By Richard A. Deutsche, MD, and James F. Holzer, JD
[Digest, Winter, 1991]
Surgical procedures involving cataracts account for over 50% of all professional liability actions against ophthalmologists. This was the conclusion in a recent study of medical malpractice suits and claims filed throughout the country against physicians insured by the Ophthalmic Mutual Insurance Company (OMIC), a risk retention group.
The review was conducted by Richard A. Deutsche, MD, of the Company's Risk Management Committee as part of its ongoing program to provide current professional liability and loss prevention information to policyholders as well as to members of the American Academy of Ophthalmology (AAO). The Academy sponsors OMIC which is currently in its fourth year of operation.
The study looked at 236 cases filed from October, 1987 through September, 1990. Over the three-year period, the number of OMIC policyholders grew to 1,072. The average number of insureds for the 36-month period was approximately 950, bringing the overall three-year claims frequency rate to 8 claims per 100 physicians. However, the estimated frequency rate for calendar 1990 was 5 claims per 100 insureds, a rate significantly better than many other surgical specialties.1 Almost three-quarters of the OMIC cases were surgery-related.
Of the 236 claims filed, over 70% (168 cases) were closed and only 9% of those cases (15 claims) involved an indemnity payment. Thirty percent of all claims, or 68 cases, remained open as of September 30, 1990 (Figure I).
Cataract Claims Frequency
Although the size of the sample is small, it is still significant to note that 120 of the 236 OMIC cases (51%) involved some form of cataract surgery, making it the single most frequently named procedure in malpractice actions against ophthalmologists. This finding is also consistent with data from 700 national ophthalmology claims collected over several decades by Jerome W. Bettman, Sr., MD, a consulting member of the OMIC Risk Management Committee.2
Extraction with IOL Implantation
In the most recent OMIC study, 95 of the 120 cataract cases (79%) involved extracapsular cataract extraction with posterior chamber intraocular lens. In one such case, an 82-year-old patient developed endophthalmitis and subsequently lost the use of her eye following an otherwise uneventful surgery. According to her clinical records, the patient had not been seen for nearly two months prior to arriving the day of surgery. Following the cataract and IOL surgery, the patient was seen on the fourth and sixth postoperative day complaining of discomfort and decreased visual activity. During the last visit, the ophthalmologist, suspecting endophthalmitis, recommended an aqueous tap which was not done until 12 hours later.
When the tap failed to produce material for the culture, the patient was referred to a retinal specialist who later did a vitreous tap and started appropriate therapy. The eye was lost, and the patient filed a malpractice action which was eventually settled with an indemnity payment. In addition to this case, there were three other cataract- related claims involving endophthalmitis. Six cataract cases were related to phacoemulsification.
Wrong Intraocular Lens Implanted
Six additional claims resulted from allegations that the ophthalmologist inserted the wrong intraocular lens. One case involved a 68-year-old male who was scheduled for a cataract extraction and intraocular lens implant. The ophthalmologist had scheduled four similar cases the morning of surgery. The plaintiff was the second of the four; when the ophthalmologist got to the fourth case, it was apparent he had the wrong lens for the last surgery. Upon investigation, it was discovered that the plaintiff had received a lens intended for the fourth patient which was four diopters off. The implant later was removed and replaced with a correct one, but not without some clinical complications.
Failure to Diagnose
Allegations of failure to diagnose accounted for 12% of the total OMIC claims reviewed. One such case involved an ophthalmologist who failed to review a preoperative radiology report showing a 2 x 2 centimeter nodule in the left hilum of his patient's lung. Although the report was in the patient's chart, it was never personally reported to the ophthalmologist or anesthesiologist according to pre-established operating procedures. The patient had surgery and returned four months later for a subsequent procedure when the problem was finally discovered. The nodule had more than doubled in size and the patient's survival rate had dropped significantly. The case was settled out of court for a significant sum, making it the largest single indemnity payment in OMIC's history.
Other Procedures Associated with Claims
Of the 236 OMIC claims, 23, approximately 10%, related to retinal surgery. There were also 11 cases involving photocoagulation, nine related to contact lenses and six associated with glaucoma treatment. Five case files involved office liability where patients claimed to have slipped or fallen on the premises. Although only 10% of OMIC insureds perform RK surgery, claims associated with this procedure accounted for 1% of the total (Figure II).
Risk Management/Loss Prevention Issues
The claims reviewed in this study raised a number of issues which made many of these losses either preventable or, at the very least, more defensible. Among the loss prevention issues identified were informed consent problems, dysfunctional communications in pre- and postoperative tests, and practice patterns which did not permit the ophthalmologist to spend enough time with a potential clinical problem or the patient.
But perhaps the most frequent risk management issue identified was faulty documentation practices. One such case involved a patient scheduled for cataract extraction who suffered a perforated globe during administration of a retrobulbar block by the anesthesiologist. The ophthalmologist was immediately notified and the surgery was canceled. The case was defensible as there was minimal liability for the ophthalmologist until he admitted that he had constructed a second set of clinical records after the suit was filed. The case was closed with an indemnity payment.
Notes:
- Socioeconomic Characteristics of Medical Practice: 1988. American Medical Association.
- Bettman JW: Seven Hundred Medicolegal Cases in Ophthalmology. Ophthalmology. 1990; 97:1379-83.
