Avoiding Errors in Paediatrics E-Book

Joseph E. Raine

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: AVE - Avoiding Errors
• Sprache: Englisch

Seitenzahl: 437

Veröffentlichungsjahr: 2012

Beschreibung

Some of the most important and best lessons in a doctor’s career are learnt from mistakes. However, an awareness of the common causes of medical errors and developing positive behaviours can reduce the risk of mistakes and litigation.

Written for junior paediatric staff and consultants, and unlike any other paediatric clinical management title available, Avoiding Errors in Paediatrics identifies and explains the most common errors likely to occur in a paediatric setting - so that you won’t make them.
 
The first section in this brand new guide discusses the causes of errors in paediatrics. The second and largest section consists of case scenarios and includes expert and legal comment as well as clinical teaching points and strategies to help you engage in safer practice throughout your career. The final section discusses how to deal with complaints and the subsequent potential medico-legal consequences, helping to reduce your anxiety when dealing with the consequences of an error.

Invaluable during the Foundation Years, Specialty Training and for Consultants, Avoiding Errors in Paediatrics is the perfect guide to help tackle the professional and emotional challenges of life as a paediatrician.

Leseprobe

Contents

Cover

Dedication

Title Page

Copyright

Contributors

Acknowledgements

Foreword

Abbreviations

Introduction

References and further reading

Part 1

Section 1: Errors and their causes

A few words about error

Learning from system failures – the vincristine case

Person-centred paediatric errors and their causes

The patient consultation (Cases 1, 2, 17, 24, 26, 36)

Failure to identify a sick child (Case 31)

Inability to perform practical procedures competently

Failure to check test results or act on abnormal findings (Cases 1, 8, 21, 27, 35)

Prescribing errors (Cases 7, 15, 30)

Failures in resuscitation

Sources of error in child protection cases (Cases 6, 33)

References and further reading

Section 2: Medico-legal aspects

Error in a legal context

Negligence

Medical negligence

Issues around consent

Confidentiality (Case 8)

References and further reading

Part 2: Clinical cases

Introduction

Case 1: A boy with a limp

Expert opinion

Legal comment

Further reading and references

Case 2: A fitting infant

Expert opinion

Legal comment

Further reading and references

Case 3: A persistent fever

Expert opinion

Legal comment

Further reading and references

Case 4: A biking injury

Expert opinion

Legal comment

Further reading and references

Case 5: A teenager with abdominal pain

Expert opinion

Legal comment

Further reading and references

Case 6: A young girl with a vaginal discharge

Expert opinion

Legal comment

Further reading and references

Case 7: An iatrogenic problem

Expert opinion

Legal comment

Further reading and references

Case 8: An infant with a large head

Expert opinion

Legal comment

Further reading and references

Case 9: An infant with bloody diarrhoea

Expert opinion

Legal comment

Further reading and reference

Case 10: An infant with persistent jaundice

Expert opinion

Legal comment

Further reading and references

Case 11: A child with leukaemia and tummy ache

Expert opinion

Legal comment

Further reading and references

Case 12: A boy with fever and rigors

Expert opinion

Legal comment

Further reading and references

Case 13: A stiff hand

Expert opinion

Legal comment

Further reading and references

Case 14: A serious feeding problem

Expert opinion

Legal comment

Further reading and references

Case 15: Fits, faints and funny turns

Expert opinion

Legal comment

Further reading and references

Case 16: A hospital acquired infection

Expert opinion

Legal comment

Further reading and references

Case 17: Recurrent wheeze

Expert opinion

Legal comment

Further reading and references

Case 18: A jaundiced neonate

Expert opinion

Legal comment

Further reading and references

Case 19: A febrile boy with a limp

Expert opinion

Legal comment

Further reading and references

Case 20: A febrile neonate

Expert opinion

Legal comment

Further reading and references

Case 21: A neonate with abnormal movements

Expert opinion

Legal comment

Further reading and references

Case 22: A teenager with scrotal pain

Expert opinion

Legal comment

Further reading and references

Case 23: A boy with nonspecific symptoms

Expert opinion

Legal comment

Further reading and references

Case 24: A delayed walker

Expert opinion

Legal comment

Further reading and reference

Case 25: A diabetic girl with a headache

Expert opinion

Legal comment

Further reading and references

Case 26: A boy with sickle cell disease and a fever

Expert opinion

Legal comment

Further reading and references

Case 27: Negative test results

Expert opinion

Legal comment

Further reading and references

Case 28: A bad case of ’flu

Expert opinion

Legal comment

Further reading and references

Case 29: A difficult transfer

Expert opinion

Legal comment

Further reading and reference

Case 30: Treatment for tonsillitis

Expert opinion

Legal comment

Further reading and references

Case 31: Increasing respiratory distress

Expert opinion

Legal comment

Further reading and references

Case 32: A feverish girl with poor feeding

Expert opinion

Legal comment

Further reading and references

Case 33: An infant with a swollen face

Expert opinion

Legal comment

Further reading and references

Case 34: Starting a new treatment

Expert opinion

Legal comment

Further reading and references

Case 35: The importance of interpretation

Expert opinion

Legal comment

Further reading and references

Case 36: A febrile boy with a scald

Expert opinion

Legal comment

References and further reading

Part 3: Investigating and dealing with errors

1 Introduction

2 How hospitals try to prevent errors and their recurrence

3 The role of hospital staff

4 External investigators

5 Hospital investigations

6 Legal advice – where to get it and how to pay

7 External inquiries

8 The role of the doctor

9 Emotional repercussions

10 Conclusion

References and further reading

Index

To Elaine, Katie and Ben Rachel and Anna and Anne

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Library of Congress Cataloging-in-Publication Data

