*General Consent for Medical and Surgical Procedures (use with addendums)

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GENERAL CONSENT FOR MEDICAL AND SURGICAL PROCEDURES

You have been given information about your condition and the recommended surgical, medical or diagnostic procedure(s) to be used. This consent form is designed to provide a written confirmation of such discussions by recording some of the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure(s).

Condition:  Dr.                                                     has explained to me that the following condition(s) exist in my case:

Proposed Procedure(s):  I understand that the procedure(s) proposed for evaluating and treating my condition is/are:

Right eye                        Left eye

Risks/Benefits of Proposed Procedure(s):
Just as there may be benefits to the procedure(s) proposed, I also understand that medical and surgical procedures involve risks. These risks include allergic reaction, bleeding, blood clots, infections, adverse side effects of drugs, blindness, and even loss of bodily function or life, as well as risks of transfusion reactions and the transmission of infectious disease, including Hepatitis and Acquired Immune Deficiency Syndrome, from the administration of blood and/or blood components.
I also realize that there are particular risks associated with the procedure(s) proposed for me and that these risks include, but are not limited to, those enumerated in the addendum.

Complications; Unforeseen Conditions; Results: I am aware that in the practice of medicine, other unexpected risks or complications not discussed may occur. I also understand that during the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to  me concerning the results of any procedure or treatment.

Acknowledgments:  The available alternatives, some of which include         , the potential benefits and risks of the proposed procedure(s), and the likely result without such treatment,         , have been explained to me. I understand what has been discussed with me as well as the contents of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers.

Consent to Procedure(s) and Treatment: Having read this form and talked with the physicians, my signature below acknowledges that: I voluntarily give my authorization and consent to the performance of the procedure(s) described above (including the administration of blood and disposal of tissue) by my physician and/or his/her associates assisted by hospital personnel and other trained persons as well as the presence of observers.

Patient (or person authorized to sign for patient)            Date

Witness                                Date

[SEE ADDENDUM]

Responsibilities of a Consulting Ophthalmologist

Digest, Fall, 1991

ALLEGATION  Insured consulting ophthalmologist allegedly failed to adequately monitor, order and apply appropriate restraints on a psychiatric patient admitted through the emergency room.

DISPOSITION  Settled out of court.

Background

Ophthalmologists are routinely asked to render emergency services and/or surgery to patients admitted through the emergency room. However, often the duties and responsibilities owed the patient seen on consult are not clear, particularly when there is an attending physician involved.

Case Summary

The patient was a 30-year-old female with a history of schizophrenia who presented to the hospital with a ruptured right globe. Upon admission, the parents indicated to the emergency room physician that their daughter had stopped taking her psychotropic medications, had not eaten for the past two days and had fallen in the bathroom. The patient’s attending psychiatrist was notified but did not come in to see the patient. The patient was ultimately admitted under the psychiatrist’s service and the insured was called in to repair the right eye. Postoperative orders included restraints if necessary.

Soft restraints were applied. However, shortly after the patient returned to her room, she self-enucleated her good left eye. She was taken to the OR where the insured again performed surgery. Unfortunately, the patient had avulsed the optic nerve which left her blind in both eyes.

Although the insured did not call or speak to the psychiatrist directly, the medical record revealed that he had ordered the patient’s psychiatrist be contacted for medications if necessary to sedate her. In addition, restraints were ordered “to keep hands from eyes.”

Medical records from past admissions revealed the patient had suicidal tendencies which her psychiatrist was aware of and which should have prompted him to take appropriate measures for her safety during this admission.

Outcome

The hospital settled out of court for $10,000. Although the OMIC insured said he did not suspect that the initial injury to the eye was self-inflicted, the insured and carrier believed the emotional issues and publicity surrounding this incident would compromise defense of the claim. The ophthalmologist agreed to a nominal settlement. The psychiatrist ultimately settled out of court for $250,000.

Risk Management Principlesand Commentary

This case offers a number of suggestions for ophthalmologists who are called in as consultants:

• Familiarize yourself completely with your hospital’s policy for admitting patients under the name of another physician.
• Communicate directly with the attending physician. Do not delegate this responsibility to the ER or nursing staff.
• Thoroughly document all conversations with the attending physician and nursing staff.
• If the emotional or psychiatric status of the patient is at question, take appropriate measures to insure the patient’s safety.

Failure to Diagnose Pseudomonas Infection

By Stacey Meyer

OMIC Assistant Claims Manager

Digest, Spring 2002

Allegation
Delay in diagnosing and treating pseudomonas infection.

Disposition
Case settled on behalf of ER physician with a nuisance amount contributed by insured ophthalmologist.

