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Systems, Patients, and Recurring Themes
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I am pleased to have this opportunity to share some of my
thinking after six months as Health and Disability Commissioner. In
this column I will consider some recurring themes arising in the
cases that have come before my Office.
Our health and disability system works well in the vast majority
of the millions of interactions with consumers that occur each
year.[1] In this context HDC advocates assist
with over 3,500 enquiries, and my Office receives around 1,500
complaints per year. Each represents an opportunity to learn. The
human stories that are reflected in the complaints I receive often
involve individual tragedies. Resolution for consumers often
involves understanding what really happened, combined with the hope
that the lessons learnt mean the same thing is less likely to
happen to anyone else.
I have been struck by the number of complaints which relate to a
failure to get the basics right. I am interested in how well we
learn as a system - why errors are repeated and how to reduce
repetition. If we are to have a learning system we need to
understand the individual and systemic causes of error and their
context.
It is in the ordinary we largely dwell and is from the ordinary
the stories of harm arise. Thus here and in subsequent columns, I
will be reinforcing the message 'patient safety begins with getting
the basics right'. I will be discussing a range of issues grouped
under the rubric 'read the notes, ask the questions, talk to the
patient'. These broad concepts provide a framework for discussing
some recurring themes that arise in the stories before me.
The stories tell of notes not read and notes that are incomplete
or disconnected. Good clinical records are integral to providing
care. They demonstrate the reasoning behind the diagnosis, set out
the key information upon which decisions about ongoing care are
based and can help safeguard practitioners when faced with
allegations of inadequate practice. The records are also vital for
enabling continuity of care and ensuring other practitioners know
what decisions have previously been made and the care that has been
provided. Notes need to be comprehensive, accurate, and
contemporaneous. If it isn't recorded in the notes the starting
point is that it didn't happen.
Consider the woman with shoulder pain who consulted five
different doctors at a medical centre over a period of seven
months.[2] Each consultation was poorly
documented and the notes provided little assistance to doctors at
subsequent consultations. After a failure to follow up on referrals
and test results, the woman was eventually diagnosed with cervical
stenosis and myelopathy.
In a similar case, a cancer diagnosis was delayed because the
follow-up GP, who had good quality notes, did not read them.
It is also vital that doctors 'ask the questions' - carry out
adequate examinations and consider what else might be going on.
In a recent case investigated by HDC[3], a
patient had consulted her GP on several occasions with various
complaints including tiredness, low energy levels, mild lower back
pain, aching upper abdomen, shortness of breath, tightness in lower
chest and a feeling of passing out. The GP diagnosed the patient
with an iron deficiency anaemia and prescribed iron supplements.
However, her health did not improve. A blood test result
included the pathologists comment "note decreased haemoglobin ?
recent blood loss - monitor".
The GP failed to carry out an abdominal or rectal examination,
and to adequately investigate the causes of her anaemia.
Subsequently, the patient sought a second opinion from another GP
who identified a swollen liver and, following a CT scan, a primary
tumor was identified in her caecum and secondary cancer in her
liver.
In another feature of that case, my expert advisor commented on
the GP's use of the "hot key" function when recording his notes and
rightly pointed out that although the use of hot keys is not
uncommon, the content of the clinical notes must accurately reflect
the activities that took place during the consultation.
The patient did not recall the GP carrying out a very detailed
cardiovascular examination on her (including normal peripheral
pulses), recorded as occurring on nine occasions, nor receiving
advice on "foods, feeds and care", recorded as occurring on eight
occasions. Nor did she recall receiving advice on diet and
exercise, recorded as occurring on two occasions. Overall, the
records were not sufficient to meet the legal requirements and the
GP was found to have breached Right 4(2) of the Code.
The importance of adequate records and examination of patients
is clearly demonstrated in the context of rest home care where
doctors are working with other staff in multi-disciplinary teams.
The communication in the clinical record should tell the whole
story about the patient's care, show the observations and how they
were acted on, show continuity of care, show the care delivered
following the observations including medications and other
treatments, specify arrangements for review and follow-up, and show
how the patient responded to the care.
Many patients now see multiple providers, GPs and practice
nurses within one practice, and poor note-keeping and processes
interfere with continuity of care and planned follow-up. Consider
the example of a fit woman in her early sixties who had been found
to have significant hypertension at a routine medical examination.
The plan was to monitor the blood pressure monthly for three months
to gain a better picture of her levels and to further investigate
and commence treatment if indicated. The patient presented to the
practice nurse as directed and elevated blood pressures were
recorded on each occasion but not conveyed to the doctor. At
subsequent unrelated consultations over the next two years the
readings were not acknowledged even though they were present in the
notes. The blood pressure remained untreated and the patient died
of a cerebral haemorrhage, thought to be due to untreated
hypertension.
Here the lack of communication with and from the practice nurse,
together with poorly structured and documented monitoring and
follow-up instructions to both the practice nurse and the patient,
contributed to a potentially treatable condition being
neglected.
I accept that many medical professionals operate under pressure
of time. It is then, however, that a structured approach to the
basics avoids the temptation of the shortcut. A fully documented
examination, assessment and management plan is vital in order to
ensure the patient is properly managed, and supports a
patient-centred system. If the basics are attended to, the
complaints and personal suffering I see will be reduced.
Anthony Hill
Health and Disability Commissioner
NZ Doctor, 9 March 2011
[1] For example, acute hospital
discharges exceed 370,000 per annum; primary care interactions
exceed 15 million consultations per annum. Source: Ministry of
Health.
[2] Opinion 08HDC06359.
[3] Opinion 10HDC00253