Interpreters for Deaf Patients
Anne M. Menke, RN, PhD, OMIC Risk Manager
For our risk management recommendations on interpreters for deaf patients, please click here. For advice on limited English proficiency patients, click here.
Digest, Winter 2006
Physicians are well aware of the central role clear communication plays in the physician-patient relationship. Patients who are deaf present special challenges to effective interactions. Ophthalmologists often have questions about how to obtain and reimburse interpreters and whether family members can fulfill this role.
Q My deaf patient insists that I provide a translator. Am I required to do so?
A Although the law has been interpreted “by some as creating a requirement that the physician provide and pay for the cost of hearing interpreters for their patients who are hearing disabled,” the American Medical Association has noted that there is “no hard and fast requirement for the provision of such services” and that the Americans with Disabilities Act (ADA) “does not mandate the use of interpreters in every instance.” The Supreme Court ruled in an education suit, for example, that American Sign Language (ASL) interpreters are not required when lip reading or other accommodations are sufficient. In the medical arena, physicians often rely upon note pads to communicate with deaf patients. At times, such as before major surgery, or when initiating a treatment plan for a complex condition, an interpreter may be necessary.
Q Does the ADA even apply to my practice?
A Yes. Intended to stop discrimination on the basis of disability, the ADA requires those who own, lease, or operate a place of public accommodation, such as a physician’s office, to make reasonable accommodations to meet the needs of patients with disabilities, unless “an undue burden or a fundamental alteration would result.” Actions, standards, and policies that either intentionally discriminate or have the effect of discrimination against persons with disabilities are prohibited. Moreover, failure to take steps that may be necessary to ensure access, such as providing auxiliary aids and services, could be seen as discriminatory.
Q What steps must my group take to meet the needs of patients with disabilities?
A First, conduct and document an analysis of your overall obligations. Decide what particular aid or service will be provided, based in part upon an analysis of the length and/or complexity of the medical service, treatment, or procedure. A patient’s request for a sign language interpreter should be a significant factor in the decision. Determine whether providing such a service would result in an undue burden on the overall practice. Second, assess the patient’s needs before providing a particular auxiliary aid or service. Ask the referring physician how he or she usually communicates with the patient. Consult with the patient about his or her needs when the appointment is scheduled and document the discussion. If a patient requests an interpreter, ask staff to acknowledge the request and gather more information about the patient’s concerns/expectations for the visit so the physician can determine the best way to meet them. Document the decision and the assistance provided. For many routine office visits, a notepad may be sufficient to ensure good communication. Office visits before major surgery or for a new, complex treatment plan may require an interpreter. If the physician and patient disagree, reconsider the decision. Finally, maintain a list of qualified sign language and oral interpreters.
Q Can I charge the patient for the cost of the interpreter?
A No, the cost of aids cannot be passed onto the patient. However, the patient’s employer, health plan, Medicare, or a local hospital may be able to help provide or pay for an ASL interpreter.
1. AMA Legal Issues: Americans with Disabilities Act and Hearing Interpreters, accessed 11/21/2005.
2. American with Disabilities Act (ADA), 42 U.S.C.§ 12101, et seq. ADA Title III Tecnical Assistance Manual, http://www.usdoj.gov/crt/ada/taman3.html, accessed 1/10/2006.
Honesty is the Best Policy When Things Don’t Go Well
By Anne M. Menke, RN, PhD
OMIC Risk Manager
Digest, Spring 2007
Faced with a medical error, patients want their doctor to do three things: explain what happened, say he or she is sorry that the patient experienced the poor outcome, and assure the patient that steps will be taken to prevent the same thing from happening to others.1 While many physicians want to talk to their patients in this way about errors and other adverse events, they may hesitate to do so for a variety of reasons. Some fear that disclosing errors and complications may prompt a lawsuit. Others may lack the communication skills necessary to respond to a patient’s anger and grief with compassion rather than defensiveness. When other health care providers or organizations are involved, some physicians may feel conflicting loyalties or be concerned about the impact of a disclosure discussion on collegial relationships, referral patterns, or credentialing.