Case Summary
A 62-year old male with a history of contact lens wear presented to the ER with complaints of pain, redness, and itching in his right eye. The ER physician examined the patient and found a tearful, hyperemic right eye and a central corneal abrasion. He irrigated the eye and treated it with Gentamicin and a patch. The patient was asked to return the following day, at which time he presented with severe pain, discharge, sensitivity to light, and inability to see. The same ER physician performed a slit lamp examination, which revealed that the corneal abrasion had doubled in size. He did not perform a visual acuity exam. The ER physician contacted the on-call ophthalmologist, who gave instructions for the patient to keep the eye patch on for 24 hours and either return to the ER the following day, which was Sunday, or follow up at his office on Monday.

The patient self-referred to another ophthalmologist on Monday and was found to have a severe, advanced inflammation of the cornea and markedly reduced vision. A culture of the eye was positive for pseudomonas. The patient underwent a corneal transplant but subsequently lost all vision in the right eye.

Analysis

The plaintiff alleged that the ER physician performed an inadequate eye examination, failed to suspect corneal infection, and failed to ensure that an ophthalmologist examined him when he returned the following day. His expert opined that the on-call ophthalmologist was equally at faulty for failing to appreciate the seriousness of the patient’s complaint and for not coming into the ER to examine the patient on Saturday when he received the call, regardless of whether the ER physician requested such an examination. According to the plaintiff’s expert, the ophthalmologist should have been suspicious of the corneal ulcer given the history of the patient’s condition, his failure to improve, and the fact that the corneal abrasion had doubled in size overnight.

OMIC’s defense expert countered that the insured ophthalmologist made a reasonable assessment that this was a non-urgent situation based upon the description provided by the ER physician. Further, lack of any evidence of a corneal infiltrate or inflammatory response effectively ruled out a significant infectious or inflammatory process of the cornea and was compatible with a traumatic corneal abrasion. Since the insured was not asked to see the patient but only to make suggestions for the patient’s care, the defense maintained that the insured’s recommendation to continue treatment with cycloplegics and re-patching was reasonable.

OMIC’s defense team filed a Motion for Summary Judgment on the legal issue of whether there was in fact a physician-patient relationship between the insured and the plaintiff. Unfortunately, the court denied the motion and held that a factual legal issue did exist. The defense team and the insured agreed this would be a difficult case to argue before a jury and settled on behalf of the ER physician with a nuisance amount contributed by the insured ophthalmologist.

Risk Management Principles
It is common practice for an on-call specialist to rely on the examination of the ER physician. Yet, as this case demonstrates, while the ER physician retains primary responsibility for the patient’s care, the on-call physician also can be held accountable and responsible for the patient’s outcome. It is up to the on-call specialist to elicit enough factual information to ensure that the ER physician has thoroughly examined the patient and that the signs and symptoms reported by the ER physician are complete and accurate.

Often in such cases, a dispute arises over what was said by the two physicians. Documenting the details of a telephone conversation with an ER physician is an important as documenting the findings of an office examination. Recollections of what was discussed weeks and months later are unreliable and open to dispute, especially when the liability of either party depends on these details.

Traumatic Eye Injury and Patient Abandonment

By Ryan Bucsi, OMIC Senior Litigation Analyst

Digest, Fall 2006

ALLEGATION:  Failure to go to ER to see patient and failure to wait for or reschedule a missed office appointment.

DISPOSITION: Case settled for $10,000 prior to litigation.

Case Summary

A 25-year-old female presented to an emergency room after accidentally stabbing herself in the left eye with a knife while she was picking up her child. The emergency room physician performed a slit lamp examination and noted an intact pupil, a partial-thickness laceration in the lower tangential cornea touching the sclera, specks of blood in the laceration, an intact anterior chamber, and normal fundus. He contacted the on-call ophthalmologist to set up a follow-up appointment for the next day. The patient was discharged with instructions to apply Erythromycin ointment and a double patch for a period of 24 hours. The next day, the patient failed to show up at the ophthalmologist’s office for her 9 am appointment. At 9:40 am, she contacted the insured as he was driving back home to say she had just woken up, would need to find a sitter for her child and a ride to his office, and could arrive there in an hour and a half. The insured became angry and instructed the patient to proceed to the ER or seek treatment from another physician. At 10:35 am, the patient presented to a different ER and was diagnosed with a full thickness corneal laceration with hypopyon. She underwent multiple procedures, was twice readmitted to the hospital, and ended up with a VA of 20/40 OS, correctable to 20/25.

