System Failure, Below Standard, and Misconduct

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.

1. Are prescription errors really easily preventable?
2. Do doctors really expect zero error in prescribing?
3. Falling short of expected standard is professional misconduct?
4. 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)