Ophthalmologists calling OMIC’s Risk Management Hotline frequently ask for advice about revealing errors, offering apologies, or waiving fees. OMIC’s approach is founded on the principles of honesty, compassion, and fairness to both the ophthalmologist and the patient, and is designed to help minimize the risk and severity of claims and lawsuits. Over the years, articles in Argus (now published by the American Academy of Ophthalmology as EyeNet) and the OMIC Digest have offered advice on this topic. Dr. Jerome Bettman noted that “when complications arise, honesty is the best policy.” He encouraged physicians to “tell the patient what has happened as soon as possible.” Dr. Byron Demorest advised that “waiving your bill may avert a claim following a poor clinical outcome.” Paul Weber, vice president of OMIC’s Risk Management/Legal Department, reminded insureds, “don’t be afraid to say you’re sorry.”2 OMIC’s claims experience indicates that whatever the event or situation, communicating with the patient or patient’s family about the adverse outcome sympathetically and non- defensively within the shortest appropriate time period may help dispel much of the patient’s anger, confusion, and distrust. A patient’s belief that he or she is not being told the whole story, or is not being given the opportunity to ask the physician questions and vent feelings, often provokes a decision to seek the advice of an attorney and pursue a medical malpractice claim against the ophthalmologist. Indeed, studies have shown that patients who sued their physician often did so because their doctor did not help them understand what happened.
Patients who experience unanticipated outcomes are often confused about the difference between a poor or unsatisfactory outcome—a maloccurrence—and malpractice. An unanticipated outcome may or may not be the result of error or negligence, and not all errors are the result of medical malpractice. In fact, further investigation into an unanticipated outcome or allegation of negligence may reveal that what initially appeared to be malpractice was actually the result of the disease process itself or an unforeseeable or unpreventable complication of a risky, or even life- or vision-saving, treatment. To assist policyholders in dealing with patients following unanticipated outcomes, OMIC offers confidential, individual counseling through our Risk Management Hotline at (800) 562-6642, ext. 651. During these conversations, we help the ophthalmologist prepare for disclosure discussions, conduct an event analysis to evaluate the causes of unanticipated outcomes and improve patient outcomes in the future, respond to complaints, and weigh options when faced with a request for a refund. OMIC’s detailed recommendations on “Responding to Unanticipated Outcomes” are available as a document from our web site and are applied to case studies in two presentation formats, a CD and online course. This issue of the Digest illustrates many of these approaches. This article presents how an error, a complication, and unmet expectations were handled by three OMIC policyholders. Policy Issues discusses apologies in relation to OMIC’s policy coverage; the Closed Claim Study examines fee waivers; and the Hotline discusses waivers, refunds, and indemnity payments.
“Taking the High Road” When an Error Occurs
A 44-year-old man presented for bilateral LASIK correction of hyperopia. The next day, he reported significant visual difficulties, which examination revealed were due to high hyperopia and astigmatism. The ophthalmologist explained that the results were not what he expected. He told the patient he wanted to review the records and asked the patient to return the next day. The ophthalmologist contacted OMIC when he discovered that the patient had been treated with another patient’s laser settings. The physician explained that the first patient of the day had cancelled his surgery and that the second patient did not correct staff members when they repeatedly called him by the other patient’s name.
The ophthalmologist planned to tell the patient what had happened and provide treatment to address his visual difficulties at no charge. We agreed with his approach. After unsuccessful trials of contact lens and glasses, the patient underwent refractive lens exchange with implantation of a toric lens, followed by bilateral LASIK to treat residual refractive error, all at no charge to the patient. While his UCVA was 20/20 on the first postoperative day, his vision quality later deteriorated. At that point, the patient not only stopped seeing the surgeon, but sought legal advice.
An independent medical examination confirmed central irregular astigmatism that could not be corrected surgically, and BCVA of 20/80 OD and 20/100 OS. The ophthalmologist was disheartened that an error had harmed his patient but remained proud of “taking the high road” to stand by his patient and develop better patient identification policies. His honest, compassionate response was acknowledged by the plaintiff and his attorney. The case was settled for $85,000 on his behalf; the refractive surgery center paid $15,000.