Raine, Joseph E. Avoiding errors in paediatrics / Joseph E. Raine, KateWilliams, Jonathan Bonser. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-65868-0 (pbk. : alk. paper) - ISBN 978-1-118-44193-0 (eMobi) - ISBN 978-1-118-44194-7 (ePDF/ebook) - ISBN 978-1-118-44195-4 (epub) I.Williams, Kate, MA. II. Bonser, Jonathan. III. Title. [DNLM: 1. Medical Errors-prevention & control-Case Reports. 2. Pediatrics-legislation & jurisprudence-Case Reports. 3. Medical Errors-legislation & jurisprudence-Case Reports. 4. Pediatrics-ethics-Case Reports. WS 100] 610.28′9–dc23

2012024676

A catalogue record for this book is available from the British Library.

Contributors

Giles Armstrong Consultant Paediatrician Whittington Hospital LondonPart 1, Section 1: Failure to Identify a Sick Child, Failures in ResuscitationCases: 4, 29, 32, 36

Edward Broadhurst Formerly Consultant Neonatologist Whittington Hospital LondonPart 1, Section 1: Inability to Perform Practical Procedures CompetentlyCases: 10, 13, 14, 18, 24

Aubrey Cunnington Specialist Registrar in Paediatric Infectious Diseases and Immunology Great Ormond Street Hospital LondonCases: 12, 16, 26-28, 34

Joanne Haswell Barrister; Director, InPractice Training LondonPart 3: The Role of Hospital Staff, External Investigators, Hospital Investigations, The Role of the Doctor

Alistair Hewitt Partner, Radcliffes LeBrasseur LeedsPart 3: Coroner's Court, Criminal Matters

Kate Hill Solicitor, Radcliffes LeBrasseur Managing Director, InPractice Training, LondonPart 3: The Role of Hospital Staff, External Investigators, Hospital Investigations, The Role of the Doctor

Sasha Howard Paediatric Clinical Fellow Royal London Hospital LondonCase 19

Heather Mackinnon Consultant Paediatrician Whittington Hospital LondonPart 1, Section 1: Sources of Error in Child ProtectionCases: 6, 23, 33

Gopa Sen Locum Consultant Paediatrician Whittington Hospital LondonCase 8Section 3: How Hospitals Try to Prevent Errors and Their Recurrence

Joanna Walker Consultant Paediatrician Portsmouth Hospital NHS Trust PortsmouthCases: 11, 15, 17, 25, 30, 31,

Acknowledgements

The authors would like to thank Dr Nick Owen, Consultant Radiologist, Whittington Hospital; Dr Tony Wheeler, Consultant Community Paediatrician, Whittington Hospital; and Dianna Scarrott, Head of Information and Knowledge Management, National Clinical Assessment Service, National Patient Safety Agency for their help and advice with different sections of the book.

Foreword

Sometimes we may learn more from a man's errors, than from his virtues.

–Henry Wadsworth Longfellow

Paediatrics is an exciting, rewarding and diverse speciality. Doctors who opt for a career in paediatrics know that the high intensity, challenging aspects of the work are balanced in equal measure by the satisfaction of supporting children and families through both acute and long-term illness. However, every practising clinician lives with the uncomfortable truth that the practice of medicine is an error-prone business; and if the stakes are high in all specialities, they are even more so in the care of children.

It goes without saying that no doctor or nurse leaves home in the morning with the intention of harming a child. Indeed, we can only function in the workplace by putting to the furthest recesses of our mind the notion that our actions, in the worst-case scenario, could result in a child's death. Nonetheless, the guilt and self-recrimination that follow even the most trivial of errors are emotions that every clinician would wish to avoid. And that is the great appeal of this book. It is not an academic treatise on the extensive literature about error, human factors, system failure and organizational accidents. Because the busiest, most hard-pressed paediatrician – arguably at greatest risk of making an error – is the one least likely to read such a book. Rather this is an accessible and engaging book, written in a way that will draw its readers in through the appeal of case studies.

For those who do want a helicopter overview of the key causes of errors and the legal context, that is provided in a short punchy style in the first section of the book. The systematic reader will start there first, whilst those who take more of a ‘bumble-bee’ approach to flitting around books will fly straight to the cases studies. These cannot be read passively! They are devised so as to challenge as well as inform, forcing the reader to really think through what they would have done in the circumstances, before presenting the expert opinion and legal comment, and rounding up with key learning points. Each one can be read in a few minutes at a bus stop or in a lull between patients in a clinic – and any one could make the difference between a clinician making or averting the same mistake. The final section wraps up with a practical account of investigation and management of errors and their fallout.

Every serious paediatric error is a tragedy for the child and family involved. Perhaps the greatest tragedy of all, as set out at the beginning of this book, is that errors fall into recurrent themes that are repeated by successive generations of doctors. Families of children who have suffered from a medical error frequently say that they don't want the same thing to ever happen to another child. This book is the most effective way to widely share learning from the case studies, and in doing so to give something back – albeit anonymously – to the children and families involved. If each case described stops even one similar recurrence it will be a worthwhile outcome.

