Avoiding Errors in Paediatrics

Joseph E. Raine, Kate Williams, Jonathan Bonser

• Publisher: Wiley-Blackwell
• Year: 2012
• Print ISBN: 9780470658680
• eBook ISBN: 9781118441954
• Edition: 1
• Topic: Medicine
• Subtopic: Pediatric Medicine

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.

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...

Table of contents

• Cover
• Dedication
• Title Page
• Copyright
• Contributors
• Foreword
• Abbreviations
• Introduction
• Part 1
• Part 2: Clinical cases
• Part 3: Investigating and dealing with errors
• Index