Failure to Disclose Is Difficult to Defend
As sometimes happens in cataract surgery, a tear occurred in the posterior capsule, allowing a small fragment to drop into the posterior chamber. The ophthalmologist performed a minimal anterior vitrectomy and proceeded to place the IOL in the posterior chamber. Postoperative visual acuity was 20/100, with the IOP elevated at 30. The surgeon prescribed anti-inflam- matory, antibiotic, and pressure- lowering drops. Over the next ten months, the IOP fluctuated from a low of 18 to a high of 38, with VA progressively declining to LP. On the last visit, the patient expressed her unhappiness about the outcome and promised to seek a second opinion.
The patient was true to her word and ultimately filed a lawsuit, during which she learned for the first time of the intraoperative complication. Defense and plaintiff experts agreed that the surgery was indicated and that the complication itself was evidence of a maloccurrence rather than malpractice. Unfortunately for both the ophthalmologist and the patient, they also concurred in their criticism of the surgeon for neither documenting nor disclosing the complication. Furthermore, they noted that the postoperative management was negligent in that no effort was made to find or remove the lost fragment, despite ongoing problems with elevated intraocular pressure and decreasing visual acuity. They felt that an early referral to a retinal specialist could have resulted in a better outcome for the patient. The policyholder agreed, and the patient was compensated $200,000.
As this case demonstrates, physicians are often reluctant to inform patients of complications, but patients clearly want to be told. Indeed, one study showed that 98% of patients want to be informed of even a minor error, and the more severe the outcome, the more patients and families desire information. While 92% of patients thought they should always be told about complications, only 60% of physicians thought so. Similarly, 81% of patients said they wanted to know about future adverse outcomes associated with complications, but only 33% of physicians thought patients should be told about such adverse outcomes.3
OMIC policyholders who are unsure about whether and how to disclose an adverse event to a patient can discuss the matter with our risk management specialists. Had OMIC been consulted in this situation, we would have encouraged the ophthalmologist to approach the patient at her postoperative visit with the following information: “Mrs. Jones, as you noticed, your vision is not what you and I expected, and your eye pressure is high today. Yesterday, there were some problems during the surgery. Part of your lens fell into the back of your eye. If I had removed it, your eye could have been injured. I am putting you on some drops to control the pressure and swelling and prevent an infection. I’ll watch your eye closely. If the pressure doesn’t come down, or your vision doesn’t improve, I’ll want you to see a retina specialist who may need to remove the piece of lens. I’m so sorry this has happened to you. I’m going to do all I can to help you deal with this complication and protect your vision. Do you have any questions?” Such a discussion will not only strengthen the physician-patient relationship and help involve the patient in his or her care, but can also prevent an allegation of fraudulent concealment, which could open the door to punitive damages.
Some Patient Expectations Cannot Be Met
A 65-year-old presented to an ophthalmologist with a complaint of droopy upper eyelids. Examination revealed bilateral ptosis and mechanical upper eyelid entropion. After a detailed informed consent discussion, the patient agreed to a bilateral upper lid blepharoplasty and internal ptosis repair. The surgeon was pleased with the outcome; the patient was not. As she put it, she “missed the face she was born with.” The ophthalmologist responded with patience and compassion as the patient continued to express her discontent. When she wrote a letter threatening a lawsuit and complaint to the Centers for Medicare and Medicaid (CMS) if he did not pay for surgery by another ophthalmologist, the insured called OMIC for assistance. He was disappointed that the patient was unhappy but felt he had provided the best possible care. We agreed with his decision to deny her request and helped him craft a letter in which he stated that while he was sorry she continued to be unhappy about her outcome and the fact that surgery had not met her expectations, he was unwilling to pay for additional consultations or treatment. In response to the patient’s claim letter, OMIC had the case reviewed by an oculoplastics specialist, who felt the surgeon had provided excellent care. The patient’s com- plaint to CMS was similarly dismissed and the patient never filed a lawsuit.
Two of the ophthalmologists discussed in this article had frank but empathetic conversations with their patients about the unanticipated outcomes, while the third chose not to document or disclose the complication. All three received written patient complaints or demands for money, two of which resulted in indemnity payments. Talking to patients in a forthright manner will not necessarily prevent claims and lawsuits, but it will help physicians feel they have responded with dignity and professionalism, in accordance with the ethical standards of the American Academy of Ophthalmology and the American Medical Association. Such an approach can also decrease the amount the physician may need to pay to compensate the patient if compensation is warranted.
