Risk Management

Use an Unusual Event to Reduce Entity Liability

Anne M. Menke, RN, PhD, OMIC Risk Manager

Digest, Spring 2011

The malpractice claims presented in this issue of the Digest raise concerns about the policies and procedures in effect at solo corporations, group practices, and ambulatory surgery centers. Indeed, inadequacies were identified in coordination of care, follow up of noncompliant patients, credentialing, documentation, use of contact lens solutions, appointment scheduling, telephone screening of ophthalmic problems, and instrument sterilization. How can you take action to identify and rectify such problems? Conduct an “event analysis” as soon as you learn of unusual occurrences; focus your analysis on the impact on the patient and the systems or processes involved.

Q   The hospital on-call ophthalmologist just informed me that one of my cataract patients developed endophthalmitis. The patient told her he tried to contact our practice three times and finally went to the ER when no one called back. Should I call the patient?

A  Yes. This patient needs to know that you care about the complication and want to learn more about the problems he reported in contacting your office. “I’m so sorry to learn that you have a very serious infection in your eye. How are you feeling today?” When you can, move on to the phone issue. “Dr. Jones tells me that you weren’t able to reach our office despite calling three times. Do you feel well enough to tell me more about that?” Keep the focus on the patient: “I can only imagine how upset you must be about not being able to speak with us. Let me assure you that I am going to check with our answering service and find out what happened. May I call you again when I find out?” Notify your partners of the situation, get buy-in on the need to evaluate the system, and identify who will lead the analysis. When you contact the service, remain polite and limit the initial contact to beginning the fact-gathering process. “We’re reviewing our call experience this past weekend. Could you please send us a list with details on all the calls you handled for us?” Ask any physicians covering for the practice to provide you with information on calls they took from the service and/or patients. Review the call documentation for clarity, adequacy, response time, and follow up. Consider expanding the analysis: ask all physicians, office staff, and answering service staff for input on questions, problems, or concerns experienced with after-hours calls during the previous six months.

The goal of the analysis is to determine if the problem was with this particular patient and whether the entire process is safe and reliable. You may identify issues such as a physician who yells at the answering service when contacted, lack of clarity on what to do when a physician does not respond, rapid turnover at the service, or malfunctioning equipment. Go back to the physicians in the group with what you have learned and develop an after-hours policy and procedure. Educate all involved parties, then analyze again. Finally, report back to the patient on your findings and your plan; patients appreciate knowing that their poor experience may lead to improved care for other patients.

Q  One of my patients was harmed when her contact lenses were cleaned with the wrong solution. Should I fire the assistant who made this mistake?

A  Termination would be indicated only in exceptional cases. Instead, start by providing comfort to the staff member. Inform her that you would like her help identifying what went wrong so it won’t happen again. Call a staff meeting, ask the staff member to explain the incident, and ask other staff to clarify all steps in the process, paying particular attention to ones that could lead to error or harm. Your written team analysis may uncover contributory causes, such as lack of labeling of solutions, similar looking containers, inadequate training, or pressures from an overbooked schedule. Develop a better process to address the causes, write it up, and test it. Modify the procedure as needed.

Q  My cataract patient experienced a refractive surprise. When I reviewed the medical record, I found a staff member had made a transcription error that led to implantation of the wrong IOL. Am I expected to review orders on each patient before surgery?

A  Not necessarily, but you and your practice need to develop some systematic review process to prevent office-based causes of “wrong IOL.” Use this opportunity to develop an office cataract surgery checklist and staff education program. Include the involved staff member, the technician who performs your A-scans, and your surgery scheduler. Have them map out the care process, and highlight steps that could lead to error or harm. Clarify points at which you will be involved, such as when you verify the results of the A-scan and IOL master. Pay particular attention to key information that needs to be transmitted to the ambulatory surgery center, such as allergies and medical and ocular comorbidities that could impact anesthesia or perioperative care. Eliminate as much transcription as possible by, for example, sending a copy of the A-scan and IOL master results along with the preoperative order. Ensure that the refractive target, type and power of IOL, and operative site are specified. Review and approve the final checklist and educational program before it is presented to the entire staff. Monitor outcomes, and adapt the checklist and process as needed. OMIC risk management staff are here to assist you. Call the confidential Hotline at (800) 562-6642, ext. 641.

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