Risk Management

Diagnostic advice from the experts

ANNE M MENKE, RN, PhD, OMIC Patient Safety Manager

As reported in the lead article, our recent study of diagnostic error (DE) claims showed that the ophthalmologist’s care was the primary factor in the delayed diagnosis of retinal detachments (RDs). Experts evaluating such malpractice claims have the advantage of knowing the patient’s outcome and reviewing the records generated by all staff members and providers. They strive to understand the ophthalmologist’s decision-making process, and may support care they understand even if they would have handled the situation differently. They might ask the following questions to evaluate the care: How did the ophthalmologist decide which exams or tests to perform? What were the results? What determined whether to monitor a patient or refer to a retina specialist? What was the patient told? The reviews help identify breakdowns in the process of care. Here are some pearls extrapolated from these RD claims.

Q. The lead article noted that most patients in the study had RD risk factors. What caused ophthalmologists to miss them?

A. Experts reviewed the patient complaint and history provided to both practice staff members and the ophthalmologist to obtain a more complete assessment of risk factors. They noted many problems with obtaining, communicating, and documenting the presenting complaint and the history. At times, the staff member did not inform the ophthalmologist of reported symptoms or history (indicating both the need for education on RDs and a clear process for how to communicate this information). At other times, the ophthalmologist did not read the notes generated by the staff member that day, or his own notes from previous exams. It was especially difficult to defend an ophthalmologist when this key information was readily available in the medical record.

Q. When must I perform a dilated exam?

A. Experts largely based their opinion on the need for a dilated exam on the presence of risk factors for RD. Experts expected ophthalmologists to perform a dilated exam in patients with risk factors who reported a sudden vision loss or visual disturbance. For example, they felt fundus exams were required in patients with a history of lattice degeneration accompanied by a new complaint of floaters, those who complained of black spots after cataract surgery or reported recent eye trauma, before deciding that cataracts were the cause of the visual decline after trauma, and when there was no explanation for the vision loss. They often criticized ophthalmologists who did not perform dilated exams when longstanding patients with chronic eye conditions reported a recent, sudden decrease in vision.

Q. Do I have to perform scleral depression (SD)?

A. Experts had mixed opinions on the need for SD. They noted that comprehensive ophthalmologists (COs) do not always perform SD, even though the PPP from the AAO recommends it. They also acknowledged that patient complaints about discomfort often influence the decision to forgo SD. They were less critical of COs who did not perform SD if the patient was promptly referred to a retina specialist. In contrast, the experts felt that retina specialists should perform SD. They understood why an experienced retina surgeon who had a good view of the entire retina might not feel one was needed, but testified that they personally always perform one. All felt that documented SD would have significantly helped defend the care.

Q. What do I need to document?

A. Experts opined that ophthalmologists should document when dilated exams are done, whether SD was performed (and if not, why not), and the results of confrontational visual fields. They should include drawings of the retina. Positive and negative findings are both important, so ophthalmologists should include pertinent findings, such as the absence of tears, RDs, lattice, or hemorrhage. Document education about RD warning signs, including the provision of written instructions or brochures, as well as telephone advice.

Q. When should I refer my patient to a retina specialist?

A. Comprehensive ophthalmologists should consider early referral to a retinal specialist if they do not have a clear view of the back of the eye (e.g., vitreous hemorrhage present). COs should refer patients with a history of trauma if no SD was performed or if a clear view of the retina out to the ora serrata cannot be obtained. COs who put RD lower on the differential should reconsider and refer patients when diagnostic studies refute the initial diagnosis, when the diagnosis does not correlate with the patient’s complaints, and when there is no explanation for the vision loss. COs should have an especially low threshold for referring any such patients if they have known risk factors for RD.