1. Vincent C, Young M, Phillips A, “Why do patients sue doctors? A study of patients and relatives taking legal action,” The Lancent, 1994; 343:1609-13.
2. Bettman, Jerome W, Sr, MD, “When Complications Arise, Honesty is the Best Policy,” Argus, May 1992. Demorest, Byron H, MD, “Waiving Your Bill May Avert a Claim Following a Poor Clinical Outcome,” Argus, Nov 1992. Weber, Paul, JD, “Don’t Be Afraid to Say You’re Sorry,” OMIC Digest, Spring 2001.
3. American Society for Healthcare Risk Management (ASHRM), “Disclosure of unanticipated outcomes: The next step in better communication with patients (first of three parts),” May 2003. ASHRM website, www.ashrm.org, accessed September 2004.
My Doctor Never Told Me That Could Happen
By Anne M. Menke, RN, PhD
OMIC Risk Manager
Digest, Summer 2007
Why do patients sue? This question, pondered by most physicians at some point in their careers, prompted a famous study that was published in JAMA in 1992. GB Hickson and his co-authors queried obstetrical patients who filed lawsuits after their infant had experienced permanent injuries or death. The study showed that patients initiated malpractice claims, in descending order of frequency, when they were advised to sue by a knowledgeable acquaintance (often a physician), needed money, believed there was a cover-up, felt their child would have no future, wanted more information, or wanted revenge or to protect others. 1 This article will explore physician-patient communication with particular focus on how to use the informed consent process to keep the lines of communication open before and after surgical procedures.
The insurance industry has long known that the majority of claims involve a relatively small number of physicians. The Hickson study authors wondered why. Do these high risk physicians attract higher risk patients? Do they practice bad medicine? Or do they relate differently with patients? In order to explore the relationship between physicians’ malpractice experience and their patients’ satisfaction, the authors devised a new study and asked a different group of mothers about their satisfaction with pregnancy and delivery care (see table 1). 2
The results confirmed the authors’ hypothesis that lawsuit frequency correlates with the volume of patient complaints about interpersonal aspects of care. Physicians with no claims history were perceived as “concerned, accessible, and willing to communicate,” whereas those with multiple claims were viewed as “hurried, uninterested, and unwilling to listen and answer questions.” In a companion article that examined quality of clinical care, SS Entmann et al found no correlation between prior malpractice history and either objective or subjective measures of quality of care. 3 This supports the Hickson findings that factors other than bad medicine are to blame for lawsuit frequency.
the central role that provider- patient rapport plays in malpractice claims was also supported by a 1994 finding by hB Beckman et al that a breakdown in patient-physician communications could be associated with over 70% of professional liabil- ity litigation.4 Patients would rather not sue their physicians. Vincent et al note that they want their doctor to do three things after a poor out- come: explain what happened, say he or she is sorry that the patient experienced the poor outcome, and assure the patient that steps will be taken to prevent the same thing from happening to other patients.5
Risk management experts have suggested that much of this communication dysfunction could be avoided by engaging the patient and family in a constructive, ongoing informed consent dialogue designed to invite them to participate in their care, clarify misconceptions, and minimize unrealistic patient expectations. Rather than being a purely legal function that must be fulfilled prior to invasive procedures, consent becomes an opportunity to establish a “therapeutic alliance” between the ophthalmologist and the patient wherein each acknowledges the clinical uncertainties that exist to some degree with each medical or surgical intervention.6 As the next section shows, forging such an alliance takes careful consideration and thoughtful communication.
What Do Patients Want?
