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New Zealand’s no-fault system. Ron Paterson NZ Health and Disability Commissioner San Diego, June 2004. Case study: Misdiagnosed MI. Mr A, a 36-year old man, presented to a medical centre with chest tightness and shortness of breath. He had a strong family history of heart disease - PowerPoint PPT Presentation
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New Zealand’s no-fault system
Ron PatersonNZ Health and Disability Commissioner
San Diego, June 2004
Mr A, a 36-year old man, presented to a medical centre with chest tightness and shortness of breath. He had a strong family history of heart disease
The nurse took an ECG which indicated significant myocardial infarction
Dr B, the on-call doctor, diagnosed a chest infection and sent Mr A home
Case study: Misdiagnosed MICase study: Misdiagnosed MI
Mr A died at home 2 hours later
Post-mortem showed the cause of death to be ischaemic heart disease
Case study: Misdiagnosed MICase study: Misdiagnosed MI
Image: www.ecglibrary.com
Since 1974, medical malpractice claims have been effectively prohibited in New Zealand, even for gross negligence
Why can’t Mr A’s family sue Dr B?Why can’t Mr A’s family sue Dr B?
Compensation for medical injury is provided by the Accident Compensation Corporation, a state-funded insurer
Concerns about the quality of medical care are resolved by an independent Ombudsman, the Health and Disability Commissioner
Why can’t Mr A’s family sue Dr B?Why can’t Mr A’s family sue Dr B?
AccidentCompensation
Corporation
Health careprovider
Health and DisabilityCommissioner
Claim
Complaint resolution
Complaint
CompensationProfessional
discipline
Competencereview
Unhappy patient
Currently, compensation is available for:
(1) medical error (the failure to observe a standard of care reasonably to be expected in the circumstances); and
(2) medical mishap (a rare and severe adverse outcome of treatment that is properly given)
Which medical injuries get cover?Which medical injuries get cover?
In 2005, medical compensation will be widened to cover ‘treatment injuries’
The reforms will remove any consideration of fault, rarity or severity
These reforms will cost US$5.37 million per year on top of the US$29 million spent currently
Are any reforms planned?Are any reforms planned?
Ruth Dyson, ACC Minister
The Accident Compensation Corporation accepted that Mr A’s death was the result of medical error
Mr A’s widow received compensation for funeral costs and loss of income
Case study: Misdiagnosed MICase study: Misdiagnosed MI
Any person can complain to the Health and Disability Commissioner, orally or in writing, alleging breach of a patient’s rights
Who can complaint to HDC?Who can complaint to HDC?
Which rights are in the Code?Which rights are in the Code?
The Code of Consumers’ Rights sets out ten rights relating to the quality of care
The Commissioner’s jurisdiction does not extend to issues of access of funding
What is the Commissioner’s role?What is the Commissioner’s role?
Education Learning, not lynching
Complaints resolution Resolution, not
retribution
Mr A’s wife complained to the Health and Disability Commissioner about the poor standard of care provided to her late husband by Dr B
Case study: Misdiagnosed MICase study: Misdiagnosed MI
How are complaints resolved?How are complaints resolved?
HDC supports low-level complaints resolution
Advocacy and mediation are often successful
Investigation is reserved for serious complaints
Judi Strid,Director of Advocacy
What is the investigation process?What is the investigation process?
Inquisitorial, not adversarial
Expert advice on clinical issues
Can examine systems issues
Cases are decided “on the papers” – usually no face to face hearing
Case study: Misdiagnosed MICase study: Misdiagnosed MI HDC asked Dr B to respond to Mrs A’s letter
of complaint
Dr B accepted that he had misread the ECG and failed to recognise the seriousness of Mr A’s condition
Dr B provided evidence that, at the time of the consultation, he had been suffering from undiagnosed concussion following an altercation with his neighbor
Case study: Misdiagnosed MICase study: Misdiagnosed MI
The evening of the death, Dr B had visited Mr A’s widow to apologise and offer his condolences
Dr B normally had no problem reading ECGs, but he nevertheless undertook further training following this incident
Case study: Misdiagnosed MICase study: Misdiagnosed MI
Mrs A’s complaint was upheld – Dr B had failed to exercise reasonable care and skill when assessing Mr A’s chest pain
Dr B’s personal circumstances (the concussion) did not dilute his professional duty of care, but were relevant in deciding what further actions were needed
Do many complaintsDo many complaintsend in discipline?end in discipline?
714 complaints to HDC
337 investigations
106 breach findings
8 disciplinary hearings 2002/2003
Health and Disability Commissioner acts as gatekeeper to disciplinary proceedings
Medical Practitioners Disciplinary Tribunal may remove a doctor’s name from the Medical Register, place conditions on a doctor’s practice, and/or impose a fine
Professional disciplineProfessional discipline
Case study: Misdiagnosed MICase study: Misdiagnosed MI
HDC decided not to refer this case forward for possible disciplinary action
HDC sent a copy of the report to Dr B’s professional body, the Medical Council, to keep on their records
HDC also sent a copy to Dr B’s employer, the Medical Centre, which confirmed new procedures for sick staff
Medical Discipline in NZ 1994-2003Medical Discipline in NZ 1994-2003
0
10
20
30
40
50
60
70
80
90
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
MPDC MPDT
Number of doctors facing disciplinary charges
l
Individual complaints offer a window of opportunity to improve health services generally.
Building a fence Building a fence at the top of the cliffat the top of the cliff
Case study: Misdiagnosed MICase study: Misdiagnosed MI In response to Mrs A’s complaint, the Medical
Centre implemented a policy on staff impairment and illness, including a stand-down period after head injury
The anonymised report was widely disseminated for educational purposes, discussed in a medical journal, and placed on HDC’s website
www.hdc.org.nz (02HDC01833)
No greener pasturesNo greener pastures
New Zealand remains the safest place in the world to practise medicine.
Professor Peter Skegg, 2003
The bottom lineThe bottom line
New Zealand’s ‘no fault’ compensation system is consistent with efforts to improve the quality of health care but needs to be complemented by a flexible and effective complaints system.
Peter Davis, Inaugural lecture, 2000
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