What measures can I take to prevent clinical errors in my practice?

Where errors happen in private general practice

The risks are those of any general practice, with some that are sharper in private work:

• Prescribing and monitoring. The PRACtICe study, funded by the GMC, found that 1 in 20 prescription items in UK general practice had a clinically important prescribing or monitoring error, and 1 in 550 a serious one.
• Incomplete history. Most private GPs cannot see the patient’s NHS record. Patients forget medicines, diagnoses and allergies, or leave out things they would rather their NHS GP did not know.
• Results and referrals. Without a practice team and a shared inbox, a result that arrives while you are away, or never arrives, can be missed.
• Fragmented care. Patients move between you and the NHS. If the NHS GP does not know what you prescribed or found, errors happen at both ends.
• Remote consultations. Identity, examination and safeguarding are harder, and prescribing without enough information is a known risk.
• Working alone. No colleague down the corridor to sense-check a decision.

Prescribing safely

• Use a record system that checks prescriptions against a drug database for interactions, allergies, contraindications and dose. Take alerts seriously rather than clicking through them.
• Record allergies and current medicines, including those prescribed by the NHS, at every first consultation, and confirm them at follow-up.
• Set recalls for monitoring of high-risk medicines, and do not issue further supplies if monitoring is overdue.
• For shared care, agree in writing who prescribes and who monitors. Never assume the NHS GP will take over.
• Follow GMC guidance on remote prescribing. If you cannot get the information you need to prescribe safely, do not prescribe.
• Know the specific rules for private controlled drug prescriptions. See private prescribing and EPS.

Decision support tools can help, but they have limits. See what is clinical decision support?

Getting the full picture

• Ask new patients for a medication list, recent letters or a copy of their NHS summary. Patients can often see this themselves in the NHS App.
• Ask for consent to contact the NHS GP. If a patient refuses, record the refusal and consider whether it is safe to proceed. See accessing a patient’s NHS record.
• Check identity, particularly for remote consultations and before prescribing.

Results and referrals

• Keep a log of every test requested and referral sent, with a named clinician responsible.
• Check the log regularly for anything that has not come back, not just for results that have arrived.
• Agree who reviews results when you are on leave, and how abnormal results reach you out of hours if the laboratory phones.
• Tell every patient how and when they will get results, and record that you did.
• Track urgent referrals to confirm they were received and booked. See referring on the suspected cancer pathway.

Communication with the NHS GP

Write to the NHS GP after any consultation that changes diagnosis, medicines or management, with the patient’s consent. It is the single most useful safety step for patients who move between private and NHS care. See sending notes to the NHS GP.

Safety-netting and records

• Give specific safety-netting advice: what to look out for, what to do and when. Put it in writing for higher-risk presentations.
• Use templates for common presentations so that key questions and red flags are not missed, but do not let templates replace thinking.
• Write records that a colleague could act on.

Learning when things go wrong

1. Record incidents and near misses in a log, not just serious events. Near misses show where the system is weak before anyone is harmed.
2. Review significant events to find the cause in the system, not just the individual, and record what you changed.
3. Share learning nationally. NHS England’s Learn from Patient Safety Events service accepts records from private providers. It is not mandatory for independent providers, but NHS England encourages them to use it. Report suspected adverse drug reactions and device problems to the MHRA Yellow Card scheme.
4. Act on safety alerts. National Patient Safety Alerts are issued through the Central Alerting System, which independent providers can register for. NHS England says the CQC may take regulatory action where required actions are not taken.
5. Be open. In England, the statutory duty of candour in CQC regulation 20 applies to registered providers. For a notifiable safety incident you must tell the patient, apologise and follow up in writing. Apologising is not an admission of liability. Tell your medical defence organisation early.

In Wales, Scotland and Northern Ireland

The prevention measures above apply everywhere. The CQC, regulation 20, LFPSE and the National Patient Safety Alerts route are English. Elsewhere:

• Wales: regulation 31 of the Independent Health Care (Wales) Regulations 2011 requires you to notify Healthcare Inspectorate Wales (HIW) of events including the death of or serious injury to a patient and any allegation of misconduct resulting in actual or potential harm, generally within 24 hours. Regulation 19 requires you, where necessary, to change care in response to the analysis of incidents that caused or could have caused harm. Standard 23 of the national minimum standards expects patients to receive an apology, updates on any investigation and its results after a patient safety incident. The statutory duty of candour in Wales applies to NHS bodies. The Welsh Government has said it will extend it to regulated independent providers through separate regulations, so check HIW for the current position.
• Scotland: the organisational duty of candour in the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 applies to organisations (not individuals) providing independent health care. It is triggered by an unintended or unexpected incident that results in, or could result in, death, permanent harm or other significant harm. You must follow the set procedure, including notifying the person, apologising, offering a meeting and reviewing the incident, and publish an annual report on how you applied the duty. Healthcare Improvement Scotland (HIS) also sets out which events providers must notify, including serious injuries and serious complications.
• Northern Ireland: regulation 28 of the Independent Health Care Regulations (Northern Ireland) 2005 requires you to notify RQIA within 24 hours of events including a patient’s death, serious injury, or any event that adversely affects a patient’s well-being or safety. Regulation 17 requires arrangements for identifying, recording, analysing and learning from adverse incidents, and RQIA’s guidance expects incidents to be audited for trends. There is no statutory duty of candour in Northern Ireland yet. The Department of Health is preparing an organisational duty of candour bill.

In every nation your professional duty of candour as a doctor still applies: be open with the patient, apologise and explain what happened. The MHRA Yellow Card scheme covers the whole UK.

If you work alone

• Arrange regular case review with another GP, even informally.
• Use clinical audit to check your own practice against standards. See how to run a clinical audit.
• Watch your workload. Private sessions added to a full NHS week are a risk in themselves.

These measures are the core of clinical governance, covered in what is clinical governance?