Weighing the risks and benefits of a proposed surgery is central to the informed consent process and begins with understanding what the patient wants from surgery. CK Pager’s expectations and outcomes in Cataract surgery (EOCS) study analyzed preoperative expectations about outcomes and studied what led to patient satisfaction.7 After an informed consent discussion, patients completed the Visual function index, known as the VF-14, and indicated what they felt their score would be after surgery. Expectations ran “unreasonably high” in the patients in this 2004 study. They anticipated achieving a mean VF-14 score of 96.1 (an 11 point gain), and fully 60% assumed they would achieve a perfect score of 100 postoperatively. One might expect satisfaction to correlate with improvement in VF or the actual outcome. instead, patients weren’t satisfied unless they got what they expected, and those with an ocular comorbidity were most likely to be dissatisfied. When patients had expectations of reading small print, doing fine handiwork, reading a newspaper, or driving at night, they were decidedly unhappy if they had difficulty performing these tasks postoperatively. Indeed, few patients realistically achieved their goal, leading Pager to conclude that 70-year-old patients expect cataract surgery to enable them to see like 20-year-olds. Given the current advertising about the benefits of “multifocal” and “premium” IOLs, it is worth noting that these unrealistic patients all had monofocal implants, and had not been subjected to advertising promising them full recovery of their youthful vision. The only suggestion the study offered was to use the informed consent process to contribute to more accurate patient expectations.
What Do Patients Hear?
What do patients hear and understand about risk during an informed consent discussion? More pointedly, if patients expect perfect vision, how can ophthalmologists prepare them to accept not only realistic outcomes but possible complications? Unfortunately, just as prospective patients overestimate the benefits of cataract surgery, they underestimate the risks.8 In a study by CG Kiss et al, patients were provided with a standardized informed consent document that fully explained the risks, benefits, and alternatives. When questioned after the consent discussion, patients nonetheless believed that cataract surgery was relatively easy. Fully 76% felt there was no risk of a complication; when pressed, 60% maintained that even in their own surgery, there was no risk of a severe complication. Even when they finally admitted that the risk of a severe vision-threatening complication was real, 77% did not take risk into account when making the decision to proceed with surgery. Indeed, 78% said that the discussion had no impact on their decision, while the rest reported that it only confirmed the choice they had already made.
What frustrates ophthalmologists and healthcare risk managers is that these same patients may well claim in court that the discussion never took place or that they never would have consented to the surgery if informed of the risks. The authors of the study acknowledge that some patients do lie, but feel this explanation does not account for flawed recall of the informed consent discussion. They concluded instead that when patients come to ophthalmologists with a visual problem, they have already made a decision to have surgery in order to solve the problem and improve their vision. When confronted with what they perceive as negative objections (i.e., an accounting of associated risks), patients experience stress. Since they need to feel comfortable with their decision and minimize the stress, patients hear (and remember) what enhances a positive attitude and devalue (and forget) objections. In other words, patients “believe in and hope for the best.” To counteract this cognitive dissonance and help patients take in more accurate information about the risks of treatment, patients should be given information about the procedure earlier than the day before surgery.7
Why Don’t Patients Hear?
JE Pauling, an expert from a non-medical field who has studied how to communicate risks to the public, feels the problems lie not so much in how patients process information as in the way it is communicated to them.9 In other professions such as aviation and nuclear energy, there is great concern about the consequences of misunderstanding. To decrease its likelihood, only a few well-trained individuals are authorized to speak to the public. They always begin their message by addressing the potential emotional impact of the message before going on to provide information in the form of visual aids.
In the medical field, almost all clinicians are called upon to communicate risk. They receive little to no training, minimize their own and the patient’s emotions, and offer data with few visual aids. Poor process and training are only part of the problem, Pauling argues. Physicians want to build trust with their patients and know that it depends in part upon showing the patient that one is a good doctor. They assume that their patients know they care (“i went into medicine to help people”) and focus their efforts on demonstrating their competence, calling upon science and probability to calculate comparative risks. they are quite comfortable both with accepting a certain level of risk as inherent in treatment and with the uncertain, ever-changing nature of knowledge. Patients, on the other hand, assume that physicians are competent (“she went to medical school”) and watch anxiously for signs that their physician cares about them. Disregarding the data, they are only interested in hearing if the proposed procedure is or isn’t safe for them and knowing the personal consequences of treatment. Moreover, patients consider any discussion of uncertainty as evidence not of competence but rather of the physician’s lack of knowledge (“he doesn’t know the answer”).
Pauling illustrates his points and begins to give some practical advice with the following example. Imagine you are an obstetrician and are trying to help a 39-year-old woman understand her risk of having a fetus with Down’s syndrome. You know that it is 1.2% or 1 in 83. You provide these figures and reassure the woman that her risk is “quite low.” As table 2 shows, however, a patient’s perception of quite low is different, as anything higher than 1% is actually considered a high risk. Only when the likelihood falls in the 1 in 1000 to 1 in 10,000 range is it considered by patients to be a low risk.
