Risk Management



Clear communication is key to timely diagnosis and treatment

ANNE M. MENKE, RN, PhD, OMIC Risk Manager

The claims discussed in the lead and Closed Claim articles resulted partly from poor communication among treating physicians and staff members. Here are some recommendations about ways to ensure that the necessary information is received from and communicated to the appropriate members of the healthcare team. The scenarios come from actual giant cell arteritis (GCA) claims, and some of the “advice” is from the defense experts who reviewed the claims.

Q An emergency room physician from one of the local hospitals called me about a patient of mine. I don’t take call at that hospital and told him to have the patient schedule an appointment with me. Now I’m being sued along with the ER physician, who says he informed me that the 72-year-old patient had a headache and vision loss. The lawsuit says I should have at least warned the ER physician about GCA. What was I required to do?

A You have no legal duty to provide assistance to a hospital when you are not on call for it. As an ophthalmologist, however, you know more about the risk of severe vision loss from GCA than an ER physician. To protect the patient, urge the ER physician to contact the on-call ophthalmologist to evaluate the patient. (The claim closed without a payment.)

Q I work in a practice that employs optometrists. One of them asked for my opinion about a 67-year-old patient who presented with vision loss, a headache, jaw pain, and scalp tenderness. The OD thought the patient had GCA. I agreed and told him to start steroids and provided the starting and maintenance dosages. The technician who was scribing made a mistake and wrote the prescription for 20 mg daily instead of four 20 mg tablets daily. Now I’m being sued for not taking over care of the patient from the OD and not adequately supervising the technician. What should I have done?

A Optometrists often perform the initial evaluation for patients in a group practice. However, when a patient has a serious, vision-threatening condition such as GCA that requires urgent treatment and careful coordination of care, an ophthalmologist should assume responsibility. Your practice’s written protocols should address this (see “Coordination of Care with Optometrists” at www.omic.com). This optometrist did not have the legal authority to prescribe systemic steroids. In addition, while your technician may know the names and dosages of the eye drops you normally prescribe, she is obviously not familiar with oral steroids. You should have written the prescription yourself and provided written instructions to the patient on how much to take each day and when to see her primary care physician (PCP). Finally, you should have conducted a formal hand-off with the PCP to clarify that the PCP would be responsible for ongoing management of the steroids. It is helpful to give the patient a referral note that explains the reason for the referral and when it should take place (available at www.omic.com/referral-note-for-patient/). (The claim settled for $350,000.)

Q A 76-year-old patient called our practice and spoke to my technician, who reported the conversation to me. I recall her telling me that the patient had pain in the back of his neck, so I instructed her to tell him to see his PCP. The lawsuit alleges that we were told that the pain was also in the temple area and accompanied by visual disturbances, and that given his age, I should have seen him right away. Am I expected to speak to each patient myself or review each note about phone calls?

A You obviously cannot talk to every patient who calls, so you need an efficient and effective way to share information. OMIC claims experience makes it clear that making medical decisions on the basis of the limited information obtained over the telephone is a risky, albeit necessary, aspect of ophthalmic practice. During the phone call, you and your staff need to gather the information necessary to assess the situation and determine the treatment plan, communicate the assessment and plan to the patient, and document the encounter and your decision-making process in the medical record. To ensure that you have the most accurate information, provide staff with a checklist of questions to ask and instruct them to document the answers. Review the contact form when you can give it adequate attention, and document the information you would like your staff to communicate to the patient. To assist you, OMIC developed a sample phone contact checklist and appointment scheduling guide called “Telephone Screening of Ophthalmic Problems” available at www.omic.com. Use this guide to develop written protocols for telephone screening and treatment that are specific to your patient population, subspecialty, and staff; train staff in the use of the protocols and verify competency; and willingly accept questions from staff members unsure of how to handle specific calls. (This claim settled for $200,000.)

 

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