Complaints, claims, 'negligence' and the practice nurse

As the role of the general practice nurse expands and nurses take on increasingly complex caseloads and more responsibility, inevitably the number of complaints and claims against us is also increasing. But how can we avoid allegations of negligence?

We live in a climate of increasing medicolegal claims against healthcare professionals. The NHS paid out more than £1 billion in settlements relating to the year 2014–15 and this is expected to rise substantially for 2015–16.¹ Potential contributors to this increase include:

• Increased numbers of patients being treated
• Increased complexity of cases
• The rising annual costs of care for those with high value claims
• A positive reporting culture
• Increased patient expectations

The rate of complaints against nurses and nurse practitioners is increasing at a steeper rate than that for doctors. During 2015, there were 25 new clinical negligence claims brought against MDU nurse practitioner members, compared to just two 10 years earlier.² Complaints notified to the MDU by nurse practitioners rose from four 10 years ago, to over forty last year. This is likely in part to be due to the expansion in practice nurse roles, in particular taking on roles such as assessing and diagnosing patients, prescribing medicines and running minor injury clinics. The most common areas of clinical complaint against practice nurses are prescribing errors, errors in diagnosis and failure to refer.

Nobody goes into a health service career planning to provide poor or half-hearted care. Nobody wants to be the human at the centre of a ‘human error.’ We do our best to avoid such unhappy outcomes. So how and why do these things happen? In this article we discuss the areas where complaints arise, in order to understand not only the pitfalls but also things that make our teams strong and which protect us individually from facing any complaint.

AREAS OF COMPLAINT

A UK paper published in 2014 examined the main areas of complaints in over 88,000 cases of complaints about health care.³ The authors considered that these might be summarised in three broad areas:

• Clinical – pertaining to poor quality care and safety incidents, including prescribing errors, failures in diagnosis, failures in the delivery of care
• Management – pertaining to problems in waiting times and access to care, and in institutional management (e.g. cleanliness)
• Relationships – pertaining to interactions and experiences of healthcare professionals. Most referred to communication issues, failure in perception of humane or caring attitude, and failure to fulfil basic patient rights.

The first and the last apply particularly to individuals, while the middle category relates perhaps more to the team and is not the specific focus of this article.

PRESCRIBING ERRORS

These comprise 10% of the nursing errors seen by the MDU. Prescribing errors may be broadly considered as

• Wrong drug
• Wrong dose
• Wrong route of administration
• Failure to explain risks/ side effects

They are likely to arise from a failure of concentration and of checking processes, or from a lack of knowledge. All may be contributed to by practitioner factors such as tiredness, illness, time pressure, pressure to exceed your area of competence or confidence, and distraction due to work or external factors.

The MDU advises: ‘Ensure you are aware of and follow local and national guidelines and practice policies and procedures. If unsure, seek advice from your colleagues or refer for further investigation or treatment.’

This is of course unarguable. On top of this we would add that your organisation needs to:

1. Use clear and meticulous protocols around the storage, prescribing and administration of drugs.

a. Safety checks such as a second individual can seem like time-consuming corners which may be easy to cut, but having a second person check your drug before you give it may save you from errors.

b. This is particularly important where the drug (and this applies to most drugs) might have serious consequences.

c. You may believe that the drug you are giving has no potentially serious consequences – but of course if you have picked up the wrong drug from the drugs fridge that guarantee falls away.

d. Consider what drugs you have which begin with the word ‘depo’.

e. Consider the possibility that whoever put the vaccines away may have inadvertently mixed child and adult doses.

f. Consider the fact that once you have given the drug the deed is done.

2. Never prescribe a drug whose effects and risks or side-effects you are unable to explain to the patient. An exception should be if you are under the direct direction of someone who does know and has taken responsibility for the situation – but in that case why are they not prescribing? If you prescribe you are taking on responsibility.

3. Always check the dose. Use the BNF. Make sure you have a copy (or online access) in your room.

4. Make sure that you have clear verbal consent for the administration of medicines and vaccines

5. Always ask yourself if the patient or carer has understood what you are giving them. If you’re not sure that they understand, ask them to explain it back to you.

6. Be fully familiar with your equipment. New devices for the delivery of depot drug systems are frequently introduced. Be sure you know how to use them.

