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21-10-2012 | Article

Learning from mistakes

Doctors make mistakes ‑ there is no doubt about that. In recent years, it has become more acceptable for us to be more open and honest about our mistakes and, if appropriate, offer an apology. As medical practice advances quickly, with new ideas, technologies and therapies becoming available, the type and nature of mistakes also changes. With every medical development comes a new range of possible trapdoors for us to fall into; and in this modern climate of openness and transparency, it is good to share our mistakes and errors with fellow health professionals. The reason is simple; so that we can all learn and avoid making the same or similar error. The trick is to spread the message far and wide but it is not always easily achieved.

One traditional and excellent source of case histories is from our medical defence unions. They are very good at highlighting trends and, after all, they are the ones with great experience in clinical litigation and a vested interest in promoting high quality practice. A good example of this was recently covered in a Univadis GP News article (click here).

The article states: "GPs must be careful to monitor patients after carrying out minor surgery, warns the Medical Defence Union (MDU)." More specifically, "over a third of problems arising from minor surgery in recent complaints made against GPs were due to post-operative complications such as infections, bleeding and pain." Now these complications may not come as a surprise to us, yet somehow they have featured in litigation. One claim for post vasectomy pain led to a £220,000 payout.

Of course we cannot completely eliminate risk, given that part of our everyday clinical practice is to manage risk and uncertainty. But we need to improve our game and try to reduce the chances of a problem occurring. Better communication with our patients (perhaps the provision of high quality written information), clear advice on when patients should seek a medical review and when it is best for GPs to request a specialist opinion may all help. Regular audits can also help to improve clinical practice.

Litigation against GPs is not common but it does happen and it is important to critically think about reducing medical mishaps. Medical defence unions are not the only source of helpful patient safety information, the NHS National Patient Safety Agency website (click here) is also a source of useful material. Putting patient safety first helps reduce all round risk and learning how and why mistakes happen and minimising their occurrence, should be an essential task for all of us.

Harry

Dr Harry Brown, editor-in-chief Univadis

By Dr Harry Brown