30 years of medical mistakes – what has changed?

1. 30 years of medical mistakes –what has changed? Miss J.E.Porter FRCS FCEM

2. 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

3. 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

4. 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

5. The Swiss Cheese Model

6. Clinical negligence claims by year

7. Clinical negligence claims by cost

8. 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

9. 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

10. 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

11. 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

12. 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

13. Changes in court procedures: • More doctors acting for complainants • Medical experts better trained • CPR • Earlier exchange of evidence • Fewer cases reaching court • Bolito

14. 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

15. 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

16. Nature of the mistakes • Administrative errors • Medication errors • Procedural / surgical errors • Diagnostic errors

17. High risk specialties

18. Reducing medical mistakes • Administrative: • Risk management • Medication errors • Risk management • Pharmacy supervision • Procedural / surgical errors • Human factors training • Patient safety education • Diagnostic errors • ??????

19. 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!

20. Diagnostic techniques • Pattern recognition • Patho- physiological reasoning • Probabilistic (Bayesian) reasoning

21. Diagnostic process • Hypothesis generation • Data collection • Data integration • Verification

22. Diagnostic process • Hypothesis generation • Recall bias • Data collection • Verification bias • Premature closure • Data integration • Over-interpretation • Conservatism • Probability estimation errors • Verification

23. Reasons for diagnostic error: student beliefs • Professional misconduct • Organisational / system problems • Communication problems • Information problems

24. 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

25. 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

26. 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

27. 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

28. 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?