Hilary CassPresident, Royal College of Paediatrics and Child Health

Abbreviations

ACRMAnaesthesia Crisis Resource ManagementALLacute lymphoblastic leukaemiaALPalkaline phosphataseALSGAdvanced Life Support GroupALTalanine transaminaseAPLSAdvanced Paediatric Life SupportARDSAdult Respiratory Distress SyndromeAXRabdominal X-rayBPblood pressureCDOPThe Child Death Overview PanelCPchild protectionCPAPcontinuous positive airways pressureCPDcontinuous professional developmentCPSCrown Prosecution ServiceCRPc reactive proteinCRTcapillary refill timeCSCChildren's Social CareCSFcerebrospinal fluidCTcomputerised tomography scanCXRchest X-rayDATdirect agglutination testDGHdistrict general hospitalDKAdiabetic ketoacidosisECGelectrocardiogramEDemergency departmentEEGelectroencephalogramESBLextended spectrum beta-lactamaseESRerythrocyte sedimentation rateFBCfull blood countFY1 and 2foundation year 1 and 2 doctors (most junior doctor training grades)GBSGroup B streptococcalGCSGlasgow Coma ScoreGMCGeneral Medical CouncilGPgeneral practitionerHbhaemoglobinHDUhigh dependency unitHIVhuman immunodeficiency virusHQIPHealthcare Quality Improvement PartnershipHVheath visitorIPPVintermittent positive pressure ventilationITintrathecalIVintravenousLFTsliver function testsLPlumbar punctureLSCBLocal Safeguarding Children BoardMDDUSMedical and Dental Defence Union of ScotlandMDOMedical Defence OrganisationMDUMedical Defence UnionMgmagnesiumMHPSMaintaining High Professional Standards in the Modern NHSMPSMedical Protection SocietyMRImagnetic resonance imagingMRSAMethicillin Resistant Staphylococcus aureusNCASNational Clinical Assessment ServiceNHSNational Health ServiceNHSLANational Health Service Litigation AuthorityNICENational Institute for Clinical ExcellenceNICUneonatal intensive care unitPALSpaediatric advanced life supportPALSPatient Advice and Liaison ServicePCRpolymerase chain reactionPETPaediatric Epilepsy TrainingPEWPaediatric Early WarningPHHIpersistent hyperinsulinaemic hypoglycaemia of infancyPICUpaediatric intensive care unitPMpostmortemPOCPaediatric Oncology CentrePOSCUPaediatric Oncology Shared Care UnitPVL-SAPanton-Valentine Leukocidin producing S. aureusRCPCHRoyal College of Paediatrics and Child HealthSaO2oxygen saturationSPOCsingle point of contactST 1-8specialist training grades 1–8; grades 1–3 are equivalent to senior house officer standard and grades 4-8 to registrar standardSUFEslipped upper femoral epiphysisTFTthyroid function testsTPHATreponema pallidum particle agglutination assayTPOthyroid peroxidase antibodyTSHthyroid stimulating hormoneTSStoxic shock syndromeU and E’surea and electrolytesUSultrasoundWBCwhite blood cellsWCCwhite cell countZIGzoster immune globulin

Introduction

In 2000, a committee established by the Department of Health, chaired by the then Chief Medical Officer, Professor Liam Donaldson, published its report An Organisation with a Memory. The report recognized that the vast majority of NHS care was of a very high clinical standard and that serious failures were uncommon given the volume of care provided. However, when failures do occur their consequences can be devastating for the individual patients and their families. The health care workers feel guilt and distress. Like a ripple effect, the mistakes also undermine the public's confidence in the Health Service. Last, but not least, these adverse events have a huge cumulative financial effect. Updating the figures provided in the report, in 2010/11, the NHS Litigation Authority (the NHSLA is the body that handles negligence claims against NHS Trusts in England) paid out £863,400,000 for medical negligence claims (these figures take no account of the costs incurred by the Medical Defence Organisations for General Practice and private health care). The report commented ruefully that often these failures have a familiar ring to them; many could be avoided ‘if only the lessons of experience were properly learned’.

The Committee writing the report also noted that there is a vast reservoir of clinical data from negligence claims that remains untapped. They were gently critical of the Health Service as being par excellence a passive learning organization; like a school teacher writing an end of term report, they classified the NHS a poor learner – could do better. On a more positive note, the report stated that ‘There is significant potential to extract valuable learning by focusing, specialty by specialty, on the main areas of practice that have resulted in litigation.’ It acknowledged that learning from adverse clinical events is a key component of clinical governance and is an important component in delivering the Government's quality agenda for the NHS.

The NHSLA has reported that its present (as of 2011) estimate for all potential liabilities, existing and expected claims, is £16.8 billion. At the time An Organisation with a Memory was written, this figure stood at £2.4 billion. (These sums are actuarially calculated figures that are based on both known and as yet unknown claims, some of which may not surface for many years to come. They should not be confused with the figure of £863,000,000 mentioned above, which was the sum actually paid out in one year.) The NHSLA also reported that the number of negligence claims rose from 6652 in 2009/10 to 8655 in 2010/11. While the increases in these figures may be due to the increased readiness of patients to pursue negligence claims and the very significant costs of claims inflation, rather than any marked decline in the standard of care provided by the NHS, the statistics clearly show that there is still room for improvement in the care provided to patients. It is this gap in the standard of care that we, the authors, wish to address through this book.

