A lifetime spent practising medicine is unlikely to be error free, but there are steps you can take to reduce risks and prevent clinical incidents. In this article we discuss six common risk areas for new doctors: Clinical records, Consent, Confidentiality, Communication, Competency and Careful prescribing.
1. Clinical Records
A good medical record summarises the key details of every patient contact and should enable the doctor to reconstruct a consultation without reference to memory. It should be clear, accurate, legible and, wherever possible, contemporaneous, allowing a colleague to carry on where you left off.
Good record-keeping is also essential in defending any potential complaints or claims that are brought against you. Imagine if you were unable to defend yourself because of a lack of notes.
A patient’s medical record should include:
• Discussions around consent, including chaperone arrangements.
• Relevant medical history.
• Details of the examination.
• Details of any investigations requested.
• Details of any treatment provided or advised.
• Clinical findings.
• Your professional opinion, for example a differential diagnosis.
• Information provided to the patient.
• Any decisions made by the patient.
• Follow up arrangements and referrals, including any safety netting advice given.
• Details of whether the consultation was face-to-face or remote, and the reason why.
Good record-keeping practices need to be supported by strong clerical processes and systems. Doctors can avoid clerical errors by:
• Reviewing all investigations, acting on the outcome and communicating results.
• Following up missed appointments.
• Taking care with prescription reviews and renewals.
• Filing, tracking and maintaining the security of medical records.
• Making and following up any referrals.
Survival Tips…
• All entries should be dated, timed and signed, or entered using your own specific log in password, if the entries are electronic.
• Any correction must be clearly shown as an alteration, complete with the date the amendment was made, your name and the reason for the addition. Never delete the original entry – just run a single line through it.
• Write assuming the patient may one day read the notes - only include information relevant to the health record.
2. Consent
Consent is founded on the principle of autonomy – it must be given freely by a competent patient, on a voluntary basis, after making an informed decision.
The Medical Council ethical guidance is helpful and provides guidance for doctors on the consent process, assessing capacity and the treatment of patients who lack capacity.
For consent to be legally valid, the patient must be:
• Capable of giving consent – They must understand what decision they need to make and why, be able to retain, use and weigh up all the relevant information, and have the capacity to communicate their decision, with assistance if necessary.
• Sufficiently informed to make a considered decision – They must be given an explanation of the investigation, diagnosis or treatment, an explanation of the probabilities of success, and the risk of failure or any harm associated with the different options for treatment, and no treatment.
• Giving consent voluntarily – They should also always be given sufficient time to ask questions and to make a decision. Consent is invalid if it is obtained under duress.
It is ultimately the responsibility of the doctor taking consent to assess the patient’s mental capacity. Unless there is reason to think otherwise, all adults are presumed to have the capacity to make decisions about their own health care.
Patients should not be assumed to lack capacity due to communication problems, their age, appearance or assumptions you make about their condition. Even if a patient does lack capacity, the onus is on you to include them as much as possible in decisions that affect their lives.
‘When patients lack capacity’
It is important that doctors take note of the Medical Council’s guidance as follows:
“If an adult patient lacks capacity to make a healthcare decision, you must take reasonable steps to find out if anyone else has the legal authority to make decisions on the patient’s behalf. If so, you should seek that person’s consent to the proposed treatment.”
“If there is no-one with legal authority to make decisions on the patient’s behalf, you will have to decide what is in the patient’s best interests. In doing so, you should consider:
• which treatment option would give the best clinical benefit to the patient;
• the patient’s past and present wishes, if they are known;
• whether the patient is likely to regain capacity to make the decision;
• the views of other people close to the patient who may be familiar with the patient’s
preferences, beliefs and values; and
• the views of other health professionals involved in the patient’s care.”
The Assisted Decision-Making (Capacity) Act 2015 which came into force on 26 April 2023 provides clarification and a process for patients to be involved in their own health care decisions as much as they are able.
Survival Tips…
• You must respect your patient’s wishes, however if you ultimately feel that a request for treatment or care would not serve the patient’s needs, you are not obliged to provide it. Record in the notes what a patient has been told, and what the patient has agreed.
• Adult patients are presumed to have capacity to consent unless proved otherwise.
• Each assessment of a person’s capacity should relate to a specific decision.
