Risk Management

Unfamiliar Procedures in Satellite Office Leads to Failure to Diagnose Retinal Detachment

Digest, Fall 1997

 ALLEGATION  Failure to diagnose detached retina.

DISPOSITION  Claim settled on behalf of insured ophthalmologist.

Case Summary

A 64-year-old woman presented to the insured’s office for the first time in October 1990 complaining of diminished vision in her left eye over a period of six months. Her past history included an eye contusion after being hit by a swing as a child. She reported no specific follow-up for this incident and no loss of sight at the time. Over the years, her eye care consisted of visits to an optometrist for periodic eye exams and treatment for minor eye irritations. She reported wearing glasses for about 35 years. Vision in her left eye was 20/200 with no improvement by pinhole; OD was 20/40 without correction. The left fundus exam revealed minimal macular degeneration; the right exam was negative.

After the insured performed a general ophthalmological examination, he directed the patient to go to the office optometrist for refraction and to return to him for a dilated fundus exam with an indirect ophthalmoscope. To ensure that this sequence occurred and that the patient returned to complete her exam, the insured intended to give the patient an office routing slip; however, there were no routing slips in the exam room so he wrote these instructions on a blank slip of paper and attached it to the chart. Unfortunately, upon completion of the refractive exam, the optometrist failed to see the insured’s note and sent the patient home with instructions to pick up her glasses in a few days. When the optometrist telephoned the patient after she failed to return for her glasses, the patient promised to pick up the glasses within the week and said she also intended to reschedule an appointment with the ophthalmologist.

The patient did not return to the insured’s office and did not have another ophthalmologic exam until March 1991 when she visited another ophthalmologist with complaints of “shrunken vision” over the previous six months. This ophthalmologist diagnosed a detached retina and referred her to a retinal specialist, who successfully performed a scleral buckle. The operative report described a long-standing retinal detachment from 2 o’clock to 9 o’clock with the macula detached. An uncomplicated recovery followed, and the patient’s last recorded visual acuity for the left eye was 20/200. At her deposition, the patient testified that she had some minimal peripheral vision, but that her central field vision was so blurred she could only identify shapes of objects within a few feet and could not read with her left eye.

Analysis

The plaintiff attorney immediately seized upon the theory that the detachment existed when the patient first visited the insured and that had he completed his exam during that visit, the diagnosis would have been made. At the very least, it was alleged, a follow-up exam should have been scheduled for any patient presenting with such a significant drop in vision. The plaintiff attorney blamed the physician for failing to complete his exam, the optometrist for failing to follow the directions in the record, and the office staff for failing to provide the routing slips referenced by the insured. In fact, this particular incident took place in a satellite office that, unlike the main office, had not instituted the use of routing slips to manage a patient’s progression through the various offices. The insured assumed the procedure was in place and wrote a note that in his mind would easily be understood by the staff. Unfortunately, it was not. The patient left the office without a complete exam and without a follow-up appointment, leaving the insured vulnerable to accusations of failure to diagnose and failure to follow up with a patient presenting with severe vision loss. Without an exam to show that the detachment had not existed at this visit and with only minimal macular degeneration as an explanation for the patient’s loss of vision, the defense counsel was unable to counter the plaintiff’s allegations. The case was settled prior to trial.

Risk Management Principles and Commentary

The error that allegedly caused this patient’s injury was a system failure, not an identified error in clinical judgment or treatment. Had procedures been more carefully matched between the home and satellite office, it is quite probable that this problem would have been avoided. If a retinal detachment had been present at the time of the office visit with the insured, a full exam would have revealed it. If not, a full exam would have been documented to that effect.

In a busy practice, particularly one with multiple locations, it is extremely important to maintain consistent patient care systems to manage patients and their data. Although it can be tedious and time consuming to review and standardize office practices, it is vital for consistent and safe quality patient care. To evaluate the effectiveness of your office systems, start with an office audit. This can be an internal collection of data that is later shared and analyzed within the practice, or a more formalized office audit by an outside firm. The important thing is to establish sound and consistent office systems to improve the overall quality of patient care, minimize patient injury, and reduce the risk of malpractice litigation.