An Organisation with a Memory as a report tried to take a fresh look at the nature of mistakes within the NHS. It looked at fields of activity outside health care, such as the airline industry. The committee commented that there were two ways of viewing human error: the person-centred approach and the systems approach. The person-centred approach focuses on the individual, his inattention, forgetfulness and carelessness. Its correctives are aimed at individuals and propagate a blame culture. The systems approach, on the other hand, takes a holistic view of the reasons for failure. It recognizes that many of the problems facing large organizations are complex and result from the interplay of many factors: errors often arise from the cumulative effect of a number of small mistakes; they cannot always be pinned on one blameworthy individual. This approach starts from the position that humans do make mistakes and that errors are inevitable, but tries to change the environment in which people work, so that fewer mistakes will be made.

The systems approach does not, however, absolve individuals of their responsibilities. Rather, it suggests that we should not automatically assume that we should look for an individual to blame for an adverse outcome. The authors of An Organisation with a Memory acknowledged that clinical practice did differ from many hi-tech industries. The airline industry, for example, can place a number of hi-tech safeguards between danger and harm. This is often not possible in many fields of clinical practice, where the human elements are often the last and the most important defences. ‘In surgery,’ they wrote, ‘very little lies between the scalpel and some untargeted nerve or blood vessel other than the skill and training of the surgeon.’ We believe that this difference is key to understanding the nature of error in healthcare and why we have placed such great emphasis on case studies that show how doctors make mistakes in treating their patients.

The committee felt that the NHS had for too long taken a person-centred approach to the errors made by its employees and that this had stifled improvement. They called for a change in the culture of the NHS and a move away from what they saw as its blame culture. More than a decade has passed since the writing of the report and there has been little change in attitudes. A sea change is required. We want to see an NHS that promotes a safety culture, rather than a blame culture, a culture where there are multiple safeguards built into the system.

However, the legal system in which the medical services operate does not foster such an approach. Although coroners can now comment on the strengths and weaknesses of systems in the form of narrative verdicts, in general, the medical complaints and litigation process still tends to focus on the actions of individuals rather than the failings of the system. Perhaps the most glaring example of this person-centred approach can be seen in the way the General Medical Council treats medical practitioners, when they receive a complaint. In that forum, doctors are expected to meet personal professional standards and will be held to account if they fall short of them in any way. Yet they may find themselves working in an environment that at times seems to conflict with those professional standards.

As authors, we believe that the committee of An Organisation with a Memory were right, when they wrote that many useful lessons can be learnt from the bitter experience of errors and litigation and that this can best be done by looking specialty by specialty at those areas of practice where errors are most frequently made. Thus, we have produced a book looking at paediatric errors. It is to be the first of a series of such books, each concentrating on a separate specialty.

If doctors are to learn lessons from their errors and litigation, then they must have some understanding of the underlying processes. Thus, in Part 1, Section 1 (Errors and their causes), we discuss types of medical error, both person-centred and systems errors. We have also summarised our research into the commonest errors in paediatrics, their types and outcomes. In Part 1, Section 2 (Medico-legal aspects), we cover the basic legal concepts relevant to medical care: negligence, consent and confidentiality.

The heart of the book is Part 2. Here, we set out a number of case studies on common mistakes in paediatrics. Each case is drawn from real scenarios, anonymised to protect patient confidentiality and is supplemented with legal comment. Most cases concern failures to diagnose an illness, the commonest source of error in medical treatment. In Part 1, we have at various points cross-referred to relevant cases in Part 2.

Finally, Part 3 provides a practical guide to the various forms of complaint that a doctor may encounter, how they may affect him and what he can do to protect his interests.

Our aim is to provide a book that will go some way to meet the challenges laid down at the turn of the millennium in An Organisation with a Memory. We hope that it will reduce the number of clinical errors and improve the standard of care provided by individual paediatricians and Paediatric Departments throughout the country.

References and further reading

Department of Health (2000) An Organisation with a Memory, the report of an expert group on learning from adverse events in the NHS, chaired by the Chief Medical Officer. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4098184

National Health Service Litigation Authority (2011) The National Health Service Litigation Authority Report and Accounts 2010-11. http://www.nhsla.com/NR/rdonlyres/3F5DFA84-2463-468B-890C-42C0FC16D4D6/0/NHSLAAnnualReportandAccounts2011.pdf

PART 1

Section 1: Errors and their causes

A few words about error

If our aim is to reduce the number of clinical errors, then we must explain what we mean by ‘error’. The Oxford English Dictionary defines ‘an error’ as a mistake. This is self-evident and does not really help us, the authors, to define our goal.

We could define our aim by looking at the end-result of errors and say that we want to prevent poor patient outcomes. That must be our primary concern, but our aim is broader; many mistakes can be rectified before any serious harm is done.

We could look at the seriousness of the error, how ‘bad’ the mistake actually was. Some errors could be so crass and the consequences so serious that they can be labelled ‘criminal’ by one and all and in fact some cases are investigated by the police and come before the criminal courts, as we shall see later. Other errors are the sort that only become obvious with the benefit of hindsight and could be made by anyone, even the best of doctors. In short, we want to look at all errors across the spectrum. What we hope to achieve is to raise the standard of care provided to patients, so that mistakes of all kinds are reduced.

Learning from system failures – the vincristine case

The way that the courts look at error is to focus on the acts of individuals and to ascribe fault to particular doctors, if their treatment of the patient falls below the standard of the Bolam test (see Part 1, Section 2, below). But as mentioned in our Introduction, there is another way of looking at errors and that is to consider system failures.

