Differential Diagnosis: Develop and Disclose It
Anne M. Menke, RN, PhD, OMIC Risk Manager
Digest, Winter 2010
Failure to diagnose is a frequent allegation in medical malpractice lawsuits. OMIC claims analysis and peer-reviewed studies point to some ways to reduce this obstacle to safe, quality patient care.
Q Are there common problems that surface in “failure to diagnose” cases?
A Yes, but they are not what the court system would lead us to believe. Alleging that a patient suffered harm due to a physician’s negligence implies that the diagnosis was missed because of that particular doctor’s shortcomings. In fact, inadequate knowledge or skill was the cause in only 4 of 100 malpractice cases in one study, and all four involved rare conditions. [1] Other cognitive errors, such as faulty data gathering and information synthesis, occurred frequently in the cases studied and were often compounded by faulty systems such as equipment and organizational issues. Cognitive scientists who have analyzed diagnostic errors point out that the way physicians reason, formulate judgments, and make decisions works well most of the time. In some instances, however, cognitive rules of thumb and shortcuts lead to error. Examples include memories of former cases, the way information is presented and framed, obedience to authority figures, and premature closure of the diagnostic process. [2] These cognitive “pitfalls” are inherent in the process itself; another physician may well make the same errors.
Q Do studies of OMIC claims data reveal these cognitive errors?
A Yes. In a recent OMIC study, three conditions were frequently misdiagnosed: retinal detachment, glaucoma, and foreign bodies. Retinal detachment and glaucoma were often missed if the patient had ocular comorbidities that could explain some of the symptoms, leading the ophthalmologist to assume it wasn’t necessary to complete a comprehensive evaluation, including a dilated eye exam. Retained foreign bodies were missed when the physician did not obtain an adequate history or failed to order x-rays to rule out their presence (see Closed Claim Study). Systems issues, particularly office appointment scheduling and follow-up protocols, also contributed to patient harm and led to settlements. When an on-call physician did not notify his staff of a patient due to come in the following morning after an ER consultation, his staff would not schedule the appointment, citing the office policy of declining public aid patients. After the child developed a corneal ulcer and needed a transplant, the practice settled for $1,000,000. Some conditions manifest themselves more clearly with time, and are often correctly diagnosed at the follow-up visit. If the patient does not show up for the visit, and staff do not notify the ophthalmologist of the missed appointment, an opportunity to intervene is lost. (See OMIC’s “Telephone Screening of Ophthalmic Problems” and “Noncompliance” at www.omic.com.)
Q What strategies do cognitive scientists suggest to improve the decision-making process?
A Strategies that encourage physicians to stop and examine their thinking process may help. Two key safety steps are: 1) pause to consider what else could produce the same signs and symptoms, and 2) entertain, however briefly, the worst possible scenario. By developing a differential diagnosis, the ophthalmologist can determine not only when a complete, dilated exam is required, but also when additional tests are needed to rule out vision-threatening conditions. A diagnosis that does not account for all of the signs and symptoms needs to be reconsidered, as does one that leads to a treatment plan that is not effective. When the patient’s course is unexpected, start over by reviewing the record with an open mind and asking questions such as “What else might be going on?” These strategies might prompt additional testing and examination, an expanded differential diagnosis, and a clearer picture. [3]
Q Why do you recommend disclosing the differential diagnosis to the patient? Doesn’t that just confuse the patient?
A In a busy ophthalmic practice, it is easy to overlook the need to obtain a thorough patient history and to rely solely upon the information provided by the patient to you or your staff. The patient’s presenting “complaint” may be misleading or irrelevant unless specific questions are asked, or the patient may have been interrupted before he or she had time to give a full account of all symptoms. Make the patient part of the healthcare team from the beginning of the diagnostic process by allowing sufficient time for the patient to present his or her concerns. Disclose your differential diagnosis and treatment plan. Ask the patient to watch for new symptoms and to contact you if the condition worsens or does not improve before the next appointment.
1. Graber ML, Franklin N, and Gordon R. “Diagnostic Error in Internal Medicine.” Arch Intern Med. July 11, 2005; v. 165: 1493-1499.
2. Redelmeier DA. “The Cognitive Psychology of Missed Diagnoses.” Ann Intern Med. 2005; 142:115-120. For a detailed discussion, see Croskerry P. “Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias.” Acad Emerg Med. 2002; v. 9, n. 11: 1184-1204.
3. “Failure to Diagnose Traumatic Eye Injuries” and “Failure to Diagnose Giant Cell (Temporal) Arteritis” at www.omic.com.
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Failure to Adequately Inform of Laser Risks
Digest, Fall, 1994
Allegation
Insured ophthalmologist and a retina specialist allegedly failed to warn of the potential danger of total blindness resulting from laser treatment.
Disposition
Charges against the general ophthalmologist were dismissed. The retina specialist settled for an unspecified amount based on the confusion around the informed consent issue.
