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How to handle treatment going wrong

Dr Bryony Hooper of the MPS looks at a typical adverse patient event and advises on how to respond.

It is a frightening thought that approximately one percent of GP consultations - about one per week for a full time GP - result in a significant adverse outcome for the patient. No GP wants to be responsible for an unintended injury to the patient, and just the possibility might make us feel anxious. Unfortunately, as the case below shows, common reactions can make things worse, and it is always better to seek help and advice as soon as possible.

Case study
An unexplained INR result
Mr J, a 74-year-old patient attended the practice anticoagulation clinic following diagnoses of TIA and atrial fibrillation by his consultant physician.

Dr L prescribed a loading dose of 10mg for two days. On day three the nurse tested Mr J for INR, and discussed the result of 2.3 with Dr L, who continued the dose. Two days later the INR result was slightly higher, and the warfarin dose continued. The following week the INR was 'off the scale'. The nurse discussed this with Dr L, who telephoned the patient at home. The patient said he had had some nose bleeds. Dr L advised him to stop the warfarin and reattend for a blood test in two days time.

Two days later the INR result was 10, and the patient was advised to take the test three days later. The following day the patient requested a home visit, and was seen by another partner Dr P.

His examination of the chest and abdomen revealed little other than some bruises on the patient's thighs and back, so he arranged for blood tests for INR, FBC, and U&E's. The patient deteriorated the next day and was admitted to hospital, revealing a large gastrointestinal haemorrhage. The ITU consultant queried why Mr J had not been admitted before, or at least given Vitamin K.

The reaction
Unsure whether Mr J would recover, Dr L was devastated by the implication of his error, and found it difficult to concentrate during his afternoon surgery. In his anxiety, he rather aggressively questioned Dr P why he had not admitted the patient.

When he reviewed the clinic records, he became angry that the nurse - who was not in surgery that day - had not given him the full clinical picture prior to his prescription.

So what should he have done?
Keep it in perspective
In an event like this, good sense tends to go out of the window, and many doctors react uncharacteristically - they may deny that their action contributed to the problem, and seek to find others to blame. Neither approach is helpful, and the best thing to do is to find a supportive colleague that you trust, to help you put events in perspective. At its worst an incident like this can make doctors question whether they want to continue practice.

Stand back
Taking time off, however difficult that might be, may be best both for the doctor and for his patients - - if you are so distracted that you cannot think clearly, you should not be making decisions about patients. It is vital that you take time to reflect on the case, and your role, to clarify events in your mind and also to allow you to consider how to prevent another similar incident occurring.

Writing a report of your involvement can be therapeutic, and very helpful if there are further developments in the case.

Seek help
Take advice from others outside the practice, such as your protection organisation or LMC. Medical protection organisations are there to help, will have experience of similar cases, and can give you objective assistance as well as support at a difficult time.

Practice review
Participating in a practice review is a professional responsibility but can also help you recognise that factors such as practice systems are just as important as your own role. Try to address any learning points productively. Things will probably go wrong for every one of us at some point during our careers, so a true professional is someone who can learn from such events and move on.

Dr Hooper is a medicolegal adviser at the Medical Protection Society

What the GMC says

The Good Medical Practice (2006)
Relationships with patients: being open and honest with patients if things go wrong.

  • If a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-term effects.
  • Patients who complain about the care or treatment they have received have a right to expect a prompt, open, constructive and honest response including an explanation and, if appropriate, an apology. You must not allow a patient's complaint to affect adversely the care or treatment you provide or arrange.

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