In order to illustrate the difference between system failures and individual fault, the authors of An Organisation with a Memory examined a case concerning the maladministration of the drug vincristine. The mistake cost the patient, a child, his life. A number of shortcomings occurred during the child's stay in the hospital. We believe that it would be useful to set out what happened in the lead up to this child's death, pointing out at each stage the failings that occurred. We will then provide a more detailed discussion of the general lessons that can be learnt from the case.

The following is taken with minor amendment from An Organisation with a Memory. It is a classic example of how a number of small mistakes can add up to a massive error and end with a fatality. The comments in italics provide a brief analysis of the faults that occurred:

A child was being treated in a district general hospital (DGH). He was due to receive chemotherapy under a general anaesthetic at a specialist centre. He should have been fasted for 6 hours prior to the anaesthetic, but was allowed to eat and drink before leaving the DGH.

Fasting error. Poor communication between the DGH and the specialist centre.

When he arrived at the specialist centre, there were no beds available on the oncology ward, so he was admitted to a mixed-specialty ‘outlier’ ward.

Lack of organizational resources; there were no beds available for specialized treatment. The patient was placed in an environment where the staff had no specialist oncology expertise.

The patient's notes were lost and were not available to the ward staff on admission.

Loss of patient information.

The patient was due to receive intravenous vincristine, to be administered by a specialist oncology nurse on the ward, and intrathecal (spinal) methotrexate, to be administered in the operating theatre by an oncology Specialist Registrar. No oncology nurse specialist was available on the ward.

Communication failure between the oncology department and the outlier ward. Absence of policy and resources to deal with the demands placed on the system by outlier wards, including shortage of specialist staff.

Vincristine and methotrexate were transported together to the ward by a housekeeper instead of being kept separate at all times.

Drug delivery error due to noncompliance with hospital policy, which was that the drugs must be kept separate at all times. Communication error: the outlier ward was not aware of this policy.

The housekeeper who took the drugs to the ward informed staff that both drugs were to go to theatre with the patient.

Communication error. Incorrect information communicated. Poor delivery practice, allowing drugs to be delivered to outlier wards by inexperienced staff.

The patient was consented by a junior doctor. He was consented only for intrathecal (IT) methotrexate and not for intravenous vincristine.

Poor consenting practice. Junior doctor allowed to take consent. Consenting error.

A junior doctor abbreviated the route of administration to IV and IT, instead of using the full term in capital letters.

Poor prescribing practice.

When the fasting error was discovered, the chemotherapy procedure was postponed from the morning to the afternoon list.

The doctor who had been due to administer the intrathecal drug had booked the afternoon off and assumed that another doctor in charge of the wards that day would take over. No formal face-to-face handover was carried out between the two doctors.

Communication failure. Poor handover of task responsibilities. Inappropriate task delegation.

The patient arrived in the anaesthetic room and the oncology Senior Registrar was called to administer the chemotherapy.

However the doctor was unable to leave his ward and assured the anaesthetist that he should go ahead as this was a straightforward procedure.

Inadequate protocols regulating the administration of high toxicity drugs.

Goal conflict between ward and theatre duties. Poor practice expecting the doctor to be in two places at the same time.

The oncology Senior Registrar was not aware that both drugs had been delivered to theatre. The anaesthetist had the expertise to administer drugs intrathecally but had never administered chemotherapy. He injected the methotrexate intravenously and the vincristine into the patient's spine. Intrathecal injection of vincristine is almost invariably fatal, and the patient died 5 days later.

Situational awareness error. Inappropriate task delegation and lack of training. Poor practice to allow chemotherapy drugs to be administered by someone with no oncology experience.

Drug administration error.

Although An Organisation with a Memory analyses this sorry tale in the context of system failures rather than individual fault, it is clear that many of the failings represent a mixture of the two. Indeed, many of the actions undertaken by individual members of the hospital staff could be analysed in terms of person-centred fault. But that is not the point. The systems approach suggests that we should not automatically assume that we should look for an individual to blame for an adverse outcome. What we are asking is that when an error is made, the finger should not necessarily be pointed at the doctor who made the final error. We are asking that a more considered approach be taken that looks at matters in the round, that digs a little deeper and tests the role of management and the systems that operate in the hospital. For experience shows that when one digs a little deeper, mistakes are usually a mixture of system failures and individual fault.

Although the errors committed in this maladministration of vincristine are, of course, specific to the case, they also illustrate general issues and a number of themes emerge that warrant further discussion.

Failure to follow protocols (Case 25)

The decade since the writing of An Organisation with a Memory has seen the introduction of numerous protocols and standard operating policies to try to improve the service offered by the NHS to its patients: protocols for the treatment of specific diseases, to stop the spread of infections such as MRSA, for the care of outliers, for the running of EDs and also checklists for use in theatres. These can only be for the good, setting in place good working practices and, therefore, improving patient care.

A doctor can take some comfort that by adhering to a protocol he1 will be protected from criticism. In principle, a protocol issued by a respectable source can be regarded as a statement by a responsible body of medical opinion on what to do in a particular set of circumstances. But adherence may not always provide protection to a doctor. There may be some circumstance relevant to the individual patient that renders a particular protocol or part of a protocol inappropriate. A protocol should not replace good judgement.

That said, a doctor should be very careful before departing from a protocol. He should have clearly thought out the reasons for doing this and ideally have discussed it with his superiors or colleagues. He should also note the reasons for his actions within the medical records.

Inadequate communication (Cases 1, 13–15, 18, 19, 27, 29, 30, 33, 34, 36)

Several of the errors in the vincristine case can be categorized as communication errors. This is not surprising. Many errors in diagnosis and treatment can be traced back to inadequate communication either between the patient and the treating clinicians or between members of the team or teams treating the patient.