Analysis

When he telephoned the ophthalmologist, the ER physician informed him that the patient had suffered a laceration that had not entered the anterior chamber, and assured him that he was comfortable performing the eye exam and didn’t need the ophthalmologist to see the patient in the ER. Experts who reviewed the records felt the ER physician failed to diagnose a full-thickness laceration and the ophthalmologist did not ask enough questions to verify the diagnosis (e.g., is the anterior chamber clear or are there white or red blood cells?). Moreover, if the insured had seen the patient in the ER, he probably would have sutured the laceration and prescribed antibiotics, thereby substantially reducing the patient’s subsequent problems. An attorney retained by OMIC to review the defensibility of this case prior to formal litigation feared the plaintiff might successfully argue that by agreeing to examine the patient the day after the ER visit, the insured had established a physician-patient relationship. Therefore, his refusal to return to the office to examine the patient might constitute abandonment and arguably could have contributed to the subsequent complications that required multiple procedures. The attorney’s main concern, however, was that the potential venue in which the case would be tried was an urban center known to be plaintiff-oriented. The insured agreed that the best course would be to settle the case, which OMIC was able to do for an amount far below the plaintiff’s demand.

Risk Management Principles

There were several things the ophthalmologist could have done to promote patient safety and reduce his liability risk. First, knowing the risk of a full-thickness corneal laceration, he should have taken a more active role in the phone conversation with the ER physician and then carefully documented the call. If the answers to his questions raised concerns, or he couldn’t rule out a full-thickness laceration, he should have evaluated the patient himself. Although his anger at the patient’s delay in presenting to his office was understandable, especially on a Sunday, it did not relieve him of his duty to provide ongoing care to a patient with an acute condition whom he had agreed to treat. Once a physician-patient relationship has been established, a physician has an ongoing responsibility to the patient until the relationship is terminated by one of the parties. In order to terminate the relationship, the physician must give the patient written notice sufficiently in advance to allow the patient to secure the services of another physician. Before sending such notice, however, acute problems must be resolved. All ER patients referred for follow-up arguably have unresolved acute problems, so the on-call physician must either continue to treat the patient or arrange for another physician to do so. In this case, the insured should have carefully queried the patient about her condition; this likely would have revealed the need for urgent care, and he could have offered to meet her at the ER to provide it. See “Terminating the Physician-Patient Relationship” at www.omic.com.

Reducing the Risks of Ocular Trauma

By Jerome W. Bettman Sr., MD

Argus, April, 1991

Trauma was the fifth most frequent condition implicated in 700 ophthalmology claims collected over several decades by this author as reported in Ophthalmology (97:1379, 1990). Several medicolegal hazards exist because ocular trauma cases are frequently emergencies. The receptionist may not recognize the need for a timely appointment. The ophthalmologist may fail to do a complete workup or to examine the uninjured eye. Records may be incomplete, making the defense of a claim more difficult.

Furthermore, a patient may expect excellent results despite a very severe injury. A number of claims are filed for no reason other than surprise over a poor result because the patient is not made aware that the prognosis is poor.

Case Study

Failure to diagnose a foreign body accounts for a significant number of trauma-related suits and frequently results when the ophthalmologist relies on one modality such as x-rays. In one such case, a 31-year-old male was seen in an emergency room following an incident in which he hit a metal bar with a sledge hammer and a foreign body struck his right eye. Visual acuity was 20/20 OU and a wound was noted in the sclera in the infero-temporal region. The foreign body was seen on x-ray, localized 4 mm behind the globe, and the patient was discharged.

Four months later, the patient was seen by another ophthalmologist because the eye had become irritated and painful and vision was blurred. A B-scan ultrasound disclosed a foreign body imbedded in the retina. The ERG was abnormal and some siderosis was noted. The patient was hospitalized and the foreign body removed from the ciliary body region. The operation included vitrectomy, cryotherapy, a sponge and encircling buckle. Three-and-a-half years after the injury, a posterior subcapsular cataract was removed from the eye by phacoemulsification with no complications. An IOL was not implanted but visual acuity was corrected to 20/40.

The patient successfully sued the emergency room ophthalmologist and roentgenologist for the missed foreign body. The subsequent ophthalmologist, who extracted the cataract, was sued for not implanting an IOL, but this claim was dropped.

Lessons to be Learned

There are several lessons to be learned from this case:

• More than one modality should be used to diagnose or localize foreign bodies. It is estimated that 20 percent of foreign bodies perforate the globe without significant pain and approximately the same number enter through the sclera. If the foreign body is very small, the entrance wound may not be apparent. None of the siderosis claims reviewed by the author was defensible;
• Contrary to traditional teachings, siderosis is reversible if diagnosed before the ERG is extinguished;
• In cases such as the one cited here, the prognosis is generally poor and the patient should be informed of this. An unpleasant surprise often triggers a suit;
• Cataract patients should be made aware that not everyone is a suitable candidate for an IOL implant.