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Risk Management Techniques in Perinatal and Neonatal Practice.
  1. ROGER CLEMENTS, Harley Street
  1. London Consultant obstetrician and conusltant in risk management

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    Risk Management Techniques in Perinatal and Neonatal Practice. Edited by Steven M Donn and Charles W Fisher. Futura Publishing, 1996. ISBN 0-87993–640-1

    Clinical risk management has been defined elsewhere as: “a particular approach to improving the quality of care, which places special emphasis on occasions on which patients are harmed or disturbed by their treatment.” Litigation undoubtedly provides the impetus for risk management on both sides of the Atlantic, but its main focus should be the prevention of harm to patients. The stated aims of this book are different: it begins by asking what are the factors that lead to medical malpractice lawsuits? This, then, is a textbook about how to avoid litigation. It is not about the avoidance of harm to patients.

    To concentrate only on those episodes of patient care that result in litigation is to miss the point. The Harvard study shows that there is a poor correlation between negligence and litigation. Eight times as many negligent errors occur as claims are made. The claims do not often relate to the negligent events either. Only 2 per cent of negligent claims lead to paid claims. Thus claims are a very remote reflection of what is happening in clinical practice, and a very poor form of audit for the clinician.

    The authors disclaim the intention of creating a new medical textbook, but most of perinatal care is here, and the list of chapters resembles that in any medical textbook on the subject. Each chapter is written by a leading practitioner, but is interrupted every few paragraphs by interpolations from a lawyer: it is as if doctors only know so much about the practice of medicine—the final word has to be with a lawyer. My understanding is that, at least in the courts of the United Kingdom, the required standard of medical practice is established by expert evidence and judges do not determine the standard of care. The interpolations of the lawyers are often banal and irrelevant, with statistics from reviews of reported cases, as if this were somehow relevant to clinical care.

    For all that, there is much good advice here. There are some excellent chapters, including a scholarly historical view of prolonged pregnancy, mercifully free—until the last page—of legal interruption. Other subjects fare less well, and I was disappointed with the scant treatment of such controversial and important areas as corticosteroids in prematurity and the management of shoulder dystocia. It is of course important that doctors understand the legal context in which they practise medicine. It is also important that lawyers understand enough medicine to try cases. In my opinion that is best done by lawyers explaining the law and doctors explaining the practice of medicine.

    The book does not travel well and the unwary reader may be confused by repeated references to informed consent, for there is no such doctrine in English law. The law on consent is still that enunciated by the House of Lords in Sidaway. The test is still that of the responsible doctor, not that of the prudent patient. In this respect the United Kingdom stands in splendid isolation in the developed world. But it does not end there. I was surprised to read (page 306) that medical textbooks are “not admitted because they are considered ‘hearsay’ evidence.”

    The UK reader will find jarring references to nurses in the labour ward, juries in civil litigation, and awards of punitive damages. There are too many differences between the North American and British legal systems—and they are too well known—for them to be rehearsed here. One important difference, which may explain the motivation for this book, is the status of the doctor in litigation. For doctors working within the NHS hospital system there is no personal financial risk in litigation. Even for the general practitioner and the private practitioner, the financial exposure is marginal. Not so in the United States where doctors are heavily penalised in their own pockets (in the form of malpractice insurance) by awards and settlements. Perhaps that explains the pre-occupation with the avoidance of litigation, but if our concern is to improve patient care, this approach rather misses the point.

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