Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3302_Библиотеки_им_академика_М_И_Перельмана
.pdf
190 Specialities
Harm includes further damage sustained unintentionally while preparing the
patient, dropping the patient, failure to provide the best care post-operation, fail-
ure to adhere to local protocols, failure to refer, presence of chronic pain aer
surgery and choosing the wrong implant size, and these are all examples of suc-
cessful claims against orthopaedic surgeons.
Measures to avoid complaints, harm and litigation in orthopaedics are similar
to those for other specialities, such as:
●
Use methodical history taking, examination and investigation to arrive at a
diagnosis. e full range of diagnoses, including all dierential diagnoses,
must be considered and documented. Following local or published guide-
lines in treating dicult cases ensures the doctor is safe, regardless of the
outcome. Most courts will ask for the opinion of an expert, who in turn will
judge the action of the defendant based on standard practice guidelines.
Usually, errors do not adversely aect the outcome.
For example, Gidwani et al. described two cases admitted with post-
trauma fractures. One had a signicant delay in diagnosis and treatment,
while the other had a lack of informed consent. When brought before the
court, the consensus expert opinion was that the outcomes of both cases
were not aected by the breaches of duty. Hence, despite the presence of
breach of duty, the cases were dropped.
16
●
Always record the ndings in writing and make sure they are clear and leg-
ible. Documentation is what saves or condemns the surgeon. Courts place
much emphasis on contemporaneous notes.
●
Avoid long delays in operating on fractures and dislocations unless clinically
justiable. Patients want their remedial surgery as quickly as possible, and
they may blame any poor outcome on the delay to surgery.
●
In cases of chronic pain or disability, the patient should receive appropriate
physiotherapy and other non-surgical management before the operation.
Document that alternative treatments were discussed.
●
In case of complicated surgeries, a consultant should at least be present, if
not performing the surgery themselves.
●
If something goes wrong, inform the patient immediately aer surgery in a
calm manner. e duty of candour must be fullled, and the patient must be
fully informed of the complication and the possible detrimental sequelae.
●
Mistakes such as skin burns, tourniquet injuries and medication errors can
be avoided with appropriate care. Such errors are usually indefensible, and
the entire team is responsible for ensuring they do not occur.
https://t.me/med1917
Radiology 191
●
Seek a second opinion if the patient’s expectations or demands are dicult to
meet and you are not sure of the successful outcome. It is better to refer the
patient to a colleague who did not have surgery rather than one who already had
an unsuccessful or unnecessary one. Unfortunately, the ‘I told you so’ defence
may not be successful, as we are duty-bound not to inict unnecessary harm.
●
Good post-operative care is vital in reducing litigation. Good liaison with
the recovery sta, ward sta, on-call team and anaesthetist is important.
Ensure that the patient is getting their antibiotics, venous thromboembolism
prophylaxis, physiotherapy, regular dressings and appropriate uids.
●
Arthroplasty surgeons see a high proportion of claims because of failure to
diagnose neurological decits and infection.
17,
18
●
Wrong-site surgery still occurs. It is entirely avoidable, and pathways should
be in place to make sure it never happens.
●
It is important that all imaging is available for clinic attendances or operative
procedures.
e consultant orthopaedic surgeon is the team leader as captain of the ship and
is held accountable for clinical errors. Skevington et al. described the environ-
mental, systematic, psychological and organisational factors that contribute to
consultant surgeons making avoidable errors.
17
Such factors must be recognised
and reected upon to avoid errors in the future.
Check-listing the surgical procedure in the perioperative period is essential
and requires a team-based approach. It should not be a simple tick-box exercise.
RADIOLOGY
Radiology claims are reasonably low, considering how many cases are handled
each day. However, when considered as part of the overall burden on health care
resources, particularly in terms of litigation costs and clinical time, they remain
an important consideration. Radiological reports are considered denite informa-
tion regarding the patient and are rarely challenged. As clinicians across the UK
depend on radiological ndings for the diagnosis and treatment plan, misdiagno-
sis can have grave consequences for patients and for the people who care for them.
According to Hulson, the most common claims between 1995 and 2014 were
based on missed diagnoses of tumours.
19
e reasons were mostly simple human
error: missing or misinterpreting a tumour, fracture or other abnormality that
should have been detected. Other causes included delays in reporting, which should
be done within 24 hours, poor communication with referrers and lack of follow-up
aer an inconclusive scan or treatment plan that deviates from standard practice.