• Every adult with capacity in Ireland is entitled to refuse medical treatment or withdraw consent. You must respect a patient’s decision to refuse treatment or withdraw consent, even if you disagree with that decision. In these circumstances, you should explain clearly to the patient the possible consequences of refusing treatment and, where possible, offer the patient a second medical opinion.
3. Confidentiality
A doctor’s duty of confidentiality to patients goes beyond health records. It encompasses all information held about patients, from demographic data to appointment details. Even the fact that a patient is registered with your practice is confidential.
You should take care to avoid unintentional disclosure – for example, by ensuring that any consultations with patients cannot be overheard.
‘Disclosures’
Express consent from the patient is usually required before you disclose information about them to a third party. However, there are some situations where disclosure is required by law, for example:
• When ordered by a judge in a court of law, or by a tribunal or body established by an Act of the Oireachtas.
• Where required by infectious disease regulations.
• Where you know or have reasonable grounds for believing that a crime involving sexual assault or other violence has been committed against a child or other vulnerable person.
If the coroner requests information about the deceased that is required by their investigation into the circumstances of a death. There are also situations where it may be justifiable to disclose information about a patient without their express consent, for example:
• If it is in the public interest to disclose the information in order to protect the patient, other people or the community more widely. You must satisfy yourself that the possible harm the disclosure may cause is outweighed by the benefits that may arise for the patient or others.
• If a patient lacks capacity to give consent and is unlikely to regain capacity, disclosure may be justified if it is in the patient’s best interests.
• When there is a claim arising out of the death of a patient.
You should ensure the disclosure is proportional – anonymised if possible – and includes only the minimum information necessary for the purpose.
Survival Tips...
• Except in exceptional circumstances, you must always obtain consent from a patient before releasing confidential information.
• Give cause of death accurately on death certificates, even where this might be embarrassing or distressing to relatives.
• Be aware of high-risk items and places where confidentiality is easily breached: computer screens, printers, memory sticks, handover sheets, emergency departments, corridors, lifts.
4. Communication
Good communication is key to an effective doctor–patient relationship and is important for all aspects of a patient’s care.
Understandably patients may experience difficulties in assessing the technical competency of a doctor, so will frequently judge the quality of clinical competence by their interpersonal interactions. Developing good communication skills will therefore improve clinical effectiveness and reduce medicolegal risk.
Beyond doctor-patient interactions, it is also essential to communicate clearly and appropriately with all clinical and administrative colleagues you work with directly, as well as doctors who refer to you and to whom you refer.
Survival Tips...
• Be patient, observant and curious.
• Show respect and self-awareness (posture, eye contact, first impression).
• Assess patients’ moods and respond accordingly.
• Show empathy but be aware that physical contact is not always appropriate (outside of an examination).
• Interact professionally with other colleagues.
5. Competency
Competency, in professional terms, is defined as the ability to perform the tasks and roles required to the expected standard. It can be applied to a doctor at any stage in their career.
Competency encompasses the need to keep up to date with changes in practice and systems that can impact on it. Continued professional development (CPD) is a prerequisite of many jobs, but no more so than in medicine which is constantly evolving. Doctors effectively never stop learning, so a heavy focus is placed on CPD whatever speciality a doctor may work in.
Recognising your own limitations is the key principle behind competency. When providing care, you must work within your own competencies, and ask for advice when you feel out of your depth.
Survival Tips...
• Recognise and work within the limits of your competence.
• Keep your professional knowledge and skills up to date.
• In an emergency, wherever it arises, you have a professional duty to offer assistance, taking account of your own safety and competence, and the availability of other options for care.
6. Careful Prescribing
The financial costs associated with adverse events and inappropriate prescribing amount to hundreds of millions of euros every year. Risk areas include:
• Transferring information to new charts.
• Transcribing medication onto GMS prescriptions.
• Team handovers.
• Over-prescribing.
• Forged prescriptions.
• Prescribing for the wrong patient.
Survival Tips...
• Prescriptions should clearly identify the patient, drug, dose, frequency and start/finish dates.
• Be aware of a patient’s drug allergies and any interactions with medications they may already be taking.
• Only prescribe drugs to meet the identified need of the patient.
• Refer to the relevant prescribing formulary.