Tracking Referrals and Test Results
Anne M. Menke, RN, PhD, OMIC Risk Manager
Digest, Fall 2009
The OMIC claim discussed in this issue’s lead article involved a patient who was never informed of the need for tests. Other claims result from patients who do not follow instructions to see consultants or undergo diagnostic testing. Both scenarios can lead to patient harm and increased liability risk.
Q Whose responsibility is it to order and review tests and disclose the results to the patient?
A This question needs to be explicitly addressed and answered for each patient when more than one physician is involved. If you want to have the results of tests in hand when you first examine the patient, consider developing a form to send to the referring physician. Ask the physician to state the reason and urgency of the appointment being requested and to provide the contact and medical information you need to evaluate the patient. Indicate the tests that should be completed before you will see the patient. Clearly state who will order the tests and verify that the patient has completed them: “Please send the patient for the following tests and contact my office when you have received the test results.” In some situations, you may not know which tests need to be done until you examine the patient. Tests you choose after examination would normally be tracked by your office.
Q Do you have a system you can ecommend to track referrals and tests?
A Yes. When you determine that a patient needs a consultation with a specialist or a diagnostic test, disclose it to the patient, explain the reason for the order, and document your discussion and order. Ask the patient to schedule a follow-up visit or telephone consultation with you before leaving the office so you can review the results and revise the care plan. Next, instruct your staff to enter the information into a tracking system (see sample below). The system can be a follow-up tracking form, logbook, card file, or spreadsheet on the computer. When the report arrives, instruct staff to attach it to the patient’s file and place on your desk for your review. Date and sign the report, indicate any follow-up needed, and place in the medical record. Disclose the results to the patient and document the discussion. Communicate and document the new treatment plan. update the tracking form.
Q What steps do I need to take to ensure that I get the report?
A There are two ways to ensure that patients obtain the requested tests/consultations and you receive a report. First, assign to a reliable staff member the responsibility of reviewing the tracking system on a regular basis. Second, ask staff as part of preparing records for the next day’s patients to review each file to see if any report or result is expected. If the report is not received in the usual time, ask staff to call for results. If you learn that the patient did not present for the test or consultation, ask staff to contact the patient to learn why. Be sure to question patients in a non-judgmental manner: “We called to get the results of your MRI and were told that you had cancelled it. Was there some kind of problem? Could you tell me why you didn’t have this done?”
Q What if patients refuse the recommended care?
A Clarify why the patient is not complying with treatment recommendations. Possible reasons for not scheduling tests or procedures may include financial difficulties, HMO authorization problems, transportation difficulties, child care problems, confusion about the disease or the need for treatment, or fear of the significance of the results of the test, procedure, or consultation. Next, educate the patient about the disease process, treatment recommendations, and consequences of non-compliance. Target the education to the reasons for non-compliance. When possible, identify social service resources that may help. For example, some pharmaceutical companies provide free or reduced-cost medications. Be familiar with the enrollment criteria and process for state and federal assistance, and of transportation services for patients. If treatment is not authorized by the patient’s HMO, act as a patient advocate and appeal the decision. Verify that the patient understands the points being made by asking the patient to explain them back to you in his or her own words. Give written materials whenever possible, and use visual teaching aids, such as videos, charts, diagrams, and models of the eye. If your efforts to educate and clarify the need for treatment are not effective, you may need to terminate the relationship (see “Noncompliance” and “Termination of the Physician-Patient Relationship” at www.omic.com.
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.
Authorization For Use or Disclosure of Health Care Information
Patient name: ___________________________________________________________________________
Date of birth:______________________________ SSN: ______________________________
I. My Authorization
You, [insert physician or practice name], may use or disclose the following health care information:
All my health information maintained by you
My health information relating to the following treatment or condition: _________________________________
My health information for the date(s):____________________________________________________________
Other:_____________________________________________________________________________________
You may disclose this health information to:
Name (or title) and organization__________________________________________________________________
Address: _________________________________City ________________________State _________Zip_______
Reason(s) for this authorization (check all that apply):
| at my request | check here only when [insert physician or practice name] will get something of value for providing health information for marketing purposes |
| other (specify)______________________________________________________________________________________________________________________________________ |
This authorization ends: on (date) __________________
when the following event occurs _____________________________________
II. My Rights
I understand I do not have to sign this authorization in order to receive treatment. However, I may be required to sign this authorization form:
- To take part in a research study; or
- To receive health care when the purpose is to create health information for a third party.
I may revoke this authorization at any time, in writing, sent to [insert physician or practice name] at the address provided below. If I do, it will not affect any actions already taken by [insert physician or practice name] based upon this authorization; uses and disclosures already made cannot be taken back. I may not be able to revoke this authorization if its purpose was to obtain insurance.
- [insert physician or practice address]
Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
___________________________________________ __________________ ____________________
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Patient is unable to sign because of:_______________________________________________
Age of minor or reason for patient’s inability to sign
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Printed name if signed on behalf of the patient Relationship & Authority (parent, legal guardian, personal representative, etc.)
III. Additional Consent for Certain Conditions
This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this information can be released.
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This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Separate consent must be given to have this information released.
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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.