It is perhaps obvious, but it is worth stating all the same. Communication is only achieved when someone says or writes information in such a way that the other understands. It must be clear. When it is done well, it facilitates good treatment. It is key to the smooth running of all organizations and the NHS is no exception. Communication, communication, communication: this should be the mantra of all medical teams.

Although communication is omnipresent and relates to all aspects of practice, we wish to point out the following issues:

Telephone advice – Frequently paediatricians are required to advise parents over the telephone. Such advice should be recorded in the medical notes or electronically to document the episode and for the information of other treating clinicians.Transfer to ICU – Poor communication between departments often causes unwarranted delays in the transfer of patients to ICU with the attendant risk of a deterioration in the patient's condition (see Case 29).Equipment – It is surprising how often a doctor will seek some piece of equipment and discover that it is either missing or does not function. Such lack of useful equipment causes delays in treatment. Often the cause lies in the fact that staff do not report equipment faults.Safety net – Clear instructions should be provided to the parents of patients prior to their discharge from the ward, ED or clinic. They should be told what symptoms and signs they should look out for and be advised on when they should take their child back to their GP and when they should return to the ED.Abnormal results – Abnormal test results should be communicated as fast as possible, so that appropriate investigations and treatment can be instigated.Poor attendance – If a patient fails to attend outpatient appointments, then this can seriously affect their care. The parents of the child should be told how important it is for them to attend appointments. If a parent consistently fails to bring a child to his appointments, this may give rise to child protection concerns that should be communicated to the appropriate authorities.

Communication can be achieved through the written or the spoken word. Although it is possible to criticize individuals for failures in communication, there will generally be a systems element to such failings. Good communication is fostered by good leadership, the type of leadership that encourages teamwork and an atmosphere in which all members of a team, even the most junior, can feel confident in expressing themselves.

Poor and inadequate record-keeping (Case 3)

We have already said that communication can be through the written or spoken word. Good record-keeping should be seen simply as a subset of good communication. Full, well documented notes are a crucial part of good medical practice.

On a more general note, accurate and full records are often the only way of gauging a deterioration in the patient's condition, allowing the clinicians to change their treatment plans to treat the patient appropriately.

Lack of knowledge and not knowing one's limitations (Cases 1, 15, 20)

In the vincristine example, the anaesthetist who administered the fatal dose of the drug knew how to administer drugs intrathecally, but had no oncology experience: he had never administered chemotherapy. A doctor's care is always judged by the standard of the reasonable or responsible doctor. The responsible doctor in this anaesthetist's shoes should have sought assistance or at least double-checked what was required.

The same applies to any junior doctor who is learning the ropes. If he is asked to do something or finds himself in a situation outside his range of experience, then he must seek advice or assistance from someone with the appropriate level of experience. Again, we come back to the importance of communication within the team.

Of course, in stating that the junior doctor should seek assistance, we are presupposing that he will recognize when he is out of his depth. Common sense should tell him this, but there will be occasions when his own lack of experience will not be apparent to him. Where this happens, we should look higher up the chain of management and question whether his superiors are supervising him or delegating tasks to him in an appropriate fashion.

Poor supervision and delegation (Case 22)

Not knowing one's limitations and poor supervision and delegation may simply be flip sides of the same coin. As we have hinted, the doctor who acts outside his range of knowledge may be put in that situation by a superior who delegates an inappropriate task to him.

Poor supervision and poor delegation are classic symptoms of a system that is poorly organized and a team that is not functioning effectively. They are symptomatic of poor management at some level.

Poor prioritization (Case 20)

Any person in a busy job must learn to prioritize effectively and doctors are no exception. A doctor can only learn this skill through experience and by weighing up the risks involved in the varying decisions that he has to make.

Tiredness and stress; lack of resources

However, prioritization may not always be that easy. It is fair to say that there will inevitably be times in the career of a doctor when lack of resources, stress and tiredness will militate against best practice.

The introduction of the European Working Time Directive should help reduce stress and tiredness, but in turn it may cause resourcing problems. These are systems issues. The solutions will not be easy. If the problems become acute, then the doctor should raise them with the hospital management. But with only a finite pot of money available for the NHS, this may not necessarily bring about the desired improvement.

Psychological factors

Psychological factors play an important role in many clinical errors. We have already mentioned tiredness and stress and these and other psychological issues will be mentioned elsewhere, but only in passing. We do not intend to provide an in-depth discussion of the psychology of error. We leave that for others to do. Our emphasis is on the case studies and what they reveal about what doctors should look for when diagnosing and treating their patients (if the reader wishes to read about the psychology of error, then we would recommend Professor Charles Vincent's Patient Safety (2005)).

That said, we cannot escape the psychological aspects of clinical error. We give one example to illustrate the importance of this issue: another vincristine case that ended with a fatal outcome.

A locum doctor was asked to administer vincristine to a patient out of hours. He had not administered the drug previously and the mother of the patient was on hand, watching. She had watched doctors administer the treatment several times before and knew the procedure well. She saw that the doctor was making a mistake and told him that the clear fluid (the vincristine) should be put into the vein and the yellow fluid (the methotrexate) should be put into the spine. The doctor ignored her, despite her comments, and administered the vincristine intrathecally. Several days later the patient died.

Humility was what this doctor lacked. He thought that he knew best when he did not. If he had been prepared to listen to the mother, the patient would not have died.