7. Use (and understand) the computer system you are using to prescribe. Read any warnings which come up when you prescribe. Many practice software programmes have the standard dose of prescriptions already preloaded. This is helpful as it means that if you are changing the dose you should ask yourself why. But you should also always ask yourself whether the patient you are treating may be an exception to the stated dose. It is less common to need to increase a drug from the ‘standard’ dose than to need to decrease it. Should you decrease it? Is the patient a child, or an elderly person with renal impairment? Try to avoid handwriting prescriptions.

8. If you have never prescribed a drug before, ask yourself if you should be prescribing it at all.

9. Don’t make assumptions about what the patient knows.

ERRORS IN DIAGNOSIS

These may relate to

• Failure to ask the right questions
• Failure to examine
• Failure to consider the diagnosis
• Failure to refer/refer urgently

Errors in diagnosing serious conditions are the fear of every practitioner.

The MDU advises you to refer to a medical colleague for a second opinion if you are unclear. However, the problem is often knowing that you are, in fact, not as certain as you need to be. The best way to limit your risk is to be systematic, careful and up to date:

• Listen to the patient
• Ask them what they are worried about
• Take time and care in your history and examination
• Keep your clinical knowledge up to date
• Ask yourself what sinister or serious conditions could share this presentation
• Be aware of red flags and worrying conditions
• Follow current guidance on red flag referrals
• Seek advice when outside your comfort zone – recognise your limitations
• Seek advice when unsure
• Use clinical colleagues to share uncertainties. Be ready to call the patient back.

You may find the recent Practice Nurse article on Recognising Red Flags helpful for reflection (January 2016).

FAILURES IN THE DELIVERY OF CARE

This includes difficulties in communication (discussed below) and problems which arise when carrying out procedures, e.g. ear irrigation, dressing changes, cervical screening.

Complaints are less likely to arise if you

• Are fully familiar with the equipment you are using and well trained in its use.
• Avoid rushing – don’t be pressured into squeezing in an extra patient unless you can give them the necessary time and attention.
• Explain fully to the patient what you plan to do, how you plan to do it, and what they should expect during and after the procedure. You should also explain any associated risks.
• If prescribing and fitting intrauterine devices, as many nurses now do, ensure you are fully trained and compliant the recommended protocols. Understand and be familiar with the devices themselves and with the process and associated risks. Regularly audit your activity.
• Avoid distractions – keep your focus and attention entirely on the patient. Don’t allow interruptions unless in cases of genuine emergency. Don’t leave your phone on. Don’t try to do a job alone if you would normally need two pairs of hands.
• Don’t take on more than you feel competent to do.

DIFFICULTIES IN INTERACTIONS WITH PATIENTS

These generally relate to

• Communication difficulties
• Attitude and manner (which encompasses misunderstanding and miscommunication)
• Issues around confidentiality

You are unlikely to have become a practice nurse if you are not a good communicator with good patient care at heart. Sometimes, though, it can be easy to assume that patients know and understand more than they do – and we can all have bad days when we are tired or distracted.

The MDU says: ‘Always take care to explain what you are doing and why, and check the patient has understood. Take particular care when providing safety netting advice such as under what circumstances and time frame the patient should seek further medical care.’

To this we would add:

• Make sure that the patient understands and has taken in what you have said. Patients are frequently confused by a mass of information that comes at them at once, and indeed if they are tired and anxious they may not take in anything you say. Check their understanding. If necessary give instructions in writing.
• Show your compassion by being interested in them and interested in solving their problem.
• Recognise limitations in yourself if you are tired and having a bad day. This happens, but we must not let it impact on patient care.
• Make sure that you have informed consent for examination and treatment – and consider whether you need to offer a chaperone when examining patients of either sex. The defence organisations advise that we always offer chaperones when examining patients, but those of us who work in primary care are aware that this isn’t always practical. Over time we tend to develop a sense of when a chaperone may be needed – but it is entirely possible that this sense isn’t well-honed enough. Consider chaperones particularly where you think misunderstandings might arise e.g. if the patient is psychologically unwell, inexperienced in accessing health care, or does not speak English fluently, or if the problem is sexual or intimate.
• Respect confidentiality. Read the Practice Nurse articles on Confidentiality in the NHS Part 1 and Part 2 (October and November 2013, respectively). The MDU says: ‘Confidentiality is easily breached inadvertently. Do not discuss patients where you might be overheard, or leave written records where they might be seen. Do not assume that a competent child or adult would be happy to share information with a close family member or spouse. Avoid leaving messages on answer machines or voicemail unless you have specific consent from the patient to do so. Do not share information about patients on social media, even if the details seem to be unidentifiable and take special care if communicating with patients by email, ensuring you follow your practice policy.’