In addition to using the same risk calculus, there are other steps physicians can take. First, use a common denominator to place the particular patient’s risk in a continuum (e.g., for a 35-year-old woman, the risk of having a child with Down’s syndrome is <3/1,000, and for a 40- year-old woman, it is <9/1,000). Second, to improve the likelihood of being understood, the physician can translate this information into a visual aid by using a graph available online at www.riskcomm.com. A 35-year-old woman would see a chart with stick figures for 1000 people. Three of those would be darkened to represent the number of women who will have a Down’s infant. The woman would also note that the vast majority—997/1000 women in her age group—are likely to have a child without Down’s syndrome. Providing both a positive and negative perspective and context enhances the message. Finally, relate the risk to one the patient knows and understands (e.g., people have a 1 in 10,000 risk of being struck by lightning or of dying from an accident in their own home).
Please go to the Risk Management Recommendations section of www.omic.com for an extended version of this article, including detailed suggestions for the consent process and footnote references.
Message from the Chairman—Hostile Patients
Over the past five years, OMIC has witnessed a steep drop in the number of claims and lawsuits reported by its members, from a high of 284 in 2003 to 203 in 2008. At the same time, the number of OMIC insureds increased from 3,200 in 2003 to 3,939 by year-end 2008. While we are delighted to see this downward trend, there has been a dramatic increase in the number of reported “incidents” (potential claims) to OMIC’s claims and risk management departments. Nearly 6% of OMIC insureds reported an incident in 2008, up from a low of 2.7% in 2004. Many of these incident reports relate to behavior problems, i.e., difficult, noncompliant, and hostile patients. What accounts for this increase?
Recent membership data from the American Academy of Ophthalmology indicates that the average ophthalmologist sees 114 patients per week. Collectively, OMIC insured ophthalmologists, now numbering nearly 4,100, see over 450,000 patients per week. Thus, it is not surprising that some of these patients and their family members will confront us with challenging behavioral problems such as those cited in the lead article.
As this summer’s angry “town hall” meetings and ongoing health care reform debate in Congress demonstrate, people are angry and fearful about the system and the health care being provided. Patients are confronted with a dizzying array of unfamiliar procedures, treatment options, and medication regimens. Issues around insurance and paying for care can further confuse and stress patients.
Physicians have a duty to their staff and other patients to provide a civil and safe practice environment, but disruptive patients expose us, our staff, and other patients to potentially abusive, violent behavior. They can affect our bottom line as well. Non-payment for services, time taken away from providing care to other patients, responding to litigation or regulatory complaints, and even, in some cases, the need for damage-control public relations all take their toll.
This year, OMIC began offering a risk management course, Difficult Physician-Patient Relationships. Some of the situations addressed include dealing with hostile and noncompliant patients, communicating with patients who are deaf or limited English speaking, and what to do when patients have vision problems that impair their ability to drive (see this issue’s Hotline article). In addition, OMIC’s web site offers a wealth of protocols on the subject of difficult patients, and risk management staff are available to answer questions and provide guidance to insureds and their staff, who are asked to apply their best clinical judgment even when faced with angry ultimatums from patients.
OMIC risk management staff have learned that one way to prevent frustration and keep patients informed is to provide procedure- specific patient education documents and videos produced by the Academy together with informed consent documents provided by OMIC. Although education is not a fool-proof method of eliminating patient dissatisfaction, it can go a long way toward making the health care you provide more understandable.
