Avoiding Errors in General Practice

Kevin Barraclough is General Practitioner, Painswick Surgery, Painswick, GloucestershireJenny du Toit is General Practitioner, Painswick Surgery, Painswick, GloucestershireJeremy Budd is General Practitioner, East Quay Medical Centre, Bridgwater, SomersetJoseph E. Raine is Consultant Paediatrician, Whittington Hospital, LondonKate Williams is Partner, RadcliffesLeBrasseur Solicitors, LeedsJonathan Bonser is Consultant in the Healthcare Department of Fishburns LLP, Solicitors, London, and former Head of the Claims and Legal Services, Department of the Leeds office of the Medical Protection Society

“My experience as an expert witness in clinical negligence cases, MPTS Panel chairman, medical adviser to a Public Inquiry and as a sometimes commissioned independent reporter on adverse incidents tells me that these are excellent books, valuable for all clinicians, not just those in high-risk specialties; and all NHS managers involved in maintaining or improving the quality of care. The case vignettes, alone, are useful source material for teaching medical trainees on what can go wrong and how to deal with it when it does.” (Harvey Marcovitch, Clinical Risk journal) “This is a tremendous exercise in critical thinking skills, i.e. the ability to think through differential diagnoses and longer-term consequences beyond the simple facts presented. This book has great learning value for young and midcareer clinicians to help them hone their diagnostic skills.”  (Doody’s, 5 July 2013)"This excellent 182-page book is designed for general practitioners in their early years. It will be a very useful source for all involved in teaching and mentoring those in general practice, and should, I think, be compulsory reading for all practice managers. It is so packed with information, concepts and case studies written in decent English that I found it difficult to put down.The first section gives a resume of the law concerning breach 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 heart felt appeal to learn from system failures. This is what I want practice managers to read.The next section looks at how an initial diagnosis is reached, and then refined. Avoiding being misled by first impressions by testing against a differential diagnosis, excluding diagnoses that must not be missed, considering non-fitting facts, and follow up review all help. Making arrangements to review the case if the illness does not follow the expected course can retrieve the situation, and a record of this can save a reputation.Communication is recognised as the core of safe practice. I like the simple concept “Ask yourself whether a colleague could work out from your notes the essential details of the consultation.”Then follows the real meat of the book. This consists of forty recent clinical cases, each demonstrating a particular mishap. These forty cases bring up 95% of causes of complaints against general practitioners. Each describes a case in a few well-chosen sentences, and asks the reader what they think, and might do next. For example, make a differential diagnosis, or perform further simple examinations. An expert opinion is then given on what good practice would involve. This is followed by a legal opinion of the case, including the likely range of damages or settlement. Some of the sums are unnerving! Each case takes up just two pages.The book ends with the various enquiries and courts that may be faced, and practical advice on addressing them.I sincerely hope that other practitioners and practice managers will find this little book as thought provoking as I have." (Daniel Haines, FRCGP, MFFLM.)

• Contributors, viiiPreface ixAbbreviations xIntroduction xiiPart 1Section 1: The legal structure of negligence 1A few words about error 1Medical negligence 1Learning from system failures – the vincristine example 6Reference 10Section 2: Causes of diagnostic errors in general practice and how they can be avoided 11How do general practitioners reach diagnoses? 11Where do errors occur in diagnosis? 15How can we minimize the risks of these errors? 17References and further reading 18Section 3: Bayesian reasoning and avoiding diagnostic errors 20References and further reading 25Section 4: A potpourri of advice on avoiding errors 26History and examination 26The telephone consultation 27Communication problems 28When lack of knowledge plays a part 28The unexpectedly abnormal result 28The standard of notes 29Drug errors or prescribing errors 30Consent 30Confidentiality 32Conditions that are 'frequent flyers' in negligence cases 33Safety netting 34References and further reading 36Part 2 Clinical casesIntroduction 37Case 1 A man with iron deficiency 38Case 2 When is a headache abrupt? 41Case 3 A woman with chest pain 44Case 4 A dizzy man 48Case 5 Rectal bleeding in a pregnant woman 51Case 6 A pulled calf muscle 54Case 7 A woman with hemiplegic migraine 57Case 8 Irritable bowel syndrome after sickness in Goa 60Case 9 A young man with back pain 64Case 10 Irregular intermenstrual bleeding in a woman on the pill 67Case 11 A boy with a limp 70Case 12 A runner with a cough 72Case 13 A woman with classical migraine 74Case 14 A young woman with diarrhoea and vomiting 77Case 15 Ill-fitting dentures in an elderly man 79Case 16 Back pain in a middle-aged woman 82Case 17 Cellulitis in a man’s foot 85Case 18 A flare-up of ulcerative colitis 88Case 19 A woman with a skin lump on her leg 91Case 20 A woman with microscopic haematuria 93Case 21 A limping young girl 96Case 22 A builder tripping over his feet 98Case 23 An anxious young woman with hyperventilation 101Case 24 A slightly raised AST in an Asian woman 103Case 25 Cough and fever in a 42-year-old accountant 105Case 26 Lost prescription: Benzodiazepine addiction 108Case 27 A febrile baby 110Case 28 A limping elderly woman after a fall 113Case 29 Indigestion in a stressed executive 116Case 30 A hoped-for pregnancy 119Case 31 A breast lump that disappears 122Case 32 Fever and cough after an ankle fusion 125Case 33 Urinary problem in a welder 128Case 34 A hypertensive 38-year-old woman 130Case 35 A swollen lip in a 56-year-old man 133Case 36 A woman with fatigue and weight gain 135Case 37 A woman told off for ignoring her friends 137Case 38 A man with a headache: Swine flu or meningitis? 140Case 39 A woman suffering dizziness 142Case 40 A middle-aged man with an ankle injury 144Part 3 Investigating and dealing with errors1 Introduction 1472 How errors and their recurrence are prevented in primary care 1473 The role of the primary care trusts 1504 Other investigations 1525 Legal advice – where to get it and how to pay 1556 External inquiries 1577 The role of the doctor 1728 Emotional repercussions 1759 Conclusion 175Reference 176Index 177