I felt obliged to share with
readers my thoughts after I read the judgment of an inquiry of the Medical Council
of Hong Kong held in June 2013. A
gynaecologist was found guilty of misconduct in a professional respect for
prescribing Amoxil to a patient who was known to be sensitive to Penicillin.
The judgment stated that: “Wrongful prescription of drugs which a
patient is known to be allergic to can
easily be prevented (my emphasis) by checking the medical record and
checking with the patient.” And
then: “in view of the fact that there are
cases in which the responsibility is plainly overlooked, we must send a message
to the medical profession that the matter will be dealt with seriously in
sentencing in future cases if patient’s known allergy is blatantly overlooked.”
It also commented unfavorably on
whether further action needed to be taken by the Education and Accreditation
Committee (EAC) in respect of her
specialist registration: “We are of the
view that to exercise proper care in prescribing medicine is a fundamental responsibility
of all doctors.” Although the doctor
was ordered to be removed from the General Register for 1 month with the order
suspended for 12 months, the EAC later removed her name from the Specialist
Register permanently. Of course she can
appeal and/or apply to be included in the Specialist Register again. Practically this meant that even though she
got a suspended sentence in the inquiry, she was still unable to practice as a
gynaecologist for a considerable period of time.
I fully agreed that the doctor
had done something wrong. In this case,
the patient did suffer allergic reactions and was admitted to a private
hospital for a few days. The doctor
actually owed the patient an apology. The
guilty verdict was a redress to the patient. The sentencing also served to alert doctors to
be more careful with medical prescriptions. However, a few questions arose in my mind.
- Are prescription errors really easily preventable?
- Do doctors really expect zero error in prescribing?
- Falling short of expected standard is professional misconduct?
- Can imposing harsher (and harsher) punishment help preventing prescription errors?
Are prescription errors easily
preventable?
Prescription errors remain one of
the leading causes of medical errors worldwide. Various measures have been implemented at
different levels in order to try tackling prescription errors. Yet no one nation or any medical organization
can claim that they can prevent all prescription errors. It might not be difficult to achieve zero
error on an individual basis for a certain period of time. However, like other human errors, prescription
errors are hard to eliminate in a system. I don’t mean that we should do nothing on this
important issue, nor that doctors are not to be blamed. It is only through recognizing the difficulties
in preventing prescription errors that we can elucidate the root causes of
them. Telling mothers to feed their
children with nutritious food spoon by spoon is unlikely to solve the worldwide
problem of malnutrition. Similarly,
educating industrial workers about the importance of fingers will not prevent
them from chopping their fingers accidentally. Sending victims of industrial accidents to
jail will certainly not be useful in cutting accident rates.
Do doctors really expect zero
error in prescribing?
Honestly, do you expect to
encounter zero prescription error in the coming year in Hong Kong? Of course the answer is “no”. Do not fall into the pitfall of pinpointing an
individual doctor facing a particular patient. With hindsight, it is negligence to give
penicillin-sensitive patient penicillin. However, this does happen repeatedly in
everyday lives when there is system failure. Human errors are bound to happen when there
are routine and repetitive actions. A
good system has built-in checkpoints to pick up such errors and to rectify
them. In the aforementioned case, in
fact the doctor had implemented measures to check for errors. There were cautionary note on the paper record
and an allergy alert function in the computer system. Sadly, both mechanisms failed in this case. Ironically, the panel regarded the doctor even
more blame-worthy with such safety mechanism in place, and implied that she had
blatantly overlooked the known allergy.
How about a surgical procedure,
such as colonoscopy? We tend to be
comfortable with the intrinsic risk of perforation of the colon. When such risk materializes, the doctor seldom
takes the blame. If he has implemented
mechanisms which can reduce the intrinsic risks, he is highly likely to receive
credits for such actions.
Falling short of expected standard
is professional misconduct?
The term “professional misconduct”
carries quite a negative sense. It is quite
a serious matter when a doctor is labeled with misconduct. However, from the decisions in the cases Koo Kwok Ho (1988) and To Chun Fung (2000), the Court of Appeal
somehow equated misconduct as “conduct fallen short of the standard expected
amongst doctors”. Taking that to the
strictest sense, misspelling a patient’s name can be professional misconduct. It all depends on what is expected amongst
doctors. If the inquiry panel thought
that prescription errors were easy to prevent, they would easily find the
defendant doctor fallen below expected standard. But, again, do doctors really expect zero
error in prescribing?
“Professional misconduct” is now
the only verdict from the disciplinary procedures. The defendant doctor is either guilty or not
guilty. Apart from the differences in
sentencing, there is no way to distinguish a doctor who maliciously harms his
patient for his personal gain from a doctor who is herself a victim of system
failure. A review of the disciplinary
procedures is seriously in need.
Can imposing harsher (and
harsher) punishment help preventing prescription errors?
While removal from the General
Register with suspended sentence was by no means lenient, it was difficult to
think of harsher punishment than removal from the Specialist Register permanently.
With the deluded view that prescription
errors were easily preventable, the doctor was regarded having done a grossly
irresponsible act. I totally agreed that
in private practice, the doctor had to take sole responsibility in mishaps in
the clinic. However, she was a
specialist in O&G, but not a specialist in system errors and risk
management. The inquiry panel had
already agreed that the risk of committing the same mistake was low. I wondered how she could further prove to EAC
that she would be fit to be a specialist.
While all doctors should be
alerted to the prevention of prescription errors, authorities should also
understand the root causes of such errors. Just as putting victims of industrial
accidents to jail would not cut accident rates; imposing harsher punishment to
doctors is unlikely to help decreasing prescription errors. A realistic assessment of resources in private
practices and facilitation of effective system management would be more
promising solutions.
(Source: HKMA News August 2013)