Case Summary
The patient was a 64-year-old woman who presented to the insured ophthalmologist after experiencing a sudden loss of vision in her right eye. She had a history of hypertension, cataract surgery, and macular degeneration in both eyes. Visual acuity on examination was hand motion at 1 ft. OD, and 20/80+2 OS corrected. Examination of the posterior segment of the right eye revealed an extensive subretinal and subpigment epithelial hemorrhage involving the macula. Both eyes disclosed extensive and severe changes in the macula consisting not only of hemorrhage, but also of drusen and atrophic pigmentary changes. The retinal arterioles were quite narrow in each eye, indicating severe arteriolar sclerosis.
A fluorescein angiogram disclosed the presence of some retinal neovascularization and RPE atrophy in the right eye, but no subretinal blood in the left eye. The recorded diagnosis was huge subretinal hemorrhage OD due to macular degeneration, and beginning subretinal hemorrhage on the left. The insured recommended that the right eye be observed for the next 6 to 12 months and that laser treatment be performed to prevent further breakage and hemorrhaging of the left paramacula. Before referring her to a retina specialist, the insured had the patient sign a fairly general consent form for laser surgery, which listed blurred vision, bleeding, and a hole in the retina as possible complications. The retina specialist also discussed possible complications of surgery with the patient, but since the patient had already signed a release, he did not document the discussion in the record nor did he have her sign a release.
The laser treatment was performed without apparent complication. Three days later, however, the patient noted severe vision loss in the left eye. Examination revealed an extensive subretinal hemorrhage in the left eye similar to that which was present in the right eye. The left eye advanced rapidly from hand movement to no light perception. The patient was left with only light perception in her right eye.
Analysis
The medical experts who reviewed this case were not critical of the technique used during the surgery. They agreed that laser photocoagulation was the appropriate treatment of choice for this patient; however, they were critical of the retina surgeon for failing to adequately document the informed consent process and for relying upon the referring physician’s informed consent. Even though the referring physician had made cursory documentation of the informed consent discussion, it was the surgeon who ultimately was held responsible for ensuring that the patient was adequately informed and for documenting that discussion. Because he did not do this, the plaintiff’s attorney was able to argue that the patient was not adequately warned of the possibility of total blindness following laser treatment. The plaintiff attorney’s final argument was that the patient was not given the pertinent facts to make an intelligent choice about her own vision.
Risk Management Principlesand Commentary
This case illustrates a deviation from one of the primary rules of informed consent: The caregiver who actually performs the procedure is primarily responsible for the adequacy of the informed consent. In the case of a referral, a surgeon cannot make the assumption that the referring physician has discussed the surgery with the patient. Even when the surgeon is certain that detailed information was previously provided to the patient, it is a good practice to review this information, especially in the case of elderly patients, to assist their understanding and allow time for questions.
The issue of adequate consent also comes up under several teaching scenarios where a resident often will secure a timely informed consent prior to a procedure at which the resident is assisting. In such cases, the attending surgeon remains responsible for the quality and completeness of the consent process, and it behooves the surgeon to doublecheck the adequacy of the resident’s consent technique. With the advent of managed care and the interdependence of ophthalmologists, optometrists, physician assistants, nurse practitioners, and others, assuming that another caregiver along the chain of health care has adequately informed or educated a patient is a dangerous practice.
Patient Slip and Fall Following Dilation
By Stacey Meyer
OMIC Assistant Claims Manager
Digest, Spring 2001
ALLEGATION Failure to provide sunglasses following dilation led patient to fall and hip fracture.
DISPOSITION Case settled on behalf of insured ophthalmic group.
Case Summary
A 72-year-old male patient was seen by the insured for a routine eye exam during which his eyes were dilated with Neo-Synephrine 2.5% and Mydriacyl 0.5%. Afterwards, as the patient was leaving the office and walking towards his son’s waiting car, he stepped off the curb outside the building and fell down on his right side. He sustained a transverse fracture through the mid-right femoral neck and eventually underwent a bipolar hip replacement. After numerous physical therapy sessions, the patient was ambulating with minimal difficulty.
Analysis
The patient alleged that the insured ophthalmologist was negligent in not providing him with sunglasses or advising him to wear sunglasses after dilating his eyes. He stated that when he left the insured’s office, his eyes were unprotected and blinded by the sun’s glare, which impaired his vision so that he did not see the step from the curb. The plaintiff’s expert opined that it was below the standard of care to allow the patient to leave without providing sunglass protection before the effects of dilation had dissipated.
The insured countered that the technicians in his office who instill dilating drops routinely warn patients that they can cause blurry vision and heightened sensitivity to light, and they keep sunshades at the front desk for patients who request them. However, there was no written office policy or procedure in place regarding this issue. Although the office administrator maintained that she offered the patient sunglasses, there was no documentation to support this, and neither the insured nor other office staff could remember specifically warning the patient of the potential problems associated with dilation. Furthermore, the OMIC Publication Archives advise physicians who administer dilating drops to instruct patients to wear sunglasses and avoid driving or operating dangerous machinery afterwards. In light of this, the defense team and insured agreed it would be difficult to defend the case and settled on behalf of the insured ophthalmic group.
