Iatrogenic Injuries ACCs General Practice Perspective Chris Moughan - - PowerPoint PPT Presentation

RNZCGP CME 2014

Iatrogenic Injuries

ACC’s General Practice Perspective

Chris Moughan

Medical Advisor, Treatment Injury Centre MB ChB, FRNZCGP, DipObst, DipOccMed

Brendan Cullen

Technical Claims Manager, Treatment Injury Centre BPhty, MSc

RNZCGP CME 2014

Agenda

• What is a ‘treatment injury’?
• When does ACC report a health professional?
• Case studies

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Woodhouse principles

USA Tort based New Zealand – non-tort

• Tort – medical negligence by act
• r omission – courts
• 15,000 and 19,000 malpractice

suits per annum

• Awards in medical liability cases

increased 43 percent in 1999, from $700,000 to $1,000,000

• 1974 ACC scheme introduced
• 1992 Medical Misadventure.
• 2005 TI introduced = aligns with

no fault intent of scheme

• 10,000 claims per annum

(approx.)

• Focus :
• Client & injury
• Open disclosure
• Needs Based entitlement

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Defining Treatment Injury

• Section 32 Accident Compensation Act 2001:

– Personal injury suffered by a person – Caused by treatment received from, or at the direction of, a registered health professional

• Physical Injury

– bodily damage – not just symptoms / signs

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Defining Treatment Injury

• Personal (physical) injury caused by treatment

AND

• Not a necessary part, or ordinary consequence, of the

treatment

• Not simply a case of treatment failing to achieve the desired

result.

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National Top 10 Accepted Treatment Injuries

100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 Gastrointestinal injury Perineal injury Pressure injury Dental injury Strain or Sprain Skin injury Nerve injury Haematoma - Bruising Adverse reaction Infection Count of accepted claims Treatment Injury 2013 2012

RNZCGP CME 2014

National Top 10 Accepted Treatment Injuries related to General Practice

50 100 150 200 250 300 350 400 450 500 Disease progression Muscle - Tendon injury Ulcer - Other Wound dehiscence Nerve injury Skin injury Haematoma - Bruising Infection Adverse reaction Count of accepted claims Treatment injury 2013 2012

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“At the Doctors” - Norman Rockwell, 1958

http://blog.silive.com/sinotebook/2009/06/our_ailing_healthcare_system_n.html

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Ordinary Consequence

• 7 year old boy receives penicillin injection standing in

upper/outer quadrant buttock

• Returns following day with bruising around the injection

site

• Not a treatment injury.

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Not Ordinary

• Same boy, returns with pain down leg and foot drop
• Injection caused sciatic nerve injury
• ACC accepts claim
• Report event to DGOH
• See case study 47

Wrong site of ventrogluteal injection 2012

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Ordinary?

• After injection it is recalled that patient had a known

allergy to penicillin

• With a known allergy a subsequent allergic reaction

would be an ‘ordinary consequence’

• However, as penicillin given in error,

‘ordinary consequence’ does not apply

• Report to DGOH.

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Reporting Belief of Risk of Harm

ACC Statutory Responsibility

• Section 284: Reasonable belief of risk of harm

– Use only cover information – Review accepted and declined claims – Notify Director General of Health (monthly)

• Facility identifiers only

– Registration authorities (extraordinary)

• Must have peer advice
• Peer advice must be critical of standards
• Sentinel and serious events may be notified

 Shouldn’t be unknown to facility

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National Top 10 Adverse Event Notifications 2013

5 10 15 20 25 30 35 40 45 50 55 60 65 Vaccination Interventional Cardiology Eye surgery Hip/Knee surgery/replacement Vascular surgery Nursing care Medication omission Treatment omission Medication - other Equipment failure Count of adverse event notifications Treatment event Sentinel Serious

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National Top 10 Adverse Event Notifications 2013 compared with 2012

10 20 30 40 50 60 70 80 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 Count of adverse event notifications Treatment event Sentinel Serious

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General Practice Adverse Event Notifications 2012 & 2013

5 10 15 20 25 30 35 40 45 50 Medication omission Treatment omission Medication - Other Count of adverse event notifications Treatment event Sentinel Serious

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Case studies

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Failure to treat?

• 43 year male consults with GP for a chest infection.

