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Resolving adverse event problems

Apologising and explaining what went wrong may be best, says the MPS's Dr Sarah Cornock.

It is sobering to realise that 70 per cent of litigation against doctors relates to poor communication after an adverse event.

The first you may hear about an adverse event is when the patient makes a formal complaint, which is then handled in line with NHS complaints procedures.

What often happens instead is that patients contact you or the practice informally, 'just to let you know' what has happened. This can be tricky to handle, but it does offer the opportunity to establish immediate communication with the patient. The following case study illustrates how sensitive and appropriate communication can lead to a satisfactory outcome.

A face-to-face meeting to explain how an adverse event occurred may be the best way of resolving the matter for both patient and doctor

Sporting injury
A male patient sustained a minor twisting injury to his ankle in the last five minutes of a football game. It became swollen and painful overnight, so he consulted his GP the following day.

Examination revealed minimal swelling, slight bruising around the lateral malleolus, no bony tenderness and a full range of movement. When the GP recommended rest and an anti-inflammatory, the patient asked for something other than ibuprofen, which he had already taken without any relief.

The patient suffered from porphyria. Knowing that ibuprofen is not contraindicated, the GP assumed that other NSAIDs were also safe and prescribed diclofenac. But had he checked for contraindications before prescribing, the adverse event could have been avoided.

Porphyria
The patient suffered severe abdominal pain following his first diclofenac dose and was admitted to hospital. Fortunately, the attack was short lived: he was discharged home the following morning and advised not to take any more diclofenac. Later that day, he spoke to the practice nurse, telling her briefly what had happened.

The nurse told the GP, who immediately telephoned the hospital to obtain a copy of the discharge summary.

The GP discussed the matter with one of his partners, who advised that when he faced a similar problem, talking to the patient had not stopped the patient suing him.

The GP felt that his partner's experience might have been more due to his sometimes abrasive style and was not convinced by this advice. He was also not happy with the practice manager's suggestion of writing to the patient, advising him of the practice's complaints procedure.

The GP felt strongly that, no matter how difficult it might be, he had a duty to be candid with the patient, who deserved an explanation. He felt terrible about his slip up and wanted to apologise face to face.

He was aware that saying sorry is not of itself an admission of liability and would not automatically lead to a successful claim in negligence.

Apology
The GP invited the patient to come to the practice and discuss the matter. He arranged a mutually convenient time outside his clinic times so that there would be no pressure to attend to other commitments.

When the patient arrived, the GP offered him coffee and seated them in comfortable chairs in a quiet room. He gave his understanding of the incident and its consequences for the patient and expressed his sincere regret about what had happened.

He then encouraged the patient to tell his story. He listened, without interrupting, to the patient's account of the experience. Once he was sure that the patient had completed his tale, the GP shared his own perspective on events, explaining why he made the assumption he did about the safety of diclofenac in porphyria. He then invited the patient to ask questions and responded as honestly as he could. They discussed strategies for avoiding similar incidents in the future and agreed that, as similar drugs may have different effects, it would be safer to always check when prescribing for a patient with porphyria to make sure that they are not contraindicated.

Before wrapping up the meeting, the GP told the patient that he has learned his lesson from the incident and would like the opportunity to continue to care for the patient, though he would understand if the patient preferred to register with a different practice. The patient said he appreciated the options and would let the GP know his decision shortly. They parted amicably with a handshake.

Two days later, the patient rang the GP to tell him that he wished to remain his patient. The GP saw the patient three times over the next month and there were no further problems with the management of his porphyria. The patient did not write a letter of complaint nor did he instruct solicitors.

  • Dr Cornock is a medico-legal adviser at the Medical Protection Society

Resources

  • The National Patient Safety Agency has published guidance on being open with patients following a patient safety incident. Details are on the NPSA website: www.npsa.nhs.uk
  • MPS Risk Consulting offers workshops on Mastering Adverse Outcomes, dealing specifically with the delicate business of communicating with patients and their families following a patient safety incident. Details about this, and other courses, are available on its website: www.mps-riskconsulting.com
  • The Welsh Medicines Information Centre's website at www.wmic.wales.nhs.uk is useful for checking medication contraindications.

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