medico-legal aspects of anaesthetic practice 10 november 2011 dr udvitha nandasoma medico-legal...
TRANSCRIPT
Medico-legal Aspects of Anaesthetic Practice
10 November 2011Dr Udvitha NandasomaMedico-Legal Adviser
© 2011 MDU Services Limited
Who decides a doctor’s accountability after a clinical
incident?
© 2011 MDU Services Limited
58%
3%
9%
5%
11%
2%4%
8%
Claims notifications over 10 yearsDental damage
Oral/airway damage
Awareness
Drug reaction
Death/Brain damage
Aspiration
Pressure/positioning
Needle misplacement
© 2011 MDU Services Limited
Anaesthetic claims (private practice)
Claims within the speciality are relatively uncommon
Members expect to be notified of one claim every 35 years, compared to:
1 in 15 yrs – ophthalmology1 in 8 yrs – orthopaedics
Not all settled as majority notified to MDU are successfully defended or discontinued by claimant
© 2011 MDU Services Limited
Recurring themes
10 yr period – 130 claims [settled, discontinued or active] Majority – Dental damage [>50% notifications] – average
compensation £1500 for those cases that settled (largest>£10,000)
Death or brain damage, anaesthetic awareness, needle misplacement [approx 10%] – average compensation £100,000 (largest >£2m)
Figures exclude legal costs For smaller payouts, legal costs can exceed award itself
© 2011 MDU Services Limited
Awareness and inadequate analgesia
‘Awareness’ = range of experiences [bad dreams, vague but painless recollections, paralysed but not anaesthetised]
Small number of notified claims/rare Minority settled Claims arise regardless of technique
– Balanced anaesthesia with relaxant & inhalational agent– Total iv anaesthesia
Misunderstanding/unrealistic expectations Notes recorded clearly = concerns easier to resolve
© 2011 MDU Services Limited
Complaints 2011
54 complaint files opened in first 10 months of 2011
Pain clinic 6ICU/ HDU 3Recognized complication 22Attitude 4Awareness/ Inadequacy 5Assault 1Other 8Preassessment 5
© 2011 MDU Services Limited
WRONG SITE SURGERY
MDU notified of 63 cases since 2000 4 Related to anaesthesia
© 2011 MDU Services Limited
How is this relevant to Preassessment?
Consent Communication
– With colleagues– Managing patient expectations
Continuity of care
© 2011 MDU Services Limited
Consent
Person conducting procedure is responsible for ensuring that the patient has been given enough time and information to make an informed decision, and has given their consent.
Seeking consent can be delegated to an appropriately qualified person.
GMC Consent: patients and doctors making decisions together 2009 Paragraphs 26 and 27
© 2011 MDU Services Limited
Scope of Consent
Do you anticipate that other interventions might be required
Does the consent process adequately reflect the range of practice the patient might experience
© 2011 MDU Services Limited
Communication with Colleagues
Is there understanding of the patient factors that might need further consideration– Anticoagulation– Medical –Comorbidity– Prescribed Medication
Do you have agreed ways of working where appropriate
© 2011 MDU Services Limited
Communication with patients
Managing patient expectations– Type of anesthesia– What sensations/ noises might they be aware of– Likely experience of post operative pain
© 2011 MDU Services Limited
Specific Issues
© 2011 MDU Services Limited
Dental Damage
Risk Management: Assess upper airway/dentition etc prior to anaesthetic Clear documentation especially of poor dentition Record warnings given to patient
© 2011 MDU Services Limited
Oral and airway damage
Soft tissue structures of– Oropharynx– Nasopharynx– trachea
3 cases notified in 10 year period involving a Laryngoscope/Laryngeal mask
Sore mouth/throat immediately post-op Recorded warnings may assist if claim brought at
a later date
© 2011 MDU Services Limited
Drug reactions and errors
this few claims from drug errors or adverse reactions
7 notifications (3 resulting in claim) in 10 year period
2 settled – drug administered to patient with allergy
IV drugs through misplaced cannula causing local damage to surrounding tissue
© 2011 MDU Services Limited
Death and brain damage
4 claims settled in 10 year period All GA where patient suffered cardiac arrest or
CVA Unique facts in each case Patients need to be offered relevant information
in order to provide informed consent GMC guidance – patients must be given
information re risks and benefits and have their questions answered fully (Consent 2008, para 9)
© 2011 MDU Services Limited
Aspiration
Very few claims Large award as patient needed life long care Presence of small bowel obstruction If specific steps are taken to minimise aspiration
this should be documented
© 2011 MDU Services Limited
Positioning and pressure injuries
Risks to patients sustaining pressure damage/nerve palsies
Small number of settled claims due to damage from application of prolonged pressure by a piece of equipment
Difficult to defend allegations of negligence successfully
Make a written record of all the steps taken to protect the patient from harm
Document any particular techniques employed
© 2011 MDU Services Limited
Needle misplacement
10 claims, 4 settled in 10 year period 3 settled – regional anaesthetic administered to
wrong side prior to limb surgery Modest compensation unless nerve injury Patient Safety Alert: WHO Surgical Safety
Checklist, NPSA, 26/1/2009 [npsa.nhs.uk] 4 claims re spinal and epidural alleged nerve
damage(1 successful, 3 discontinued)
Clear details re risks were given to patients
© 2011 MDU Services Limited
Learning lessons
Are there areas where you see your preassessment system not working as well as it should?
Adverse incidents do occur: recognise risks and reflect on ways to reduce the possibility of an error
Effective Adverse Incident Reporting Departmental Audit Identify ongoing systemic risks Develop risk management procedures Contact MDO for advice
© 2011 MDU Services Limited
Managing risk 1
Discussion prior to anaesthetic – Why treatment is necessary– Risks involved– alternatives
Record warnings given pre-op– Post op sore throat– Awareness during sedation
Discuss risks specific to that individual if appropriate
© 2011 MDU Services Limited
Managing risk 2
Develop a routine for pre & post-op assessments Check PMSHx, allergies, concurrent medications
before prescribing new drugs Document you have checked pressure points and
ensure those assisting are aware of risks Procedures in place to eliminate risk of ‘wrong
side’ errors – check records, confirm with patient If something goes wrong – full explanation,
apology [GMC guidance]
Any Questions?
MDU Services Limited (MDUSL) is authorised and regulated by the Financial Services Authority in respect of insurance mediation activities only. MDUSL is an agent for The Medical Defence Union Limited (the MDU).The MDU is not an insurance company. The benefits of membership of the MDU are all discretionary and are subject to the Memorandum and Articles of Association. MDU Services Limited is registered in England 3957086. Registered Office: 230 Blackfriars Road London SE1 8PJ . Copyright MDU Services Limited 2011.