30 years of medical mistakes –what has changed?

Miss J.E.Porter FRCS FCEM

What has changed?

• The size of the problem– Numbers of negligence claims– Cost of negligence claims

• Attitudes to the problem– Risk management– Patient safety agenda

• The process– Complaint procedures– Court procedures

What has not changed:

• The nature of the problem– Number of mistakes made– Type of mistakes made– The specialties that make them

• The nature of the process– Slow– Inequitable– Unjust in outcome

From mistake to payment

• Mistake• Adverse outcome• Recognised by patient• Complaint made• Dissatisfied with response• Case suitable for litigation• Access to legal system• Supportive report• Win case• Financial compensation

The Swiss Cheese Model

Clinical negligence claims by year

Clinical negligence claims by cost

Current costs to NHS

• 2007 – 8 5470 claims £633 m costs

• 2008 – 9 6080 claims £769 m costs

• Highest single claim in 1989: £900,000

• Highest single claim in 2009 £7.6 m

Current costs to medical staff:

• General Practice approx 6% of income

• Private practice (low risk specialty) approx 10% income

• Private practice (high risk specialty)approx 30% of income

• Trainee (covering non NHS work only) Approx 1% income

Changing attitudes

Increasing focus on:• System failures• Risk management• Clinical governance • Audit• Incident reporting • “no-blame culture”• Early education on patient safety issues• Human factors training

Process changes: Key landmarks

• 1982 foundation of AVMA (now AvMA)• 1985 NHS complaints procedure revised• 1990 NHS indemnity• 1995 NHS complaints procedure revised• 1996 Clinical negligence scheme for trusts• 1999 Woolf reforms• 2000 Conditional fee arrangements• 2001 National Patient Safety Agency set up• 2009 NHS complaints procedure revised• 2010 RSM patient safety section inaugurated

Changes in complaint procedures

• 1985: – Consultant letter / interview– Hospital administrator letter / interview– Stage 3 independent review

• 1995:– Chief executive letter– Review panel – lay members with expert advice

• 2009– “Local resolution”– Health Ombudsman

Changes in court procedures:

• More doctors acting for complainants

• Medical experts better trained

• CPR

• Earlier exchange of evidence

• Fewer cases reaching court

• Bolito

What has not changed:

• The nature of the problem– Number of mistakes made– Type of mistakes made– The specialties that make them

• The nature of the process– Slow– Inequitable– Unjust in outcome

Frequency of mistakes

• Royal College of Surgeons trauma study 1984:– 30% of deaths avoidable

• Harvard study 1991: – 3.7% adverse events– 27% of these negligent– 0.25% of admissions leading to avoidable death

• Birmingham ITU study 2003:– 39% of diagnoses incorrect at post mortem

• NPSA 2008:– 850,000 adverse incidents per year– 70% preventable

Nature of the mistakes

• Administrative errors

• Medication errors

• Procedural / surgical errors

• Diagnostic errors

High risk specialties

Reducing medical mistakes

• Administrative:– Risk management

• Medication errors– Risk management– Pharmacy supervision

• Procedural / surgical errors– Human factors training– Patient safety education

• Diagnostic errors– ??????

Diagnostic errors

• Are very common• Are the major issue in A&E practice• Are usually due to faulty thinking not lack of

knowledge– Logical errors– Psychological errors

• Are therefore not amenable to system changes

• And are a really interesting problem!

Diagnostic techniques

• Pattern recognition

• Patho- physiological reasoning

• Probabilistic (Bayesian) reasoning

Diagnostic process

• Hypothesis generation

• Data collection

• Data integration

• Verification

Diagnostic process

• Hypothesis generation– Recall bias

• Data collection– Verification bias– Premature closure

• Data integration– Over-interpretation– Conservatism– Probability estimation errors

• Verification

Reasons for diagnostic error: student beliefs

• Professional misconduct

• Organisational / system problems

• Communication problems

• Information problems

Reasons for diagnostic error:research findings

• It never crossed my mind• I paid too much attention to one finding -especially lab

results• I didn’t listen to the patient’s story• I was in too much of a hurry• I didn’t know enough about the disease• I let the consultant convince me• I didn’t reassess the situation• The patient had too many problems at once• I was influenced by a similar case

Reducing diagnostic errors

• Formal training in clinical reasoning

• Formal study of diagnostic errors

• More clinical experience

• Remove time-based targets

• More supervision of junior staff

Effect of supervision

A&E study of 556 patients:

• Initial outcome plan changed in 28%– Of proposed admissions 15.8% discharged– Of proposed discharges 9.4% admitted– Of proposed specialty referrals 61% cancelled

And in the next 30 years?

• Expectations will continue to increase

• Costs will have to be controlled

• There will be further changes to complaints procedures

• Mediation will be used more widely

• There will be further legal changes– Pre-court trial of evidence– ?? No fault compensation

Will mistakes be reduced?

Air travel deaths have gone from

1.19 to 0.27 per million journeys in 30 years

Road deaths have gone from

6000 a year to 3000 a year in 30 years

Can we do the same for medicine?