Delayed diagnosis — how to minimise your risk of a claim
‘Delayed’ diagnosis is one of the most common reasons for a complaint or claim for clinical negligence, but good risk management systems can help general practice nurses reduce their risk
Delayed diagnoses contribute to two thirds of settled claims for clinical negligence in primary care, of which one third relate to delay in diagnosis of cancer, with breast, bowel and skin cancers most common.1 These delays can unfortunately have traumatic consequences for the patient, their relatives and the general practice team.
As many cases of delayed diagnosis involve both doctors and nurses, it is important that nurses are aware of potential adverse patient outcomes and possible subsequent implications. This article will discuss how good risk management systems can help prevent delayed diagnosis, how to recognise when a delay has occurred and how to respond to minimise any potential negative outcomes for the patient.
WHAT DOES ‘DELAY IN DIAGNOSIS’ ACTUALLY MEAN?
There is no definitive definition for ‘delayed diagnosis’. The term is generally used within healthcare to refer to situations where the diagnosis of a patient’s condition occurs later than would have been expected, resulting in a delay in the patient accessing further assessment or treatment.
A delay in diagnosis can occur due to several factors, including:
- Patient delay – the patient may not think their symptoms require attention, and may delay seeking medical advice.
- Healthcare professional delay – this can be at any stage, from the healthcare professional’s first contact with the patient, to the initial assessment of the patient, through to further investigation of symptoms. Additional contributory factors can include inadequate assessment of the patient’s presenting condition, insufficient monitoring of their condition and/or a failure or delay in referring them to a GP/specialist.
- System delay – this may involve delays when accessing diagnostics, errors with the laboratory services, administrative problems, cancellation of procedures, and/or issues relating to the availability of staff and resources (such as medical equipment).
Nurse claims relating to delayed diagnosis
The role of nurses working within general practice is ever-changing, with an expectation that they take on additional responsibilities and increased autonomy. Practice nurses and nurse practitioners, many of whom are nurse prescribers, may find themselves involved in a range of functions including managing chronic diseases, telephone triage, minor illness, family planning and childhood and travel immunisations.
A Medical Protection study of general practice claims opened over the four year period from 2007 – 2011, where practice nurses/nurse practitioners were involved in the care of patients, identified that delayed diagnosis was the most common issue, in 33% of cases.2 Many of these claims related to nurses failing to refer the patient, either to a medical colleague or a specialist healthcare professional.
PROFESSIONAL RESPONSIBILITIES
It is essential that nurses are trained and competent to undertake the roles required of them. The NMC states in The Code: Professional standards of practice and behaviour for nurses and midwives (March 2015) that nurses must:3
- Make sure that any information or advice given is evidence-based (including information relating to using any healthcare products or services),
- Maintain the knowledge and skills needed for safe and effective practice,
- Ask for help from a suitably qualified and experienced healthcare professional to carry out any action or procedure that is beyond the nurse’s limits of competence, and
- Complete the necessary training before carrying out a new role.
With this in mind, nurses need to be aware that they have a professional responsibility to ensure that they make a timely and appropriate referral to another practitioner when it is in the best interests of the individual requiring any action, care or treatment. It is important to note that according to the General Medical Council (GMC), GPs also have a professional responsibility to ensure that when delegating to a member of the healthcare team, that person has the ‘knowledge, skills and experience to provide the relevant care or treatment; or that the person will be adequately supervised.’4
THE IMPORTANCE OF PROTOCOLS
In order to reduce the risk of delayed diagnosis, it is vital that nurses working in general practice have clinical protocols to follow. These help to define areas of responsibility, provide documentary evidence of the standard of care, help to safeguard nurses and contribute to good clinical governance.
All protocols should summarise the standards and processes that encourage consistent action in any given set of circumstances. Chronic disease management and triage protocols, for example, should outline all the circumstances where patients should be referred on from nurse-run clinics to either a GP colleague or to secondary care.
WHEN THINGS GO WRONG
On acknowledging that a delay in diagnosis has occurred, all healthcare professionals have an obligation under the Care Quality Commission’s (CQC) Fundamental Standards to report the event and ensure that appropriate investigation takes place.5 Learnings should then ensue and be shared with the practice team to prevent recurrence of a similar situation.
Duty of candour also applies to healthcare professionals, and requires general practices to act in an open and transparent way when providing care and treatment to patients. Guidance on the duty of candour was developed in collaboration with the NMC and the GMC, and sets out what is expected of every nurse, midwife and doctor in the UK when something goes wrong.6 This means that general practice teams must ensure they have a practice policy in place for reporting incidents involving delayed diagnoses.
CONCLUSION
The impact of a delay in diagnosis can have a profound effect on the patient, their family and healthcare professional. It is therefore essential that effective risk management strategies, such as robust and safe systems to ensure timely referrals and review, are in place to provide good quality of care and reduce harm to patients.
In addition, nurses undertaking extended roles in general practice must ensure not only that are they competent but also that they work within their own sphere of competence. Contemporaneous record keeping is also essential for continuity of care and to assist if professional care is challenged.
Finally, it is important for nurses to ensure that they have the appropriate level of indemnity. The NMC states: ‘By law, nurses and midwives must have in place an appropriate indemnity arrangement in order to practise and provide care. While the arrangement does not need to be individually held by the nurse or midwife, it is their responsibility to ensure that appropriate cover is in force.’7
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REFERENCES
1. Medical Protection. Learning from clinical claims. Medical Protection Society Casebook 2012;19(3):9
2. Medical Protection. Rising nurse claims. Medical Protection Society Practice Matters (2013), http://www.medicalprotection.org/uk/practice-matters-issue-1/rising-nurse-claims
3. The Nursing and Midwifery Council. The Code: Professional standards of practice and behaviour for nurses and midwives, 2015.
4. General Medical Council. Good Medical Practice, Domain 3 Communication, partnership and teamwork, 2013
http://www.gmc-uk.org/guidance/ethical_guidance/21187.asp
5. Care Quality Commission. Regulations for Service Providers and Managers, 2015. http://www.cqc.org.uk/content/regulations-service-providers-and-managers
6. Nursing and Midwifery Council, General Medical Council. Duty of Candour, 2015.
7. Nursing and Midwifery Council. Professional indemnity arrangements, 2014.
https://www.nmc.org.uk/globalassets/sitedocuments/registration/pii/pii-final-guidance.pdf
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