Conflicts between system issues and personal responsibility: a healthy work environment

In our Introduction, we explained that the GMC expects each doctor to fulfill his personal responsibilities. However, he may have to do this in an environment which may conflict with these responsibilities. A doctor in such a situation will be required to perform a balancing act. If that act becomes impossible, then he must ‘blow the whistle’ and bring the matter to the attention of his managers. Again, we repeat our mantra: communication, communication, communication.

Despite the publication of An Organisation with a Memory, the NHS still maintains an unhealthy blame culture. The report pointed out the difficulty faced by individuals who draw attention to problems in their working environment. Its authors recommended that the NHS should foster a more open culture in which errors can be admitted without fear of discrimination or reprisal (though individuals still need to be held accountable for their actions).

We believe that the best work environments are those where good, professional teamwork comes naturally and people are pleased to come to work. This is an intangible element. It requires each person within the workplace to think about how he can help himself and others to work better together. If it can be achieved, then it should go some considerable way to meeting the aims of An Organisation with a Memory and the number of clinical errors should consequently be reduced.

Having looked at system errors, we now turn our attention to more specific areas of error, those that could perhaps be considered more person-centred. But before doing so, we wish to share some research that we have conducted on errors in paediatrics. It highlights those areas where paediatricians as individual doctors could do better. It has also helped us to establish the sort of errors that we need to focus on in the rest of Part 1, Section 2 and to determine the type of case studies that we should cover in Part 2.

Person-centred paediatric errors and their causes

We found that the NHSLA database provided the best source of information on paediatric errors. In the five years between 2005 and 2010, 195 paediatric claims were settled in favour of the claimant. The top ten most common incidents are summarized in Table 1.1:

Table 1.1 Incidents leading to successful litigation, 01/04/2005–31/03/2010

Number%Medication/vaccination error105.1Delayed/failed diagnosis of septicaemia84.1Delayed/failed diagnosis of meningitis73.6Extravasation73.6Delayed/failed diagnosis of unspecified sepsis63.1Delayed diagnosis of anorectal abnormality63.1Delayed/failed cardiological diagnosis63.1Delayed diagnosis of appendicitis63.1Misdiagnosis of epilepsy63.1Delayed diagnosis of a fracture42.1

The other incidents included a delay or failure in diagnosing a number of conditions including brain tumours, tumour recurrence, testicular torsion, bowel perforation, shunt blockage, Turner's syndrome and intussusception. Further events that led to successful litigation were gastrostomy-related errors, cold-light injuries and pressure sores.

The NHSLA were also able to provide a breakdown of the causes of the errors that led to litigation in these 195 cases. These are summarized in Table 1.2:

Table 1.2 Causes of incidents leading to successful litigation, 01/04/2005–31/03/2010

Number (out of 195)%Delayed/failed diagnosis9146.7Delayed/failed treatment2512.8Inadequate nursing care157.7Medication/vaccination error126.2Infusion problems105.1Failure to recognize a complication94.6Operative problem63.1Failure to act on results52.6

The NHSLA listed the outcomes that resulted in these 195 incidents. The most common outcome was death (74 out of the 195 cases), followed by unnecessary pain (35 cases), unnecessary surgery (16) and brain damage/developmental delay and scarring (both 12 cases); 5 cases resulted in amputations, 3 in visual problems and 2 in a perforated appendix.

The total cost of litigation in each of the 195 cases (including the damages and the costs) ranged from £600 to £3,044,943.

We also obtained information from NCAS which is a division of the National Patient Safety Agency. It provides advice, support and formal assessments of doctors working in the United Kingdom, the Isle of Man, Channel Islands and Gibraltar. The nonclinical reasons for referral to this service comprise predominantly behavioural and conduct issues such as poor team working and bullying. But we concentrated on those paediatric cases, where the doctor had been referred for assessment because of specific clinical concerns. Over the ten years from 2001 to 2011, there were 63 cases. The most common reasons for referral are shown in Table 1.3:

Table 1.3 Most common reasons for referral, 2001–2011

Diagnosis and management of child protection cases19Prescribing errors13Diagnostic errors other than child protection cases12Treatment incidents7Difficulties with transfer of patients to other units6Poor resuscitation4Slow response to an emergency2

Common themes emerge from these studies (details of which appear in the references below). The most common error in the NHSLA cases was a failure to treat or diagnose an infection, particularly meningitis and septicaemia. The NHSLA and NCAS studies also showed failings in prescribing.

In contrast to the NHSLA, the NCAS study showed that the commonest reason for a complaint against a paediatrician was related to the diagnosis and management of child protection cases. This reflects the focus of NCAS referrals, which is different from that of the NHSLA; most NCAS referrals are made by NHS managers and doctors, rather than by patients.

The main causes of the errors in the NHSLA study were very much as expected, with a delay or failure in diagnosis and treatment being by far the commonest.

Most errors in clinical practice result in little or no harm. However, the NHSLA study shows that the commonest outcome in the cases analysed was death. Looking a little further down that list, the fourth most common outcome was brain damage. These observations reinforce the importance of trying to minimize errors in clinical practice. When things go wrong, they can go spectacularly and tragically wrong.

Pulling all this research together, we believe that there are certain keys areas where doctors would benefit from advice. We aim to provide such advice in the following sections. This will include advice on how to make the correct diagnosis promptly, avoiding prescribing errors, checking test results and acting on abnormal findings, avoiding errors in practical procedures, avoiding resuscitation errors and how to act in child protection cases. We shall start by looking at the patient consultation and how to identify the sick child.