Radiologists are required to interpret thousands of images every day under
pressure and tight deadlines. ey are also expected to work in high-tech
https://t.me/med1917
192 Specialities
environments that increasingly use automated processes and algorithms to aid
with diagnosis. Although the potential benets oered by articial intelligence
are signicant, there is still no substitute for experience, expertise and common
sense when it comes to interpreting X-rays and scans.
Interventional radiology may seem like a high-risk area; however, claims are
surprisingly low. When claims do occur, they typically involve post-procedure
bleeding, substandard technique (almost 50%) and failure to obtain consent.
Compared to this, non-clinical departmental injuries are higher in number
and much more likely to result in a claim. ese are not related to the treatment
of radiology at all but rather adverse accidents, such as falls. Examples of in-
department injuries include having a patient in the MRI suite even though they
have a permanent cardiac pacemaker, placing a heavy oxygen cylinder close to
the private parts of a male patient, resulting in injury, and a patient sent to the
MRI suite without removing their hearing aids and metal body accessories.
19
According to Craciun et al., a few preventive measures can signicantly reduce
the risk in the radiology department.
20
ey recommended the following:
●
Quality assessing and enforcing systems, such as quality maps, measurable
metrics and performance indicators for audit and accreditation programmes,
should be in place. A benecial practice is to follow the ‘as low as reasonably
practicable’ routine, which entails assessing risks and comparing them to
the resources needed to address them. e idea is that residual risk can be
reduced as much as reasonably possible. Another way of saying this is that if
there is a potential risk in the department, all attempts within reason should
be made to avoid it.
●
A clear disclosure aer any radiological errors can help to avoid most radio-
logical claims. e key is to catch the error as quickly as possible and to
report it to the associate doctor or surgeon so that any potential delays can
be mitigated.
●
Being available for phone calls from clinicians and actively calling clinicians
when there are doubts or concerns about an image can help both avoid litiga-
tion that stems from missing critical ndings on an image.
●
Being up to date in the latest technology and techniques is important. Failure
to refer to regional centres if they have a more appropriate imaging device
can result in a claim.
●
Proper written information should be given in the form of leaets and sheets.
Also, all the information given to the patient and communications with cli-
nicians and patients must be documented in the medical record to ensure the
doctor’s version of events is on record in case there is a later dispute about
what information was or was not provided.
https://t.me/med1917
Radiology 193
●
Written consent should be required for unusual patients. is is especially
important for patients who have a history of mental illness or substance
abuse. If the patient has any history of violent or irrational behaviour, they
should be required to sign paperwork that states they are aware of the risks
of their treatment and agree to the terms.
Radiology is particularly vulnerable to framing bias in that the clinician can
focus on the presumptive diagnosis and on that area on the imaging while miss-
ing some other lesion. A classical example is missing an anterior brain tumour
when imaging is requested querying a cerebellar or brain stem issue.
REFERENCES
1. Oglesby, F. C., Ray, A. G., Shurlock, T., Mitra, T., & Cook, T. M. (2022).
Litigation related to anaesthesia: Analysis of claims against the NHS in
England 2008–2018 and comparison against previous claim patterns.
Anaesthesia, 77(5), 527–537. doi: 10.1111/anae.15685
2. How common is anaesthetic negligence? NHS resolution and the asso-
ciation of Anaesthetists’ review of claims related to anaesthesia (2022,
March 9) Boyes Turner. Retrieved from https://www .boyesturnerclaims
.com /news /how -common -anaesthetic -negligence -nhs -resolution -and
-association -anaesthetists ’ -review -claims.
3. McCombe, K., & Bogod, D. G. (2018). Learning from the law: A review
of 21 years of litigation for pain during caesarean section. Anaesthesia,
73(2), 223–230.
4. Singh, M., Liao, P., Kobah, S., Wijeysundera, D., Shapiro, C., & Chung,
F. (2013). Proportion of surgical patients with undiagnosed obstructive
sleep apnoea. British Journal of Anaesthesia, 110(4), 629–636. https://doi
.org /10 .1093 /bja /aes465.
5. Pearson, A., & Cook, T. (2017). Litigation and complaints associated with
day-case anaesthesia. BJA Education, 17(9), 289–294.
6. Jena, A. B., Seabury, S., Lakdawalla, D., & Chandra, A. (2011). Malpractice
risk according to physician specialty. New England Journal of Medicine,
365(7), 629–636.
7. Wong, K. E., Parikh, P. D., Miller, K. C., & Zonfrillo, M. R. (2021).
Emergency department and urgent care medical malpractice claims
2001–15. Western Journal of Emergency Medicine, 22(2), 333.