Risk Management Principles
Failure to provide for a patient’s safety has been the basis of many “slip and fall” suits against ophthalmologists. Oftentimes, a slip and fall claim will cross over both a physician’s general liability and professional liability coverage, depending on whether the treatment rendered to the patient contributed to or caused the incident in question. Responsibility for patient safety does not begin and end in the exam chair, but extends to the entire premises, regardless of whether the physician owns or controls the property outside the office
Visual impairment following dilation raises questions of patient safety and establishes a duty on the part of the caregiver to provide for the patient’s safe transport out of the office. Settlements and judgments involving patient falls post-dilation can range a few thousand to tens of thousands of dollars, particularly if the ophthalmologist or office staff are found negligent in supervising an elderly or visually impaired patient.
Providing a safe environment for patients should be a priority in all practices. Conduct periodic audits of the office premises and safety policies. Develop written procedures establishing safety guidelines and practices to be followed by office staff. A routine checklist or mechanism to record that a patient has been warned of potential glare problems and instructed to wear sunglasses can serve to protect the physician and staff from failure to warn allegations.
Elderly Patient Falls from Wheelchair Following a Dilated Exam
By Ryan Bucsi, OMIC Senior Litigation Analyst
ALLEGATION: Failure to assess fall risk and to warn patient of effects of dilating drops on visual accuity.
DISPOSITION: Case dismissed following patient’s death from causes unrelated to injuries sustained in fall.
Case Summary
An elderly patient underwent a dilated examination by an optometrist at an OMIC insured ophthalmology group. She was unaccompanied and used an electric wheel- chair. As she was leaving the building following the exam, staff gave her a pair of sunglasses and asked if she required assistance to her car; she declined. Shortly thereafter, some staff members were eating lunch outside the office when they heard a loud crash. They found the patient lying on the steps with her head bent into the stairs. Apparently, she had misjudged the stairs for the wheelchair ramp upon exiting the building.
An ambulance was called, and the patient was admitted to the ICU where a CT scan displayed a small intra-parenchymal contusion. She remained neurologically intact and was not felt to be an appropriate candidate for rehabilitation service at the hospital. Instead, she was discharged nine days later and admitted to a long-term skilled nursing facility where she received care for a rotator cuff tear on her right shoulder. She was subsequently discharged from the skilled nursing facility and was followed by a neurologist. The neurologist noted that her double vision had gradually subsided and that her memory for recent and remote events was unaffected. The patient remained independent in all activities of daily living. She died of an unrelated illness during the investigation of her claims.
Analysis
Staff at the OMIC-insured facility certainly did the right thing by providing sunglasses, offering assistance, and documenting the patient’s refusal of it. In retrospect, however, it is clear that the patient was a poor judge of her own need for help. Moreover, the offer of help did not prevent the plaintiff attorney from alleging that more proactive care in the form of a fall risk assessment was required. Indeed, this patient had several risk factors, including her advanced age, wheel- chair use, unaccompanied status, and a decline or alteration of vision due to dilating drops.
Furthermore, the wheelchair ramp and stairs leading out of the building were the same color, and it was arguably difficult to distinguish between the two, even with good vision. The lawsuit also alleged a failure to warn since the patient was not told of the risk of a fall or the danger of operating machinery, i.e., driving a motorized wheelchair, while her vision was impaired.
Risk Management Principles
Falls are the most common type of accident in the hospital setting and the fifth leading cause of death among persons over age 65.1 Ophthal- mologists routinely treat elderly individuals with physical limitations, motility impairment, and poor visual acuity. When these same individuals are administered dilating drops, the known side effects—decreased visual acuity, photophobia, lack of accommodation, glare, blurred vision, and decreased contrast threshold and contrast visual acuity—can prove to be much more than they can safely handle.
Fall prevention requires assessment, assistance, supervision, and surveillance. Assistance to and from the office and when getting up from a chair should specifically be offered or supplied to the elderly, handicapped, and/or visually impaired. Thorough evaluation of all of a patient’s risk factors as well as an evaluation of the general surroundings should be performed in assessing each patient’s risk for an accident following a dilated examination. Utilizing color schemes that maximize the differences between floors, steps, walls, and ramps can decrease the likelihood of a patient fall and injury.
In addition to assessing patients for fall risk, ophthalmologists and/or their staff should also obtain informed consent for dilating drops and offer patients sunglasses. While this case involved a fall, patients and other injured parties have also sued ophthalmologists when patients whose eyes were dilated were involved in motor vehicle accidents after leaving the ophthalmologist’s office. See the Risk Management Hotline article in this issue as well as OMIC’s risk management recommendations and sample consent form at www.omic.com.