Antibiotics prescribed

• At end of short consultation he advises his father had

been diagnosed with bowel cancer at age 55 and died at age 59

• GP recommended a screening colonoscopy at age

45 and provided lab form for “cholesterol test”.

RNZCGP CME 2014

Failure to treat?

• Patient turned 45 but did not return to GP to arrange

colonoscopy

• GP did not contact patient to remind
• Patient finally had “cholesterol test” performed.

Normal

• Patient did not return to GP clinic again until just

before diagnosis of bowel cancer at age 47

• Patient subsequently died of metastatic bowel

cancer.

RNZCGP CME 2014

Failure to treat?

• Claim was lodged with ACC for treatment injury
• Basis of claim that GP should have recalled the

patient at age 45 for colonoscopy

• ACC sought advice from an independent expert peer

GP

• Expert referred to NZ Guidelines Group’s

“Surveillance for people at increased risk of colorectal cancer”, January 2012.

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Failure to treat?

• Independent expert GP concluded (in part):

“The GP took a cautious approach and offered colonoscopy at age 45.”

• Should the GP have recalled the patient?

“In my opinion, unless the GP quite clearly told the patient that he would recall him at age 45, he discharged his duty and acted properly according to currently understood practice….”

• ACC declined claim.

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Failure to treat?

• Decision upheld at review and in the District Court.
• Another expert GP opinion obtained:

“The doctor fulfilled his obligation to his patient by recommending a colonoscopy at 45 and did not thereby take on any obligation for ensuring that this happened. This advice is supported by that of a number of colleagues whose opinion I have sought.”

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Metallosis

• 57 y/o female with acetabular dyplasia and OA
• Elective ‘metal on metal’ hip replacement
• 2 years later pain and unable to walk
• Serum cobalt 314 nmol/L, chromium 380 nmol/L
• USS abnormal soft tissue thickening
• See case study 45 Failure of

Hip Replacement published June 2012

RNZCGP CME 2014

Nitrofurantoin lung disease

• 62 yr old female – diabetic/hypertensive/hyperthyroid
• 2 year Hx of UTIs – treated with Nitrofurantoin
• C/o SOB, cough and recurrent infections
• X-ray showed extensive disease and CT interstitial fibrosis
• See case study 48

Prolonged Nitrofurantoin Usage published September 2012

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Temporal arteritis

• Ms. P, 74 y/o, history of RA and PMR
• C/o bitemporal headache -> sinusitis
• 2/52 later facial pain on chewing, ?transient visual disturbance. Dx

still sinusitis

• Admitted to hospital 1/52 later with sudden visual loss -> temporal

arteritis

• GP ECA: “not an easy diagnosis”, but classical presentation and

“should not have been missed”

• See case study 53 Delay in Diagnosis published March 2012

RNZCGP CME 2014

Warfarin haemorrhage

• 82 y/o woman developed AF
• PMHx HT, mild RF, aortic valve homograft
• CHAD score/Cardiologist recommend Warfarin
• Patient not keen in blood tests
• 9 months later collapsed and died
• CT intracerebral haemorrhage
• See case study 22 Warfarin and Aspirin published May 2010

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And finally….

• ACC

– Sharing information – TI.info@acc.co.nz – Case Studies – www.acc.co.nz > for providers > clinical best practice > treatment injury case studies

Providers

• Targeted & appropriate lodgement
• Consent

Feedback Welcome

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Bio’s

• Dr Chris Moughan is Medical Advisor to the Treatment Injury

Centre, ACC Wellington. Chris graduated from Otago University in 1976. FRNZCGP 1988. GP and GP Obstetrician, in Hastings from 1980. Chris has also worked in Occupational Medicine from 2000, and has been Medical Advisor to the Treatment Injury Centre from 2007.

• Brendan Cullen graduated with a Bachelor of Physiotherapy

degree from the University of Otago in 2000. After working at Wellington Hospital and in private practice for a few years, Brendan returned to Dunedin and undertook a Masters degree through the Department of Anatomy and Structural Biology, graduating in 2006. Brendan returned to Wellington and continued to work as a physiotherapist and was also involved in research and teaching roles. Brendan joined the ACC Treatment Injury Centre in 2011 and is now a Technical Claims Manager.