8. Selbst, S. M., Friedman, M. J., & Singh, S. B. (2005). Epidemiology and
etiology of malpractice lawsuits involving children in US emergency
departments and urgent care centers. Pediatric Emergency Care, 21(3),
165 –169.
9. Nowak, R., Farrar, J. R., Brenner, B. E., Lewis, L., Silverman, R. A.,
Emerman, C., ... Wood, J. (2013). Customizing anaphylaxis guidelines for
emergency medicine. Journal of Emergency Medicine, 45(2), 299–306.
10. Neighbour, R. (1987). The inner consultation. Radcliffe Publishing Ltd.
https://t.me/med1917
194 Specialities
11. NHS Resolution annual reports and accounts 2019/20. https://resolution
.nhs .uk /wp -content /uploads /2020 /07 /NHS -Resolution -2019 _20 -Annual
-report -and -accounts -WEB .pdf
12. Cohen, W. R., & Schifrin, B. S. (2007). Medical negligence lawsuits relat-
ing to labor and delivery. Clinics in Perinatology, 34(2), 345–360.
13. Bolcato, M., Fassina, G., Borgato, I., Sanavio, M., Rodriguez, D., & Aprile,
A. (2020). Obstetrics-gynecology litigation 17 years of medico-legal
experience in professional liability watchdog. Acta Medica Mediterranea,
36(5), 3161–3166.
14. Hüner, B., Derksen, C., Schmiedhofer, M., Lippke, S., Janni, W., & Scholz,
C. (2022). Preventable adverse events in obstetrics—systemic assess-
ment of their incidence and linked risk factors. Healthcare, 10(1), 97.
15. Mouton, J., Gauthé, R., Ould-Slimane, M., Bertiaux, S., Putman, S., &
Dujardin, F. (2018). Litigation in orthopedic surgery: What can we do to
prevent it? Systematic analysis of 126 legal actions involving four uni-
versity hospitals in France. Orthopaedics & Traumatology: Surgery &
Research, 104, 5–9.
16. Gidwani, S., Zaidi, S. M. R., & Bircher, M. D. (2009). Medical negligence
in orthopaedic surgery: A review of 130 consecutive medical negli-
gence reports. Journal of Bone and Joint Surgery, British Volume, 91(2),
151–156.
17. Skevington, S. M., Langdon, J. E., & Giddins, G. (2012) ‘Skating on thin
ice?’ Consultant surgeon’s contemporary experience of adverse surgical
events. Psychology, Health & Medicine, 17, 1–16.
18. Bhutta, M. A., Arshad, M. S., Hassan, S., & Henderson, J. J. (2011). Trends
in joint arthroplasty litigation over five years: The British experience.
Annals of the Royal College of Surgeons of England, 93(6), 460–464.
19. Hulson, O. (2018). Litigation claims in relation to radiology: What can we
learn?. Clinical Radiology, 73(10), 893–901.
20. Craciun, H., Mankad, K., & Lynch, J. (2015). Risk management in radiology
departments. World Journal of Radiology, 7(6), 134.
https://t.me/med1917
SECTION 9
Learning and avoiding
errors
https://t.me/med1917
https://t.me/med1917
197
34
How we learn
As professionals in a eld that is ever-changing, health care professionals are
expected to keep their knowledge up to date and skills sharp. Moreover, while
the curriculum of medical schools and nursing schools tries to be thorough, all
health care professionals have to relearn and modify much of it when they start
practising in the eld and refresh their knowledge on a periodic basis as science
and technology improve.
Junior doctors, especially, are oen expected to memorise an immense amount
of data and procedures in very little time as they train in every branch of health
care. Oen, they are thrown in the deep end and expected to know everything
in a short period.
Guidelines change and evolve, and if we do not adhere to them, we can be
criticised. If we allow our knowledge to become out of date, we can fall afoul of a
clinical error that may be indefensible.
e GMC guidance on keeping up to date includes:
●
Responsibility for identifying our needs and planning how to address them
●
A requirement to reect regularly on the standards of our medical practice
●
Remaining competent and up to date across the scope of our medical role
●
Maintenance and improvement of the standards of our practice and that of
the team in which we work
Every health professional needs to learn throughout their career, so it is impor-
tant to focus on how we learn and what learning techniques work for us. Care
professionals have limited time and thus need to maximise learning eciency.
According to Mayer, ‘Learning is the relatively permanent change in a person’s
knowledge or behaviour due to experience’.