Richard L. Abbott, MD OMIC Chairman of the Board
Assuring Safe Passage Through the Healthcare System
By Anne M. Menke, RN, PhD
OMIC Risk Manager
Digest, Fall 2009
During our recent OMIC Forum on “Shared Care” at the AAO annual meeting, Dr. Steven Brown presented the following case involving four competent, experienced physicians. A primary care physician (PCP) referred an elderly gentleman to a comprehensive ophthalmologist (CO) for evaluation of a grey spot in his eye. After diagnosing a melanoma, the CO referred the patient to a retina specialist for confirmation and treatment options. The retina specialist offered the patient a choice between radiation and enucleation, and reported back that the patient chose enucleation. The CO then referred the patient to an oculoplastic surgeon for the procedure, which was completed two weeks after the initial ophthalmological evaluation. So far, the patient had received timely, effective, well-coordinated care. Nonetheless, when the patient died from metastatic disease that was diagnosed by his PCP eight months after his eye was removed, his family requested the medical records and concluded that the care was negligent. They reached their conclusion after finding a report from the retina specialist to the CO, advising him of the need for tests to monitor for metastasis. The family proceeded to sue the PCP, CO, and oculoplastic surgeon, alleging failure to follow-up and coordinate care. Investigation revealed that all three physicians knew the patient was at risk for metastatic disease, and knew which tests to order to monitor for it. Yet no one took the responsibility to clarify who was in charge, and none of them ordered the necessary tests. The oculoplastic surgeon testified that he had explained the need for follow-up to the patient but did not provide his recommendations in writing or document them in his record. No doubt the patient was not able to truly hear these care instructions while facing a new diagnosis of cancer and recovering from an enucleation.
Patient “Hand Off” A Critical Moment In Care
The Joint Commission (TJC) receives regular reports of medical errors that occur at the hospitals, ambulatory surgery centers, and other healthcare organizations that it accredits. By analyzing the problems, TJC hopes to understand not only which errors occur but more importantly what causes them. What TJC determined echoes the findings of the OMIC case. The top factor contributing to medical error was not lack of knowledge or technical skills or inexperience. Rather, it was problematic communication: the information conveyed during care was incomplete, inaccurate, and/ or misinterpreted. Ineffective communication occurred in 70% of “sentinel events,” a term TJC uses for incidents that have the most serious outcomes. Just as with the OMIC case, fully half of the time, the harmful communication breakdown occurred during a “patient hand off.”1
Patient safety experts, aware of the dangers of the hand off, have focused attention on ways to ensure communication and coordination of care during the moments when patients transition from one provider, facility, or unit to another. “Lost in Transition: Challenges and Opportunities for Improving the Quality of Care” points to our fragmented American healthcare system as the cause: decreasing numbers of primary care physicians, increasing numbers of patients with more than one disease who require diagnostic tests and specialists, and a payment system that does not reimburse physicians for the time it takes to communicate with one another and coordinate care.2
A literature review of care transitions found that patients referred to a specialist arrived 49% of the time with no information about the patient. The consultants apparently responded in kind, as the referring physicians complained that even four weeks after the consultation, 25% had not received a report back. PCPs said they were not notified that patients had been hospitalized and rarely received discharge summaries. The few that came were inadequate for directing care. Patients received even less information. Those sent for tests said that 17% of the time the physician had not received the results by the time of the office visit scheduled to discuss them. More than 75% of physicians report not informing patients when test results are normal, and 33% do not even disclose abnormal results. The author concluded that, “Care among multiple providers must be coordinated to avoid wasteful duplication of diagnostic testing, perilous polypharmacy, and confusion about conflicting care plans.”3
To help ophthalmologists coordinate care and follow up on referrals, test results, and appointments, OMIC developed a tracking system, which is discussed in the Hotline article and presented in detail in our document, “Noncompliance: A Frequent Prelude to Malpractice Lawsuits,” available in the risk management recommendations section at www.omic.com. A tracking system is only effective, however, if all physicians involved in the care of a patient are clear on who is in charge of ordering, interpreting, communicating, and acting upon the results of tests and consultations. As the OMIC case demonstrates, sending a letter with the proper recommendations does not lead to safe care if the message is not received and acknowledged. A more active process is required. Several new regulations imposed on healthcare facilities have been adopted to force physicians, nurses, and other caregivers to better coordinate care and hand off patients. The first is medication reconciliation, the second is standardized hand-off discussions; each will be addressed in turn.
Reducing Errors from Medication Changes
OMIC claims experience and the studies discussed so far show that patients and providers alike appear to be inadequately prepared for their role in the next phase of care. This is particularly true with changes to medications, which occur regularly when patients undergo diagnostic/surgical procedures, are diagnosed with new conditions, or are hospitalized. Too many times, neither the patient nor the prescribing physician has accurate and complete information about the patient’s current medication regime. The stage is thus set for errors and adverse drug events that result in patient harm, hospitalization, increased costs, and allegations of medical malpractice.
