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his GP’s minor surgery clinic to have a mole removed from his upper arm. Histology received by the practice confirmed a malignant melanoma that required a wider margin of excision. The report was promptly actioned to indicate that the patient should be asked to return for an appointment. Unfortunately, the system then broke down and the report was filed, only to be revisited to the horror of all concerned two years later when the patient returned with an axilliary lump and metastatic disease.
RISK MANAGEMENT POINT
You are responsible for ensuring proper follow- up for the tests and investigations you are aware of. Consider whether the system you work in or are responsible for adequately supports you and your colleagues to do this.
Prescribing and medication errors The second most common area for settlement of claims in primary care is that of prescribing and medication
errors. Of the prescribing errors, the most frequent involved a contraindicated drug (most commonly antibiotics), followed by choosing the wrong drug (eg, unsuitable choice of antibiotic for wound infection) and selecting the incorrect dose of the correct drug (most commonly opiates).
Failure to assess adequately
This is of particular importance in the out-of-hours setting, where inadequate assessment led to the greatest number of indefensible cases. These cases tended to occur where there had been purely telephone contact and triage. A particular example involved a young male patient who called the out-of-hours service, reporting to the GP a short history of pain and swelling in the right testicle. The GP (GP1) took a history, which included the absence of trauma and a previous similar history, when the pain had resolved within a day. GP1 advised the patient to take pain relief, apply heat and see his own GP in the morning. Four hours later the patient rang again and spoke to another GP (GP2), reporting that he now felt feverish and that the pain continued. GP2 reiterated the earlier advice. On attending his own GP’s surgery the next morning, he was admitted as an emergency. As by then the testis was gangrenous, he underwent an orchidectomy. The case was settled against both doctors, following expert
opinion that concluded: “The history given by the claimant and recorded in the triage system on two occasions in the OOHs service is of acute testicular condition requiring prompt surgical review.”
RISK MANAGEMENT POINT
■ Based on the history taken, an acute surgical problem cannot reasonably be excluded. An urgent surgical review should have occurred.
■ Each GP is expected to ensure they take an adequate history and perform an appropriate examination where required.
Surgical technique The most common problems arising from minor surgical procedures carried out by GPs included burns from cryotherapy, and nerve damage following excisions of skin lesions.
RISK MANAGEMENT POINT
Ensure you follow the manufacturer’s instructions when using cryotherapy, particularly with reference to skin contact times.
What about the experiences of GPs working elsewhere in the world?
In Canada, for example, the three most commonly missed or delayed diagnosis cases involved cancer, fractures and diseases of the circulatory system (mainly myocardial infarction
ARTICLE
ASIA CASEBOOK | VOLUME 19 | ISSUE 3 | SEPTEMBER 2011
www.medicalprotection.org
© PCD
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