By Mark Dinwoodie.
– Director of Education, Medical Protection Society.
Reviewer – Amanda Pine Clinical Fellow in Trauma Leeds Teaching Hospitals Trust (LTHT)
To provide an overview of the precipitating and predisposing factors that lead to adverse events and outcomes and the potential consequences for clinicians, such as patient initiated action or the reporting of those events to regulatory bodies. To outline the support available from the Medical Protection Society for the individual involved and the challenges of navigating a way forward
It goes without saying that health care professionals are passionate about providing the best care possible for all their patients and have the very best of intentions. However, unfortunately this is not always the case, things do go wrong. According to international research1,2, around 10% of patients admitted to hospital will suffer an adverse outcome, around a fifth of these will be serious and around a half are preventable. It is estimated that 1 in 300 patients who are admitted to hospital die due to medical error or harm from their healthcare.
The Medical Protection Society is very passionate about helping health care professionals avoid causing preventable harm to their patients through risk management and education. As well as this the Medical Protection Societyaim to support individual health care professionals who suffer when things go wrong. Whilst traditionally the focus has been on the individual health care professional involved and their perceived shortcomings, there is an increasing awareness that system and process errors can contribute significantly to adverse events. A better understanding of patient safety has emerged and as a profession we are increasingly aware of the importance of latent system errors and error producing conditions, as well as human factors that can affect human performance. Whilst we know what safe and effective patient care ideally looks like, the challenge is providing this to every patient on every occasion.
Dr Dinwoodie highlighted some of the specific problems faced by emergency medicine clinicians, in particular undifferentiated presentations, the volume of cases, time-critical conditions, recurrent attenders and the significant potential for misdiagnosis and medical error that this provides.
Inevitably when things go wrong and significant medical error occurs some of the focus will be on the individual heath care professional involved and factors that might have contributed will be considered. There are a number of factors that may contribute to an individual making an error: it could be that there is a lack of capability or competence, the individual may have health or personal concerns and/or there may be a problem with the conduct or behaviour of the individual involved. Whilst this may be the case, it must be acknowledged that health care professionals are human and that errors and mistakes are inevitable particularly when undertaking busy and long shifts on a regular basis.
Dr Dinwoodie spoke about predisposing and precipitating factors which may make patients or relatives much more likely to take action against a health care professional. These predisposing factors can include unprofessional behaviour, poor communication and interpersonal skills or clinicians displaying a general lack of empathy and compassion. For some individuals these predisposing factors can be quite extreme, the term ‘disruptive doctor’ has emerged and is defined as personal or professional behaviour, whether verbal and physical, that negatively affects patient care and the ability of the team to function effectively. Around 5% of the workforce is thought to display these characteristics3 but they have a disproportionately negative affect compared to their absolute numbers.
As well as the medico-legal consequences of serious medical error there is undoubtedly an impact on the individual involved and can easily lead to the development of a ‘second victim’. The process of dealing with the consequences of a serious medical error has been likened to bereavement and there are thought to be six steps to recovery. A Medical Protection Society survey in 2014 found that 72% of doctors who had been referred to the General Medical Council reported a detrimental impact on their mental or physical health and that 47% felt unsupported.
The professional outcome for these doctors is variable; the same survey showed that 2% left medicine completely, 8% changed to a different specialty considered to have a lower stress level and 28% considered leaving the profession. However there are many clinicians who emerge from this process to use the experience positively to learn and develop, to improve their clinical practice and grow professionally.
Unfortunately some doctors receive significantly more complaints and regulatory referrals than their peers and these doctors are can be extremely vulnerable. Doctors often blame themselves when adverse events occur but sometimes people shift the focus of blame externally and start to push responsibility onto colleagues and other team members, they may start to blame the system or even the patients. However this has also been shown to be a negative coping strategy. Support in these situations falls into three dimensions: firstly professional including dealing with regulatory issues, secondly medico-legal in terms of the practicalities of the case itself and thirdly emotional support including providing access to counsellors. Overall is it important to continue to behave in a professional manner and to engage with the support available, and to try to learn and develop from what is undoubtedly a very difficult and challenging experience.
The Medical Protection Society has developed a number of workshops which aim to help people limit the impact of the predisposing factors mentioned earlier in the talk, they aim to support the individuals involved and develop their communication and interpersonal skills. Unfortunately disruptive doctors and some of those who get a significant number of complaints can be much more challenging to engage with and support. For this reason, MPS has developed a six-month Clinical Communication Programme to help them develop the insights and skills to reduce their risk of further complaints.
There are a number of factors that contribute to both the occurrence of adverse events and the reporting of those events by staff, patients and relatives. It is important to be aware that these events have a significant effect on the patient and their relatives as well as the health care professional involved. When dealing with the aftermath of an adverse event, it is important to engage with the support and services available to you and to ensure that you learn and develop from the experience.
- de Vries E et al, The incidence and nature of in-hospital adverse events: a systematic review, J Qual Health Care 17:216-223 (2008).
- Lessing C et al, Impact of sample size on variation of adverse events and preventable adverse events: systematic review on epidemiology and contributing factors, Qual Saf Health Care 19(6):1-5 (2010).
- Leape L, Shore M, Dienstag J, et al. Perspective: A culture of respect, part 1: The nature and causes of disrespectful behaviour. Acad Med. 2012;87:845–852.