Take anticoagulants, for example, which are among the top three classes of drugs involved in medication errors. Ophthalmologists who are planning procedures with a high risk of bleeding, such as blepharoplasty, routinely inquire about prescription and over-the-counter drugs that influence the clotting cascade, and make changes to the drug regimen preoperatively. OMIC claims studies have shown, however, that patients misremember which medications they are taking, misrepresent—often when faced with financial problems—when they last had clotting studies done by their primary care physician, or do not think to report recent cardiac procedures, such as the placement of stents. Failure to confirm dosages, test results, and the intended change in medication with PCPs and cardiologists, failure to confirm that a patient has indeed stopped medications as directed, and failure to provide comprehensible, written instructions on how and when to restart medications have all led to malpractice lawsuits. Adverse medication events such as these indicate the need for an explicit process of “medication reconciliation” at key transition moments, such as a new diagnosis, admission for surgery, or discharge from a healthcare facility. This step is now a “National Patient Safety Goal” that facilities must meet in order to maintain accreditation by organizations such as TJC and AAAHC.4 And while time consuming, the process works: studies show that medication reconciliation decreases medication errors by 70% and adverse drug events by 15%.2
Tools to Improve the Quality of Hand Offs
One study of hand offs looked at the accuracy of information exchanged by nurses during shift change. Twelve fictitious patients were created, and nurses passed on information during five consecutive hand overs.
Oral communication resulted in the loss of all data. Note taking during hand off reduced data loss to 31%. It was only when a standardized form was combined with oral exchange of information that data loss was minimal.5 Studies such as this convinced many organizations, including the Institute of Medicine, the Department of Defense Patient Safety Program (DOD), Kaiser Permanente, and AORN (Association of periOperative Registered Nurses) to produce tools to better structure patient hand offs. These teams learned that standardized hand offs shifted the focus from the people involved in the exchange (often hierarchical) to the patient, and led to common expectations about what was going to be communicated, how the communication would be structured, and the required elements. Most importantly, the process requires two-way conversation in which critical information is verified and clear responsibility for ongoing care is established.
The toolkit jointly developed by the DOD and AORN is particularly useful to ophthalmologists as it focuses on team building and was developed specifically for perioperative care.6 It provides information on several standardized hand-off formats (see TALK TO ME IN SBAR and I PASS the BATON). Ophthalmologists would be well advised to become familiar with these hand-off processes, now that the Joint Commission, in National Patient Safety Goal 2E, requires facilities to implement a standardized approach to hand offs. TJC has clarified its expectations: hand offs must be interactive, allowing for participants to ask and answer questions; they must include accurate, current information; interruptions during hand offs should be minimized; they must include a process for verification of the received information, including read back or repeat back if needed; and other necessary patient information should be available for review.7 It will no doubt take time to hone the hand-off process, but the effort will clearly result in safer care and less liability.
1. JCAHO. “Improving Hand-off Communications: Meeting National Patient Safety Goal 2E.” Joint Perspectives on Patient Safety 2006; 6(8): 9-15.
2. Coleman EA and Berenson RA. “Lost in Transition: Challenges and Opportunities for Improving the Quality of Care.” Ann Intern Med 2004; 140: 533-536.
3. Bodenheimer, Thomas. “Coordinating Care—A Perilous Journey Through The Healthcare System.” New England Journal of Medicine 2008; 358: 10.
4. Several resources provide medication reconciliation tools. The Agency for Healthcare Research and Quality has a primer available at http://www.psnet.ahrq.gov/primer.aspx?primerID=1. The Institute for Healthcare Improvement has a tool to help review medical records to catch medication errors and develop an effective reconciliation process; this tool is available at www.ihi.org.
5. Pothier D, Monteiro P, Mooktiar M, Shaw A. “Pilot study to show the loss of important data in nursing handover.” British Journal of Nursing 2005; v.14, n.20.
6. The toolkit, which includes slide presentations, sample tools, and forms developed for perioperative use, is available at www.aorn.org.
7. The Joint Commission’s National Patient Safety Goal on hand-off communication can be found at www.jointcommission.org.