RECOGNISING ISSUES IN OURSELVES

Nothing in this article is likely to surprise you. When we read about what generates complaints, and the ways in which we can strengthen our practice and our systems to avoid them, we may feel that this all seems very obvious. So why do things go wrong? Why does our attention and care, so practised and trained and repeatedly employed, sometimes fail our patients?

Sometimes the patient has something so terrible and so rare that we simply fail to spot it because nobody could have spotted it. This is the missed diagnosis we all fear – but it is the one we are least likely to encounter. In truth most complaints arise from small and simple misjudgements on our part.

It is important to reflect on factors in ourselves which may contribute to this. These include:

• Tiredness
• Time and pressure (patient numbers, patient expectations, short-staffing)
• Lack of protected time – for professional development, to reflect
• Distraction – internal and external, professional and personal
• Fear of revealing lack of knowledge leading to working outside our competence
• Cutting corners
• Burnout
• Illness, psychological or physical
• Drug and alcohol misuse

We need to look after ourselves in order to look after our patients. Are you proofed against these risk factors? The things that proof us include:

• Good teams who support one another
• Opportunities to offload and manage work-related stress
• Avoidance of excessive working hours
• Regular appraisals in which concerns can be freely aired
• An open work culture that allows concerns to be raised
• Breaks and holidays
• Good programme of professional development and knowledge updating
• Remaining well hydrated when at work
• Regular and sufficient sleep
• Awareness of your own health – if you are unwell you should be off work if
  • Your illness affects your ability to work
  • Your work worsens your illness
• Taking care with crash diets while working – they might make you irritable and tired and affect your concentration
• Consider and be aware of the symptoms of burnout

RECORD KEEPING

It’s essential to keep full and accurate records of all consultations, including those on the telephone. We should make those records at the time of the consultation and we should make them legible and accurate. Records are extremely important when responding to a claim. Where you are ruling out sinister conditions which you have considered – such as meningitis in a person with a headache – record your negative findings too.

As an aside keeping a good record is one of the secondary reasons why you should take special care – and if possible avoid – quick ‘consultations in the corridor’ or advice to friends or family whose notes you cannot access. One of the many pitfalls in such encounters is the difficulty in keeping a proper record.

WHAT TO DO IF THINGS GO WRONG

If the worst happens and you feel you may have done something that may generate a complaint, then the MDU advises that you need to do several things:

• Be open and honest
• Apologise where appropriate
• Explain what has happened, and what can be done to rectify things
• Document what has happened and your discussion with the patient carefully.
• Log the incident in accordance with your practice policy, which should comply with the statutory duty of candour.
• Consider whether to submit a patient safety incident online to the National Reporting and Learning System.

To this list we would add:

• Seek help and support from within your organisation. All complaints feel huge and serious when they are received. They hit at the very heart of what we do and are committed to. They threaten our reputation and possibly our career and livelihood.
• Seek external help where needed, particularly if the complaint may go beyond your practice in-house complaints procedure. Consider contacting your nursing union.
• Find out who your defence organisation is. Most practices arrange cover for their nurses and nurse practitioners through their own defence organisations, so find out who this is and how you should contact them, if needed. Defence organisations have people on call to advice those who face a complains or potential complaint. They can help you with your response and advise you on what to do next.

SUMMARY

We live and work in a culture that is open to and encouraging of complaints. We should not be afraid of this – it is a good thing that patients are empowered enough to seek explanation and redress if things go wrong. Most of us wouldn’t want to live and work in a society where this wasn’t so.

However, none of us wants to find ourselves the focus of a serious complaint. We can reduce the chances of this happening considerably through professionalism, teamwork, self awareness and good communication.

REFERENCES

1. NHS Litigation Authority Annual Review 2014/15: Report and Accounts. http://www.nhsla.com/AboutUs/Documents/NHS%20LA%20Annual%20Report%20and%20Accounts%202014-15.pdf

2. Medical Defence Union. Nurse practitioners at increased risk of complaints and claims, warns MDU. Press release, 16 February 2016. http://www.themdu.com/press-centre

3. Tom W Reader, Alex Gillespie, Jane Roberts. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf doi:10.1136/bmjqs-2013-002437 http://qualitysafety.bmj.com/content/early/2014/05/29/bmjqs-2013-002437.full