findings and results; she also writes “bloods”, followed by a tick, meaning they have been sent.
During the handover she doesn’t tell the next doctor that the blood results need checking.
Mrs G becomes unwell within the next few hours, and the doctor on duty comes to see her. He is reassured by the notes, which imply that recent blood results were normal, and checks on the results server himself. It is only at this stage that it is discovered that the patient is severely anaemic.
Dr P failed to ensure that the documentation clearly indicated what had and what had not been done. Luckily, Mrs G came to no harm.
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. 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.
• Sufficiently informed to make a considered decision - They must be informed of the range of diagnostic procedures and treatment options generally available; the benefits, risks, costs and consequences generally associated with each option; and their right to refuse treatment, with an explanation of the implications, risks and obligations of such refusal.Where possible, the patient must be informed in a language they understand, taking into account their level of literacy.
• Giving consent voluntarily - They should always be given sufficient time to ask questions and to make a decision. Consent is invalid if it is obtained under duress.
Who is responsible for assessing capacity to consent?
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 assumed to be competent.
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.
The doctor no longer “knows best”. Instead, many patients now expect to be part of the decision-making processes concerning their own care.
Most models of shared decision making include the following steps:
• Listen - Elicit the patient’s views. What do they know about their condition? What are their expectations of treatment?
• Inform – Add to (or correct) the patient’s existing knowledge. It is not enough to just ‘transmit’ information – you should also check that they have understood it.
• Discuss – Talk through diagnosis and treatment options, including anticipated benefits and potential risks. The discussion should include the option, and possible consequences, of no treatment.
• Decide – Usually the discussion will lead to one preferred and mutually agreed decision. If more than one option remains, the patient will have to decide which they prefer and may now turn to the doctor for a final recommendation. A second opinion may be sought.
• Document – The key elements of the discussion must be fully recorded in the patient’s notes, including details of all options and risks discussed.
• Record in the notes what a patient has been told, and what has been agreed.
• Adult patients are presumed competent to consent unless proved otherwise.
• Each assessment of a person’s capacity should relate to a specific decision.
• Any competent adult can refuse treatment.
Dr U is in the first week of his rotation in ENT. A nurse tells him that there is a patient going to theatre in the next few minutes and the consent form is missing from his notes. She insists that the consultant “will get very cross” if the patient turns up in theatre without all the appropriate documentation.
The nurse mentions that the patient’s operation has already been cancelled once, and it would be terrible if it happened again. Dr U explains that he has never consented a patient for a tonsillectomy before and doesn’t think he should do it. But the nurse is insistent, saying “it’s only a tonsillectomy, not rocket science”.
Dr U rushes through the consent form without exploring all relevant risks and explaining these to the patient. Unaware of the drowsiness he may suffer after general anaesthesia, the patient believes he is safe to drive home following the operation and subsequently crashes his car.
A doctor’s duty of confidentiality to patients goes beyond health records. It encompasses all information held about patients, from demographic data to appointment details. Even the fact that a patient is registered at your clinic is confidential.
You should take care to avoid unintentional disclosure – for example, by ensuring that any consultations with patients cannot be overheard.
There are some situations in which it may be justifiable to disclose information about a patient without their express consent, for example:
• If the public interest in disclosing the information outweighs the patient’s interests in keeping it confidential, such as if the disclosure is necessary to protect others from risk of serious harm or death.
• If the police are required to investigate the circumstances of a death, and you hold information about the deceased that is likely to be relevant to the investigation.
• Doctors are required by law to report certain information to the authorities, such as notifiable diseases.
• The courts can compel doctors to disclose information.
You should ensure the disclosure is proportional – anonymised if possible – and includes only the minimum information necessary for the purpose.
• 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.
Dr A is working in the ED where he treats a young man with several cuts on his hands. The man claims that he was washing a glass at home and accidentally shattered it, injuring himself. Dr A believes that the pattern of cuts is unlikely to have been caused by that mechanism of injury, but the patient sticks to his story.
Later that day, a police officer comes to the ED enquiring about any men who may have attended with cuts to the hands. A young man had broken into an empty property through a glass window and stolen some goods. There were no victims, and no suggestion of threat to public safety.
Dr A is unsure whether he should mention his earlier patient. He talks to his consultant, who advises him not to mention this to the police, as he owes a duty of confidentiality to the patient. The consultant points out that there is no risk to the general public, even if his patient was the man in question. He adds that you can breach confidence if it can assist in detecting and preventing serious crime.
Good communication is key to an effective doctor–patient relationship and is important for all aspects of a patient’s care.
Understandably patients 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.
Many patient complaints are the result of unmet expectations. This is especially true within certain areas of medicine, for example laparoscopic surgery: the short hospital stay, the small scar and the anticipation that contemporary medicine is nearly perfect all contribute to high expectations. While uncommon, it is important for the patient to understand that complications may still occur.
Communication with colleagues
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.
See also Surviving Medical School: Communication between colleagues
• 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.
Dr J is a junior doctor working a night shift. He takes a call from a doctor in the ED (Dr A), who wants to refer an elderly patient with sudden breathlessness. Dr A has taken a history, examined the patient and diagnosed congestive heart failure. Dr A agrees that he will give a diuretic, perform a chest x-ray and take the bloods before transferring her to the ward.
Later in his shift, Dr J sees the same patient in the ward. He notices she is still in heart failure and from the notes, it is apparent that Dr A did not carry out any of the tasks he had agreed to do.
After treating the patient, Dr J contacts Dr A to check what happened. Dr A says he had not had time to perform the investigations as he was rushed off his feet and he forgot to tell Dr J.
Dr J stresses upon him the importance of clear and concise handovers and logs this as a clinical incident.
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 medicine which is constantly evolving. Doctors effectively never stop learning, so a heavy focus is placed on CPD whatever specialty a doctor may work in.
Recognising your own limitations is the key principle behind competency. When providing care, you must work within your own competence, and ask for advice when you feel out of your depth.
• 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.
Dr Q is a community service doctor working in the ED and sees a patient with a sudden thunderclap headache at the back of the head. He organises a CT scan to rule out a subarachnoid haemorrhage, which comes back clear, so his next course of investigation is to test the CSF for xanthochromia.
Dr Q begins setting up a tray and equipment to perform a lumbar puncture. A couple of nurses spot that Dr Q is setting up the tray incorrectly, so alert the senior medical officer to what is going on.
When questioned, Dr Q admits that he is unfamiliar with some of the equipment and has only ever read about the procedure. The senior medical officer explains that Dr Q is working beyond his competence, which could have caused the patient harm. He uses the opportunity to give Dr Q an impromptu lesson, explaining the procedure as he successfully undertakes a lumbar puncture.
6. CAREFUL PRESCRIBING
Prescribing can be a significant source of incidents and complaints. Risk areas include:
• Transferring information to new charts
• Team handovers
• Forged prescriptions
• Prescribing for the wrong patient
• 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.
• Prescriptions should be written or typed and signed by the prescriber. Verbal prescriptions are only acceptable in emergency situations and should be written up at the first available opportunity.
Dr S is on duty in the children’s area in ED. He has just seen Jack, a two-year-old child with a high temperature. He sits down to write his notes and asks one of the nurses to give Jack 180mg of paracetamol (appropriate for his weight).
The nurse asks for it to be prescribed, but Dr S insists that he needs the ED card to write his notes, and the child is in the cubicle opposite the nursing station (he points to it). The nurse agrees reluctantly.
When Dr S approaches the cubicle, there is now a different child sitting there – Alex. He anxiously asks the nurse if she has given the medication to this child, and she says “yes”.
Dr S informs Alex’s family of what has happened and explains that the paracetamol was not prescribed for their child. He apologises profusely. Luckily Alex is a bigger child, and has not taken any paracetamol recently, so no harm has been done.
Dr S makes sure Jack gets his paracetamol, fills in an incident form and apologises to the nurse involved. They discuss what happened and agree that it was an easily preventable mistake.
If you’re worried about these issues, or any other problems you may face, you can email us or call our student support and advice line on 0800 952 0442.