1
According to Wade et al., learning,
or more precisely, memorising, is all about reciting what one has read or memo-
rised. ey support the 3R technique – read, recite, review – for optimal eective
learning, especially for students.
2
DOI: 10.1201/9781003179351-43
https://t.me/med1917
198 How we learn
THEORIES OF LEARNING AND HOW THEY APPLY TO
HEALTH CARE PROFESSIONALS
Learning theories are organised frameworks for understanding how individu-
als acquire and retain knowledge. ey provide explanations for how we learn,
including the thought processes that take place during learning events. ere are
a few theories on how professionals such as doctors and nurses learn at their job.
According to Taylor and Hamdy, like most other individuals, the general theories
of adult learning apply to health care professionals as well.
3
INSTRUMENTAL LEARNING THEORIES
●
Behavioural theories: People learn to change their behaviour following a
stimulus in the environment. is is the most basic theory of learning that
applies to the animal kingdom. For health care professionals, this theory
applies when taking exams, followed by positive reinforcement of the desired
results with grading systems.
4
In everyday hospital settings, this may trans-
late to patients getting well or the rapport and respect a professional builds
among their colleagues and seniors. e theory is applicable for continuous
professional development.
●
Cognitive learning theories: ese are based on perception and the process-
ing of information in the mind of the individual.
5
For health care profession-
als, this theory mostly applies to undergraduates. Cognitive learning applies
to doctors and nurses when they apply the theories they learned to come up
with new solutions or techniques to treat a patient.
●
Experiential learning: Experiential learning theory ‘focuses on developing
competences and practising skills in a specic context’.
6
Simply put, expe-
riential learning is the process of learning through experience. e most
widely used model of experiential learning is Kolb’s, who proposed that
one learns from concrete experiences, which are transformed into reective
observations and then into abstract concepts (or observations), which are
then used to create new experiences.
7
e importance of experiential learning in medicine is obvious. We learn
from our mistakes and successes, as well as from those of others. In the
practice of medicine, we oen rely on our own experience but have to be
aware that this may not be enough. We have to augment it with guidelines
and evidence-based protocols, both of which oen come from places and
times that may not be directly applicable to our situations. Nevertheless, it is
important to encourage and practise experimentation or doing. For exam-
ple, a nurse in training will remember the procedure to place an IV catheter
for longer and more accurately when they practise it rather than just read
aboutit.
https://t.me/med1917
Social theories of learning 199
HUMANISTIC THEORIES
Humanistic theories of learning are based on the premise that humans are active,
not passive, participants in their own learning.
8
ese theories are more individ-
ual centred. Although a doctor’s journey begins with mastering the theory and
practice of medicine, it continues with the development of their personal style as
a physician. e same applies to all avenues of health care. Self-actualisation is
attained through one’s own knowledge and skills and the need to improve as an
individual.
Knowles’ theory of andragogy, or adult learning, is based on the following
assumptions that t health care professionals perfectly: they are self-directed, are
problem centred, bring life experiences and knowledge to learning experiences,
are goal oriented and are relevance oriented.
9
As health care professionals, self-
improvement and self-directive methods of learning are apt when expected to
direct and take responsibility as a senior.
TRANSFORMATIVE LEARNING THEORY
Transformative learning theory is about critical reection on our beliefs and
thoughts. is theory is based on the form of learning that involves signicant
changes to the way that we perceive our world.
10
In medical education, this can be
practised when a critical or rare case is presented or through group discussions,
idea presentations, etc.
11
is is a good exercise for junior medical professionals,
as it teaches them to think elaborately and with an open mind.
According to this theory, people learn by experiencing a transformative crisis
that challenges their assumptions. When faced with such a crisis, we must be
able to confront these dilemmas. rough these methods, we can learn to let
go of our previous presumptions and open up to new medical procedures and
protocols. Specically, having regular discussions regarding new developments
teaches doctors not only about the medical inventions themselves but also how to
broaden our minds and learn to learn.
SOCIAL THEORIES OF LEARNING
e social theories focus on context and community. Social learning theory is
an approach to understanding the learning process. is theory, which draws
on ideas from social psychology and developmental psychology, focuses on the
importance of observing and modelling others’ actions, beliefs and behaviours.
12
According to this theory, people learn not just by doing but also by observing
others’ actions and attitudes and the outcomes of those actions.
For example, health care professionals oen perform procedures and duties
in a specic manner, mirroring what they observed their teachers doing during
training.
13
e theory is partly true in medicine. Physicians oen follow their mentors’
methods and techniques. However, as a medical professional is expected to work
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана