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 i njury’? • When does ACC report a health professional? • Case studies RNZCGP CME 2014
Woodhouse principles New Zealand – non-tort USA Tort based • Tort – medical negligence by act • 1974 ACC scheme introduced or omission – courts • 1992 Medical Misadventure. • 15,000 and 19,000 malpractice • 2005 TI introduced = aligns with suits per annum no fault intent of scheme • Awards in medical liability cases • 10,000 claims per annum increased 43 percent in 1999, (approx.) from $700,000 to $1,000,000 • Focus : - Client & injury - Open disclosure - Needs Based entitlement RNZCGP CME 2014
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 RNZCGP CME 2014
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. RNZCGP CME 2014
National Top 10 Accepted Treatment Injuries Infection Adverse reaction Haematoma - Bruising Treatment Injury Nerve injury Skin injury Strain or Sprain Dental injury Pressure injury Perineal injury Gastrointestinal injury 0 100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 Count of accepted claims 2013 2012 RNZCGP CME 2014
National Top 10 Accepted Treatment Injuries related to General Practice Adverse reaction Infection Haematoma - Bruising Skin injury Treatment injury Nerve injury Wound dehiscence Ulcer - Other Muscle - Tendon injury Disease progression 0 50 100 150 200 250 300 350 400 450 500 Count of accepted claims 2013 2012 RNZCGP CME 2014
“At the Doctors” - Norman Rockwell, 1958 http://blog.silive.com/sinotebook/2009/06/our_ailing_healthcare_system_n.html RNZCGP CME 2014
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. RNZCGP CME 2014
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 RNZCGP CME 2014
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. RNZCGP CME 2014
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 RNZCGP CME 2014
National Top 10 Adverse Event Notifications 2013 Equipment failure Medication - other Treatment omission Medication omission Treatment event Nursing care Vascular surgery Hip/Knee surgery/replacement Eye surgery Interventional Cardiology Vaccination 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Count of adverse event notifications Sentinel Serious RNZCGP CME 2014
National Top 10 Adverse Event Notifications 2013 compared with 2012 2013 Equipment Failure 2012 2013 Medication-other 2012 2013 Treatment omission 2012 2013 Medication omission 2012 Treatment event 2013 Nursing care 2012 2013 Vascular Surgey 2012 2013 Hip/Knee Surgery/replacement 2012 2013 Eye Surgery 2012 2013 Interventional Cardiology 2012 2013 Vaccination 2012 0 10 20 30 40 50 60 70 80 Count of adverse event notifications Sentinel Serious RNZCGP CME 2014
General Practice Adverse Event Notifications 2012 & 2013 Medication - Other Treatment event Treatment omission Medication omission 0 5 10 15 20 25 30 35 40 45 50 Count of adverse event notifications Sentinel Serious RNZCGP CME 2014
Case studies RNZCGP CME 2014
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. RNZCGP CME 2014
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. RNZCGP CME 2014
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.” RNZCGP CME 2014
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 RNZCGP CME 2014
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 RNZCGP CME 2014
And finally…. Providers • Targeted & appropriate lodgement • Consent • ACC – Sharing information – TI.info@acc.co.nz – Case Studies – www.acc.co.nz > for providers > clinical best practice > treatment injury case studies Feedback Welcome RNZCGP CME 2014
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. RNZCGP CME 2014
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