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In this article Irene O'Byrne-Maguire, Clinical Risk Advisor, presents learnings from claims and incidents related to the speciality of dermatology and shares key learnings to improve safety.

Skin disease is very common. In Ireland, some 54% of persons are affected by skin disease annually, accounting for an estimated 15-20% of GP consultations, and some 65,000 referrals annually to the speciality of Dermatology. These include referrals for complex and severe skin conditions, with some 50% of referrals for skin cancer.1

The State Claims Agency recently undertook a review of claims and incidents related to the specialty of dermatology. The review included claims finalised between 2012 and 2021 and, as part of the State Claims Agency's incident surveillance process, incidents recorded on the National Incident Management System (NIMS) for two-quarters between 2021 and 2022. The aim was to identify aspects of care that could be improved on and to disseminate that learning nationally to help improve safety for dermatology service users, and mitigate the risk of claims in the future.

Learning from dermatology-related claims and incident data

Twenty-three claims, categorised on NIMS as relating to the subservice of dermatology, were identified over a 10-year period. Of these claims:

  • 52% were not previously reported as incidents
  • The majority (48%) were rated as moderate in severity based on the outcome at the time of injury, with 30% rated as extreme or major
  • 57% of the claims recorded the care process as being either a ‘delay’ or ‘incomplete/inadequate’ or ‘not performed when indicated’

Ten of the 23 claims, where damages were paid, were subjected to an in-depth analysis using NIMS and claims-related documentation, including healthcare records available in electronic form. These ten claims incurred total payments (damages, legal and other costs) of €0.65 million.

Of the ten claims, 50% related to diagnostic errors. Of the three related to delayed diagnoses of skin cancer, one related to a misdiagnosis of cancer and one related to the delayed diagnosis of a complication of treatment for an underlying condition. The remaining five claims involved treatment deficits, with one related to a complication of treatment. Of the ten claims subjected to an in-depth analysis, two related to a fatal outcome.

Issues identified from these claims

  • Deficits in the triage of service users considered high risk
  • Failure to recognise and respond to a deteriorating patient
  • Failure to listen to service user advocate
  • Failure to take account of family history of cancer, and to provide follow up care
  • Deficits in the handling of biopsy samples, including loss of biopsy specimen
  • Deficits in consenting process as to potential procedure complications, risks, benefits
  • Failure to take account of service user factors such as allergies/intolerances
  • Inadequate monitoring for complications post-procedure
  • Incorrect use of medication
  • Use of non-sterile and incorrect equipment during procedure
  • Inadequate implementation of discharge protocol post-surgical intervention

Incident analysis

In the analysis of 21,886 clinical care incidents reported on NIMS over a six-month period to the end of Quarter 1, 2022, only seven incidents related to the subservice of dermatology, suggesting under-reporting of these incidents. The themes identified in incident analysis mirrored those already identified in the claims analysis.

Minimising the risk

To improve the safety of service users and mitigate the risk of reoccurrence of incidents and claims, we advise the following:

  • Ensure robust triage and referral processes for service users considered to have high risk pathologies
  • Enhance communications within and between teams and services through having agreed multi-professional care pathways and processes for transfers of care2
  • Ensure adherence to the HSE Deteriorating Patient Improvement Programme3 to recognise, respond to, and manage in a timely manner a service user whose clinical state is worsening
  • Ensure appropriate discharge processes, including the monitoring of possible complications after therapeutic interventions
  • Ensure mechanisms are in place to effectively listen to service users and their advocates in line with HSE Partners with Patients’ practices4, so that relevant family histories and allergies are identified
  • Ensure service users are adequately consented to make informed decisions in relation to their care and record such discussions in line with the HSE’s National Consent Policy (Health Service Executive 2022)5
  • Record all dermatology-related patient safety incidents on NIMS, in line with the HSE’s Incident Management Framework6 and the statutory requirement to report incidents to the SCA

References available upon request.

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