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    Issue 16

  • Small but significant

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    Clinical decisions under pressure

     
    Dr Andrew Broad

    Dr Andrew Broad

    MBChB

    Senior Medical Adviser

    Avant
     
    Clinical decisions main image

    It’s sometimes difficult to keep a clear head when facing urgent medical situations and pressure from family members. These situations can lead you to ignore your gut instincts and cloud clinical decisions, but how you manage them can make all the difference.

    Glue in child’s eye

    A GP registrar found himself in a pressured situation when a mother made a last-minute appointment for treatment of a laceration near her toddler’s eyebrow. The child was a new patient and the doctor’s last appointment at the end of a long day*.

    The child’s mother was understandably frantic and urged the doctor to use glue to seal the wound. In hindsight, the trainee said he would have used Steri-Strips™, but at the time he yielded to the mother’s demands.

    He applied GluStitch® to the cut in small drops and spread it over the wound. Unfortunately, a small amount trickled onto the child’s eyelid and dried. As a result, the eyelid on the medial side became stuck together and would not fully open.

    The mother panicked and the doctor immediately flushed out the child’s eye with water and sent him to the Emergency Department (ED). When the ED doctor examined his eye, it was approximately 60% open. Fortunately, a few days later, he was able to fully open his eye and there was no corneal damage.

    Following the incident, the doctor called the child’s mother to check there were no ongoing problems, and the child made a full recovery.

    Legal action avoided

    The doctor contacted Avant to notify the incident and seek advice. He was provided peer support by one of our medical advisers who reassured him that problems with liquid adhesives can occur. The trainee was reminded to take stock if necessary, during urgent situations, and to resist pressure from patients or family members to treat if their opinion differs.

    He was advised to document the incident in the child’s medical record and that the child was sent to the ED. The medical adviser also encouraged him to say sorry to the child’s mother for any harm and stress caused, in line with the open disclosure process.

    The doctor empathised with the stress and worry the child’s mother had gone through, and said he was sorry the incident had occurred. Ultimately, she was satisfied with the course of action taken and her child’s recovery.

    Demonstrating empathy

    In cases like this, an apology can help diffuse the situation because it acknowledges what the patient or their family has suffered and validates their experience. It can also often minimise the chance of a complaint or legal action being brought against a doctor. An apology is not about blame or liability, but about expressing empathy with the patient or their family for the events that occurred. Saying, “I’m sorry you had this experience,” in a genuine manner is often appropriate.

    Key lessons

    • Take stock before making any important clinical decisions. Being pressured by a patient into providing treatment you believe is inappropriate, is generally not accepted as a defence if a complaint or claim is made.
    • Document any adverse event in the patient’s medical records and any further treatment.
    • Follow the open disclosure process. Where appropriate, say you are sorry for what has happened. This acknowledges the harm the patient or family has experienced and can preserve the doctor-patient relationship and prevent the incident from escalating into a complaint or claim.
     

    What are doctors-in-training calling about?

    As trainees, many new situations will arise on the job. That’s why members have access to expert advice from our team of doctors, solicitors and case managers.

    In the financial year 2019-20, our Medico-legal Advisory Service received almost 3,500 calls from trainees – a 14% increase compared to the previous financial year. The most common reason for trainees’ calls were questions about the medico-legal aspects of clinical treatment, including procedural complications or errors, and medication issues, among others.

    clinical decisions graph

    Clinical treatment

    Many trainees have found it helpful to have an independent doctor to offer another perspective. Trainees who called about procedural complications or errors usually wanted advice on what steps they should take following an adverse event. In some cases, the trainee had performed the procedure, and in others they were part of a treating team. We also provided advice to trainees where a formal complaint about the complication or error had been made and/or an investigation was being undertaken.

    Medication queries often revolved around prescribing, particularly drugs of dependence. Other common questions included what to do when the wrong medication or dose was administered, a vaccination was given to a child at the wrong age or an adverse reaction to a medication had occurred.

    Other clinical treatment issues included how to manage non-compliant or non-contactable patients who needed treatment or follow-up, and responding to investigations into treatment provided following a patient’s death. Another query was how to respond to patients requesting inappropriate medical certificates, including COVID-19 related medical clearance or leave certificates.

    Advice on many issues

    Trainees also frequently called us for medico-legal advice on employment issues in relation to contracts or pay, workplace bullying or harassment and complaints made against them by other employees.

    There is a wide range of issues that can arise in medicine, as the pie chart shows. Getting the best outcome when these arise is more likely when you have discussed the situation with someone who can offer sound advice. Don’t hesitate to contact us.

    Useful resources

    Managing adverse clinical events
    Open disclosure: how to say sorry
    Visit the Avant Learning Centre

    *This is a scenario based on a compilation of member calls to our Medico-legal Advisory Service.

    Medico

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