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An essential guide to clinical management

Post date: 04/07/2017 | Time to read article: 7 mins

The information within this article was correct at the time of publishing. Last updated 14/11/2018

Written by a Senior Professional
Endorsed by a Senior Professional
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This Essential Guide was produced as a resource for Medical Protection members in the UK. It is intended as general guidance only.

Medical Protection members are always welcome to telephone our medicolegal advice line for more specific practical advice and support with medicolegal issues that may arise. Alternatively, members may  submit a medicolegal query online.
Click here to go to our medicolegal advice page.

Download guide as a PDF

Introduction

Most incidents leading to medicolegal problems fall into one of the following categories:

  • Failure to appreciate legal and professional responsibilities
  • Problems in clinical management
  • Medication errors
  • Administrative errors
  • Failure of communication, including inadequate medical records.

Problems in clinical management

Negligence is a legal concept. It does not mean neglect or wilful misconduct, but a failure to attain a reasonable standard of care. In cases of negligence, the claimant must prove all three of the following:

  • They were owed a duty of care.
  • There was a breach of that duty of care.
  • Damage was suffered as a result.

Clinical practice

The courts assess standards of clinical practice by the “Bolam test” (in England and Wales, though similar standards exist in Scotland and Northern Ireland). Bolam sustained fractures during electroconvulsive therapy carried out in the early 1950s. In the subsequent court case, experts for the claimant and defendant could not agree on whether Mr Bolam should have been given a muscle relaxant.

Medication errors

Medication errors account for a high level of complaints, claims and patient safety incidents. Some causes of medication errors:

  • Wrong name
  • Wrong drug
  • Wrong dose
  • Wrong frequency
  • Wrong supply

Write legibly, taking special care if the drug name could easily be confused with another

When writing prescriptions

  • Be sure that the treatment is indicated.
  • Check that the intended drug is not contraindicated and that the patient does not have a history of adverse reactions to it.
  • Ensure that it will not interact with the patient’s other medication and warn the patient about any potential interactions with over-the-counter medicines.
  • Write legibly, taking special care if the drug name could easily be confused with another – use capital letters and give the generic rather than trade name.
  • If you’re not sure which of two similar sounding drugs you should be prescribing, check with a senior colleague and confirm the correct spelling in a national formulary.
  • Write clear and unambiguous instructions for dosage, frequency and route of administration, avoiding abbreviations and leading decimal points (put a zero in front of it, eg, 0.2mg).
  • Note the prescription and any other relevant information (eg, warnings given to the patient) in the medical record.
  • Ensure that the patient is aware of what is being prescribed, and why.
  • Use patient information leaflets to augment your verbal instructions, and be particularly careful to warn patients about possible side-effects, adverse drug interactions (including herbal medicines), or potentially dangerous activities, such as driving while taking drugs that induce drowsiness.

Prescribing for children

While all the foregoing advice on avoiding medication errors applies to both children and adults, special care is needed when prescribing, preparing and administering drugs to children. Drugs that are relatively innocuous in adults may have adverse effects in children. Variations in height, weight and body mass can make them more susceptible; or they may quickly accumulate toxic levels as a result of slower metabolism and excretion.

In many cases referred to MPS, errors occurred because the doctor failed to check the appropriateness of the drug and its route of administration in children or infants, or to prescribe the correct dose.

Advice for safer paediatric prescribing

  • Limit the drugs you use to a well-tried few and familiarise yourself with their dosages, indications, contraindications, interactions and side-effects.
  • Refer to a paediatric formulary when appropriate.
  • When writing a prescription, include the child’s age and write the exact dose in weight and (if liquid) volume required for administration.
  • Always calculate doses on paper and, if possible, get a competent colleague to check your arithmetic.
  • When writing dosage, take special care not to lead with a decimal point.
    Never abbreviate micrograms.
  • For amounts less than 1 milligramme, prescribe in microgrammes to avoid confusion over the placing of decimal points.

Parents must always be warned about side-effects, particularly those that will be distressing to the child

When prescribing for a child, it is particularly important to give the parents all relevant information such as:

  • The name of the drug.
  • The reason for the prescription.
  • How to store and administer the drug safely (if appropriate).
  • Common side-effects.
  • How to recognise adverse reactions.
  • Parents must always be warned about side-effects, particularly those that will be distressing to the child. It is also helpful to remind them of the importance of storing drugs in their labelled containers and out of the child’s sight and reach.

Two illustrative cases

Case 1

A patient was seen on a Friday and was prescribed a loading dose of 1g of phenytoin, followed by a maintenance dose of 1g twice a day.

The usual maintenance dose is around 300mg daily. Over the weekend, five 1g doses were administered; a pharmacist then screened the patient on Sunday and the incorrect dose was not picked up or queried with the medical team.

The patient was not seen by any member of the medical team on Monday, and it was not until Tuesday morning that the wrong dose was noticed and crossed from the prescription. The patient died the next day.

a pharmacist then screened the patient on Sunday and the incorrect dose was not picked up or queried with the medical team

Case 2

A patient was prescribed 62.5 micrograms of digoxin. On 27 January, 250 micrograms was erroneously dispensed, with the patient then feeling unwell for a few days. On 12 February, a family member noticed the error and contacted the pharmacy. The overdose was identified and a doctor examined the patient, advising the withholding of the next dose. However, the patient collapsed and later died in hospital.

Reference: NPSA, Safety in Doses: Improving the Use of Medicines in the NHS (2009)

Failure of Communication

A fatal miscalculation

A doctor was deputising for a colleague absent on leave. After a particularly demanding night, he was asked, in the early hours of the morning, to see a premature infant with congestive heart failure. He was not normally responsible for the care of premature infants but he requested Digoxin to be given intramuscularly and calculated (by mental arithmetic) that the dose should be 0.6 mg.

Just as he settled down for a restorative nap, the nurse phoned to ask whether the dose shouldn’t be 0.06 mg as she had had to open two ampoules. Without thinking he told her to “give it as I ordered”. An hour later, he was called to the ward because the baby had suffered a cardiac arrest.

Underpinning good patient care is good communication, and this goes beyond establishing good relations with patients. In today’s team approach to delivering healthcare, communication has to extend to more people and there are therefore more opportunities for it to fail.

Keeping each other informed

The divide between primary and secondary care is an area where communication can easily break down, particularly when patients are receiving long-term treatment. See the case below:

Kept in the dark

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.

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 him of the diagnosis so his referral letter to the eye clinic made no mention of the fact that he was taking ethambutol.

His referral letter to the eye clinic made no mention of the fact that he was taking ethambutol

The patient attended the eye clinic several times over a month, but no history of TB or of 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.

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.

If patients are receiving treatment, 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 call you if it doesn't transpire 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.

Being open

Despite your best efforts, things may go wrong. The first step is to take some of the emotion out of the situation: try not to react defensively by avoiding the issue or making counter-threats. Remember, however good a doctor you are, in your career you will receive complaints and you will probably be involved in at least one claim.

An apology goes a long way in diffusing a situation, and is not necessarily an admission of liability. Where there are differences of opinion between you and a patient, or a patient’s relatives, there is much to be gained by acknowledging the mistake and empathising with their situation rather than trying to cover up the mistake or become defensive.

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