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Dr Lynne Burgess, MDU medico-legal adviser looks at how medical errors on the ward can be avoided and explains how reflective practice can lead to better patient care.
A female patient with a fractured neck of femur was admitted through the emergency department. She commented that she had been feeling more short of breath than usual so the ED doctor requested an urgent CTPA. The investigation was arranged but straight afterwards the radiologist had to go and attend to several other emergencies. There was therefore a delay in providing a report and it wasn't available when the consultant respiratory physician came to review the patient as requested by the orthopaedic team.
However, the consultant physician reviewed the images on the ward computer and provisionally noted that he could not see any evidence of pulmonary embolism. The patient was booked in for surgery and when the orthopaedic F2 went off shift, she verbally handed over to her colleague, telling him that the formal report was not yet available.
By the time the anaesthetist undertook a pre-operative assessment the CTPA report was available and multiple small pulmonary emboli were identified. The anaesthetist was concerned, however, as he had noted the F2's comment, made after the physicians' review, "CTPA – nil seen". He felt that if he had taken this at face value the patient could have been at risk. He suggested that the F2 reflect on what could have been done to improve care.
This is fictitious but the general scenario, where a number of minor events combine to create a potential risk, may be familiar. In this case, there is the potential that the pulmonary embolus might not be identified, at least not until the patient suffers a potentially fatal embolic event in the theatre recovery room.
Hospitals are expected to have policies and procedures in place to identify all adverse events. There is on-going focus on trusts employing an open and honest culture of identifying and learning from adverse events and avoiding blame. Trusts should have policies in place to encourage adverse event reporting and, should a significant event be identified, may ask the doctors involved to participate in a review. The trust may ask the doctor to write a factual statement of their involvement, or to complete a trust proforma including sections on risks and learning points identified and planned learning activities. The doctors may also be asked to attend an interview with the investigator or a meeting of all staff involved.
A review into the care of this patient may have identified that the computers on the ward were of lower resolution than the radiology reporting stations and ensured that the physicians were aware of this. The radiology department may have been asked to ensure that a system was in place to inform the clinicians of potentially significant findings. However, in addition to formal trust procedures, as individual doctors we can also make a difference to patients' experiences in hospital by concentrating on quality improvement both at an individual level and within our larger teams.
The GMC is explicit in its advice that we must make the care of patients our first concern, take part in activities that maintain and develop our competence and performance and contribute to and comply with systems to protect patients. More specifically, we are advised to take steps to monitor and improve the quality of our work and regularly reflect on our standards of practice and the care we provide. There is no substitute for experience, of course, and allowance is made for our stage of training. However, we can all learn from events and improve patient care.
Current training offers multiple opportunities for reflective practice, indeed we are required to provide evidence of our learning in order to progress in our training. It's vital that we maintain and improve our clinical skills. Junior doctors are expected to attend essential training and undertake CPD activities and workplace-based assessments. You may also be involved in audits or research.
In order to learn from events, the potential problems first need to be identified. This can be challenging as it is not always easy to identify what we do not know, to see where our actions could have been improved. However, as no doctor is perfect it is likely that any clinical scenario can be a potential learning experience. Doctors in training have the benefit of clinical and educational supervisors to review the clinical care and identify any learning points. It can also be helpful to review any local or national guidelines to ensure that you are following the accepted standard. We are expected to work within the limits of our experience and obtain suitable senior advice as required.
Not all learning points are clinical. The GMC in its publication The State of Medical Education (2013) states that 7% of complaints made to the GMC were regarding communication with patients and 24% involved clinical care combined with concerns about communication. A further 2% of GMC complaints related to working with colleagues, such as when a doctor does not share relevant information with other members of the healthcare team. As part of quality improvement it may also be helpful to review our communication and note keeping, particularly at handovers from shift to shift.
The GMC advises that clinical records should include relevant clinical findings, the decisions made and actions agreed, who is making the decisions and agreeing the actions, the information given to patients, any drugs prescribed or other investigation or treatment and who is making the record and when. It can be simple to audit whether your clinical records are timed, dated and legibly signed. Medical records are usually made contemporaneously with the events. They may appear detailed and clear to the person writing them with full and recent knowledge of what has happened. However, if you are asked to write a report, many months may have passed. From your notes it should be possible to say exactly what history and examination was undertaken, including the negative findings, and who did what and when. Are your conversations recorded along with the names of the people you spoke to? If your colleague needs to review the records for on-going care will all the events be clear?
In the scenario the doctor could reflect on whether she followed this advice. Is it clear from her notes who reviewed the patient's CTPA, in what circumstances, and what their full opinion was? Will her colleagues realise that a formal report was required?
We are all potential patients, so it is reassuring that the NHS is focused on continual assessment and improvement of the quality of healthcare. As doctors, we have a role to play in improving patients' experiences. Evidence that a doctor in training reflects on the quality of their clinical care and communication can stand them in good stead in their career.
This article originally appeared in the printed edition of wardround April 2014 entitled "Room for improvement".
This page was correct at publication on . Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.
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