HPCSA ethical guidelines for dietitians

Background

Medico-legal claims in South Africa have been on the increase as highlighted in the 2020 Budget review from the National Treasury. This increase in medico-legal claims has not been consistent with certain indicators of health outcomes in the public sector. e.g., the overall death rate in public hospitals declined from 5.4% in 2013/14 to 4.6% in 2018/19. The maternal mortality in facilities decreased by 20.5% over the same period. To address this challenge, the South African Law Reform Commission (SALRC) was tasked with investigating the medico-legal cases in SA under project 141. This commission found the following factors to be associated with the increase in medico-legal claims: 

1. Patient awareness of their rights.
2. Litigious climate and patient-centred jurisprudence
3. Patient expectations which can sometimes be unrealistic 
4. Amendment of Road Accident Fund Act
5. Contingency fees. The Contingency Fees Act, 66 of 1997 (CFA) allows patients, who would normally not be able to afford litigation, to institute legal proceedings on a “no win no fee basis”. 
6. Conduct of lawyers such as the active pursuit of patients with possible claims due to medical negligence. Touting and theft of files.
7. Inadequate complaints system which makes litigation the only viable avenue for redress.
8. Claim size where the potential size of the compensation awarded is an incentive for plaintiffs and attorneys.
9. Doctor/patient relationship – poor communication, especially about the possible outcome and the risks inherent to some procedures; a perception that the medical practitioner does not care about the patient; patient dissatisfaction and poor management of adverse events. 
10. Quality of health services and clinical errors. The deterioration in the quality of public health services and the standard of care because of a decline in professionalism or skills among healthcare practitioners generally both in the public and private sector.

Dietitians should therefore make sure that they adhere to protocols and guidelines when treating patients and maintain the highest level of professionalism.

Incidents related to administration of food, diet, nutrition supplements and nutrition services

According to the United Kingdom’s (UK) National Health Services’ (NHS) Reporting and Learning System, a nutrition‑related patient safety incident is “an incident where the provision of nutrition (or nutritional services) either caused harm or had the potential to cause harm to an individual”. There is no South African database of adverse events related to the administration of food, diet, nutrition products or provision of nutrition and dietetic services. The National Guideline for Patient Safety Incident Reporting and Learning in the Health Sector of South Africa provides a safety walk around toolkit and classification of incident types. The guideline does not provide any indication of the type of information that should be collected or reported regarding diet, food or nutrition related incidents. Data on diet and nutrition related incidents from the UK’s NHS 2006- 2007 patient safety report has shown that most of the nutrition related incidents occurred during the provision of artificial feeding and when patients were kept nil by mouth (NBM). Feeding tube and pump placement, feed type, amount of feed and feeding rate were some of the prevalent artificial feeding related incidents.  In the NBM category, non-observation of the NBM orders and prolonged NBM were the most common reasons why incidents occurred. Table 1 below shows a summary of the UK’s report of national patient safety incidents related to food and nutrition. 

Table 1. The UK report of National Patient Safety incidents, 2006 – 2007. 

Category	Number	Percentage of total sample
Provision of nutrition via artificial feeding	328	23
Nil by mouth/fasting	326	23
Provision of nutrition via oral feeding	247	17
Nutritional assessment or support	158	11
Discharge related/community assistance in relation to feeding	108	8
Food hygiene and food safety	82	6
Diabetes and blood glucose levels	64	5
Consequences of malnutrition	55	4
Fluid management	47	3
Falls/slips/trips with nutritional involvement	28	2
Patient refusals of food or drink	17	1
Allergy	9	1
Other or insufficient information available	15	1
TOTAL (sample of 29% of all incidents reported)	1 433

This information highlights important areas of nutrition care and support where dietitians need to have safety checks, protocols in place and adhere to guidelines to ensure patient safety. One of the guidelines that dietitians should follow is the HPCSA’s Booklet 1 – General Ethics Guidelines for the Health Profession’s on patient safety. A summary of the booklet’s patient safety related aspects is given below:

HPCSA booklet 1 – General Ethics Guidelines for the Health Professions  

According to Section 5.1 of HPCSA Ethics Booklet 1, healthcare practitioners should:

1. Always consider the best interests or well-being of their patients.
2. Honour the trust of their patients.
3. Be mindful that they are in a position of power over their patients and should avoid abusing that position.
4. Be accessible to patients and make arrangements for access when not on duty.
5. Make sure that personal beliefs do not prejudice their patients’ healthcare. 
6. If beliefs might affect the treatment, explain this to patients, and inform them of their right to see another healthcare practitioner.
7. Not refuse or delay treatment because they believe that patients’ actions have contributed to their condition, or because they, the healthcare practitioners may be putting their own health at risk.
8. Apply their mind when making diagnoses and considering appropriate treatment.
9. Respond appropriately to protect patients from any risk or harm.
10. Promptly and constructively respond to criticism and complaints.
11. Not employ any intern, healthcare provider in community service, or healthcare practitioner with restricted registration with the HPCSA, as locum tenens – or otherwise – in their own or any associated healthcare practice.
12. Inform their patients if they are in the employ of, in association with, linked to, or have an interest in any organisation or facility that could be interpreted by an average person as potentially creating a conflict of interest or dual loyalty in respect of their patient care.
13. In emergency situation, provide healthcare – within the limits of their practice, according to their education and/ or training, according to their experience and competency, under proper conditions and in appropriate surroundings. If unable to do so, refer the patient to a colleague or institution where the required care can be provided.

Ensuring that one is adequately educated and/or trained to treat the patient

HPCSA Ethics Booklet 1, Section 5 on patient duties specifies the requirements for a practitioner to qualify as adequately educated and/or trained. These requirements are summarised below. 

The individual practitioner must have:

1. Successfully completed an educational training programme approved and accredited by the HPCSA within the field of practice and category of registration.
2. Completed the training programme in a training entity/institution/hospital that has been accredited by the Professional Board.  
3. Undergone an initial training period under supervision, 
4. Completed undergraduate or postgraduate training. 
5. Been evaluated and accredited as having met the requirements of the training programme.
6. A short course to enhance or maintain skills that have been accredited and registered by the Professional Board.

References 

1. National Treasury, RSA. 2020. Budget review. Government printers. Pretoria. 
2. SALRC. 2021. Discussion Paper 154 – Project 141: Medico-legal claims. SALRC. Centurion.
3. National Patient Safety Agency. 2009. Patient safety incident reports in the NHS: Reporting and Learning System Quarterly Data. Summary, Issue 12 May 2009. England.  
4. Health, RSA, British High Commission, WHO. 2022. National Guideline for Patient Safety Incident Reporting and Learning in the Health Sector of South Africa – Version 2. 
5. HPCSA. 2008. General Ethics Guidelines for the Health Professions ethical guidelines on patient safety. HPCSA. Pretoria. 
6. WHO. (nd). Briefing Note, safety of medicines, Adverse drug reactions. WHO. Accessed online. 
7. Institute of Medicine 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. 
8. Wu, A.W., Cavanaugh, T.A., McPhee, S.J., Lo, B., Micco, G.P. 1997. To Tell the Truth, Ethical and Practical Issues in Disclosing Medical Mistakes to Patients. Journal of General Internal Medicine. 12 (12): 770-775. 

Terminology

Adverse drug reaction (ADR): “Unintended harmful reaction to medicines”.⁶
Adverse Event: “An injury resulting from a medical intervention.⁷
Adverse drug event (ADE): An injury resulting from the administration of a drug.⁷
Medical Errors (Medication Mistake): “A commission or an omission with potential negative consequences for the patient that would have been judged wrongly by skilled and knowledgeable peers at the time it occurred”.⁸ OR Accidental, unintentional nonadherence to a therapeutic programme.⁷
Medication Error: “Accidental poisoning by drugs, medicaments, and biologicals that resulted from acknowledged errors by patients or medical personnel” OR “A mistake made at any stage in the administration of a pharmaceutical product to a patient”.⁷
Medical Malpractice:“Incorporates all forms of intentional and negligent professional medical misconduct as well as professional negligence of medical practitioners.²
Medico-legal claim: “A civil claim of alleged wrongful medical treatment against a health provider”.¹
Medical Negligence:“Care that falls below the standard of care reasonably expected of an average physician qualified to take care of the patient in question”.⁷

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Last Updated on 1 March 2023 by HPCSA Corporate Affairs