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Avoiding Errors in General Practice

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Table of Contents

Contributors, viii Preface ix Abbreviations x Introduction xii Part 1 Section 1: The legal structure of negligence 1 A few words about error 1 Medical negligence 1 Learning from system failures ? the vincristine example 6 Reference 10 Section 2: Causes of diagnostic errors in general practice and how they can be avoided 11 How do general practitioners reach diagnoses? 11 Where do errors occur in diagnosis? 15 How can we minimize the risks of these errors? 17 References and further reading 18 Section 3: Bayesian reasoning and avoiding diagnostic errors 20 References and further reading 25 Section 4: A potpourri of advice on avoiding errors 26 History and examination 26 The telephone consultation 27 Communication problems 28 When lack of knowledge plays a part 28 The unexpectedly abnormal result 28 The standard of notes 29 Drug errors or prescribing errors 30 Consent 30 Confidentiality 32 Conditions that are 'frequent flyers' in negligence cases 33 Safety netting 34 References and further reading 36 Part 2 Clinical cases Introduction 37 Case 1 A man with iron deficiency 38 Case 2 When is a headache abrupt? 41 Case 3 A woman with chest pain 44 Case 4 A dizzy man 48 Case 5 Rectal bleeding in a pregnant woman 51 Case 6 A pulled calf muscle 54 Case 7 A woman with hemiplegic migraine 57 Case 8 Irritable bowel syndrome after sickness in Goa 60 Case 9 A young man with back pain 64 Case 10 Irregular intermenstrual bleeding in a woman on the pill 67 Case 11 A boy with a limp 70 Case 12 A runner with a cough 72 Case 13 A woman with classical migraine 74 Case 14 A young woman with diarrhoea and vomiting 77 Case 15 Ill-fitting dentures in an elderly man 79 Case 16 Back pain in a middle-aged woman 82 Case 17 Cellulitis in a man?s foot 85 Case 18 A flare-up of ulcerative colitis 88 Case 19 A woman with a skin lump on her leg 91 Case 20 A woman with microscopic haematuria 93 Case 21 A limping young girl 96 Case 22 A builder tripping over his feet 98 Case 23 An anxious young woman with hyperventilation 101 Case 24 A slightly raised AST in an Asian woman 103 Case 25 Cough and fever in a 42-year-old accountant 105 Case 26 Lost prescription: Benzodiazepine addiction 108 Case 27 A febrile baby 110 Case 28 A limping elderly woman after a fall 113 Case 29 Indigestion in a stressed executive 116 Case 30 A hoped-for pregnancy 119 Case 31 A breast lump that disappears 122 Case 32 Fever and cough after an ankle fusion 125 Case 33 Urinary problem in a welder 128 Case 34 A hypertensive 38-year-old woman 130 Case 35 A swollen lip in a 56-year-old man 133 Case 36 A woman with fatigue and weight gain 135 Case 37 A woman told off for ignoring her friends 137 Case 38 A man with a headache: Swine flu or meningitis? 140 Case 39 A woman suffering dizziness 142 Case 40 A middle-aged man with an ankle injury 144 Part 3 Investigating and dealing with errors 1 Introduction 147 2 How errors and their recurrence are prevented in primary care 147 3 The role of the primary care trusts 150 4 Other investigations 152 5 Legal advice ? where to get it and how to pay 155 6 External inquiries 157 7 The role of the doctor 172 8 Emotional repercussions 175 9 Conclusion 175 Reference 176 Index 177


About the Author

Kevin Barraclough is General Practitioner, PainswickSurgery, Painswick, Gloucestershire Jenny du Toit is General Practitioner, PainswickSurgery, Painswick, Gloucestershire Jeremy Budd is General Practitioner, East Quay MedicalCentre, Bridgwater, Somerset Joseph E. Raine is Consultant Paediatrician, WhittingtonHospital, London Kate Williams is Partner, RadcliffesLeBrasseurSolicitors, Leeds Jonathan Bonser is Consultant in the HealthcareDepartment of Fishburns LLP, Solicitors, London, and former Head ofthe Claims and Legal Services, Department of the Leeds office ofthe Medical Protection Society


My experience as an expert witness in clinical negligencecases, MPTS Panel chairman, medical adviser to a Public Inquiry andas a sometimes commissioned independent reporter on adverseincidents tells me that these are excellent books, valuable for allclinicians, not just those in high-risk specialties; and all NHSmanagers involved in maintaining or improving the quality of care.The case vignettes, alone, are useful source material for teachingmedical trainees on what can go wrong and how to deal with it whenit does. (Harvey Marcovitch, Clinical Riskjournal) This is a tremendous exercise in critical thinking skills,i.e. the ability to think through differential diagnoses andlonger-term consequences beyond the simple facts presented. Thisbook has great learning value for young and midcareer clinicians tohelp them hone their diagnostic skills. (Doody s, 5 July 2013) "This excellent 182-page book is designed for generalpractitioners in their early years. It will be a very useful sourcefor all involved in teaching and mentoring those in generalpractice, and should, I think, be compulsory reading for allpractice managers. It is so packed with information, concepts andcase studies written in decent English that I found it difficult toput down. The first section gives a resume of the law concerningbreach of medical duty, including the Bolam test. Causation,damages and time limits for litigation are discussed. Protocols,guidelines and communications are considered followed by a heartfelt appeal to learn from system failures. This is what I wantpractice managers to read. The next section looks at how an initial diagnosis isreached, and then refined. Avoiding being misled by firstimpressions by testing against a differential diagnosis, excludingdiagnoses that must not be missed, considering non-fitting facts,and follow up review all help. Making arrangements to review thecase if the illness does not follow the expected course canretrieve the situation, and a record of this can save areputation. Communication is recognised as the core of safe practice. I likethe simple concept Ask yourself whether a colleague couldwork out from your notes the essential details of theconsultation. Then follows the real meat of the book. This consists offorty recent clinical cases, each demonstrating a particularmishap. These forty cases bring up 95% of causes of complaintsagainst general practitioners. Each describes a case in a fewwell-chosen sentences, and asks the reader what they think, andmight do next. For example, make a differential diagnosis, orperform further simple examinations. An expert opinion is thengiven on what good practice would involve. This is followed by alegal opinion of the case, including the likely range of damages orsettlement. Some of the sums are unnerving! Each case takes up justtwo pages. The book ends with the various enquiries and courts that may befaced, and practical advice on addressing them. I sincerely hope that other practitioners and practice managerswill find this little book as thought provoking as I have."(Daniel Haines, FRCGP, MFFLM.)

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