The patient consultation (Cases 1, 2, 17, 24, 26, 36)

The patient consultation is, in a very practical sense, at the heart of the doctor–patient relationship. It gives an opportunity for face-to-face communication and for the doctor to build up a rapport with the patient and to win his trust. If handled correctly, at the end of the consultation, the doctor should be armed with the information that he needs to reach a diagnosis, or at least a differential diagnosis. And of all consultations, it is the first that is perhaps the most important; that first consultation will strongly influence all that follows. How should it be conducted?

A good history is essential in making a correct diagnosis. The history on its own leads to the diagnosis in over 60% of cases. Once a patient has given his account of the presenting complaint, the doctor should ask questions to clarify his understanding of the patient's symptoms. All this is perhaps obvious, but it all comes down to communication. Good communication should aid diagnosis; poor communication will hamper it. Thus a doctor must listen carefully to patients and their parents. In the words of the nineteenth-century Canadian physician Sir William Osler, ‘Listen to the patient. He is telling you the diagnosis.’ This requires skill and patience and can be difficult if time is short.

And to continue with the theme of listening and understanding … Doctors often see patients who speak poor English. Where this gets in the way of understanding, the doctor should find a translator who can speak the language of the patient. If one is not on site, most hospitals have phone access to translators 24 hours a day. A judge is unlikely to excuse a mistake caused by a failure to use a translator.

After the history comes the examination. Examining any patient may be difficult, but examining a sick child even more so. A general examination should be conducted with a particular focus on the ailing system. A doctor should try to put the child at ease; it may be a good idea to give them a toy at the beginning of the consultation, if they are very young. Starting with the hand is often a nonthreatening way of commencing the examination and talking to the child may well help to calm him down. The examination may need to be opportunistic: for example, the doctor may have to wait until the child is quiet and calm, before he can listen to the precordium. If the child is very fractious, the doctor may wish to leave the child for a while, if the situation is not urgent, and to examine the child a little later, perhaps after a feed or after analgesia has had time to take effect.

There are key areas that should not be omitted in the course of particular examinations, such as the examination of the throat in a febrile child. If the doctor were to omit this, he could be committing a significant error; he may fail to diagnose tonsillitis; he may fail to find the source of the fever. If a doctor finds a child difficult to examine, a more experienced doctor with a better, more experienced examination technique should be asked to see the patient.

If the examination is limited one should make that clear in the notes, together with the reason why.

Once the history and examination have been completed it is important to make a diagnosis or to consider the differential diagnoses in order of probability. The doctor should list the investigations required to clarify the diagnosis and to provide further details about the illness. A management plan should then be constructed. Following this pathway encourages a doctor to rigorously analyse the ailment afflicting the patient.

The history, examination, diagnosis, investigations and management plan should be clearly documented. It is also very important to note negative findings in the history and examination. The investigation results should be obtained and documented promptly. The importance of clear and thorough documentation cannot be overemphasized.

The requirement to see all patients who present to the ED within four hours can sometimes cause doctors to prioritize patients inappropriately. Thus a doctor may find himself rushing the history and examination in order to meet this deadline. Errors may occur as a result. But it is no defence for a doctor to argue this in court. This, along with ergonomic factors such as the stress, tiredness and depression, is a system issue which may adversely affect the outcome of the patient consultation. If the doctor has concerns about the systems in place at his hospital, he should discuss them with his superiors.

A delay or failure in making a diagnosis and a delay or failure of treatment are the two commonest causes of errors. The reasons behind these delays and failures are many; they include poor paediatric training, a lack of knowledge, failure to recognize when help is required and when a more senior opinion is needed, and an inadequate hospital and departmental induction to the job.

Clinicians often form a hypothesis about the likeliest diagnosis early on in the consultation. A doctor should repeatedly question this hypothesis and reassess alternatives. He should also bear in mind the diagnoses that he cannot afford to miss. So when he is presented with a febrile child, meningitis should be on his list of differential diagnoses. Meningitis may be both clinically and statistically unlikely, but it should at least be considered, if only because it is a treatable condition with potentially catastrophic sequelae.

Doctors can also make what are termed cognitive errors when they are looking for a diagnosis. A detailed analysis of cognitive errors is outside the scope of this book and the reader is referred to the references at the end of this section. However, these are some examples:

‘Confirmation bias’, where information gathering is geared towards confirming rather than refuting the diagnosis. This may cause a doctor to overlook important alternative diagnoses. In the course of his examination and assessment of the child, the doctor should not overlook symptoms and signs that may be inconsistent with the initial diagnosis and may suggest other possible conditions.‘Premature closure’, where a doctor makes what he considers to be a definitive diagnosis early on in his treatment of the patient and then fails to reconsider the diagnosis at a later stage even if the circumstances have altered.‘Availability bias’, where a doctor gives too much weight to his own past experience and easily recalled examples, at the expense of other and often rarer diagnoses.

Hospital protocols and national and international protocols on different conditions provide information on the symptoms that need to be asked about, the signs that need to be checked, the differential diagnoses in a given set of circumstances and the appropriate treatment plan. Likewise, different courses such as the Advanced Life Support Group's courses on Advanced Paediatric and Neonatal Life Support, and Child Protection provide very useful training in important areas of paediatrics.

As a very basic comment, it is training and experience that will lead to improved and more efficient history taking and examinations, to more accurate diagnosis and to better treatment.

Failure to identify a sick child (Case 31)