Risk Management

Failure to Provide Urgent Eye Exam

Digest, Winter 1997

ALLEGATION  Failure to provide an urgent eye examination, resulting in delayed diagnosis and treatment of a retinal detachment.

DISPOSITION  Case settled with a small indemnity payment.

Case Summary

The claimant, a 67-year-old male, was first examined by the insured ophthalmologist at a rural satellite office for complaints of seeing floaters and flashes of light for three days. Examination revealed a posterior vitreous detachment with no retinal holes or tears. The patient was instructed to call the insured if the floaters or flashes increased or if there was a vision change. Three weeks later the patient presented with complaints of seeing spiderwebs. A repeat retinal examination was normal, and the patient was told to call immediately if there was any change in symptoms.

A month later, the patient called the insured’s office on a Thursday and told the receptionist he was seeing a dark spot in his peripheral vision OD. He was told that due to a medical convention there would not be any physicians in the satellite office for several days, but his message would be relayed to the practice’s main office in a nearby city and he would receive a return call. The patient’s message was phoned in to the main office by the receptionist and given to one of the nurses. According to the patient, a nurse later called him back and, after discussing his visual complaints, told him there were no appointments available for the remainder of the week, but if his symptoms did not resolve, he should call back the following Monday.

On Friday evening, the patient experienced increased loss of vision and was referred to a local on call ophthalmologist by the insured’s answering service. The on call physician diagnosed a rhegmatogenous retinal detachment and immediately sent the patient to a retinal specialist. Visual acuity at this time was 20/30 OD. By the time the patient reached the specialist’s office an hour later, the detachment involved the macula. Following a retinal procedure, the patient suffered a redetachment and required additional surgery. Ultimately vision could be restored to on the 20/400 level. The patient filed suit against the insured ophthalmologist and the corporate employer of the administrative and nursing staff at the practice.

Analysis

The claimant argued that had he been examined on Thursday, his retinal detachment would have been diagnosed early enough to prevent macular involvement, thereby significantly increasing his chances of regaining good vision. Deposition testimony by two subsequent treaters supported this theory. The defense contended it was the development of proliferative vitreoretinopathy after the initial retinal surgery, not a delayed diagnosis and macular detachment, that caused the claimant’s damages.

Based on the available evidence, experts on both sides were critical of the fact that the patient was not referred to an ophthalmologist when he reported his vision change to the office on Thursday. In the face of this serious standard of care issue, the carrier and insured agreed that a small settlement on behalf of the corporation would be appropriate. The ophthalmologist who was individually named in the suit was dismissed because there was no direct criticism of his examinations and patient instructions prior to the detachment.

Risk Management Principles

Unfortunately, the only documentation concerning the patient’s call was a telephone message stating that the patient was seeing a black spot OD. By the time the suit was filed, none of the nurses in the principal office remembered talking to this patient. Perhaps in part because the chart was located in the satellite office and not immediately available, the unidentified nurse made no notes concerning the oral triage of patient. Thus, the defense was unable to present any testimony or documentation that could challenge the claimant’s version of events concerning the nature of the symptoms reported to the nurse.

This case illustrates that it is good risk management practice to ensure that documentation concerning a patient’s contact with a principal office is transferred to the medical chart located in a satellite office. It is difficult to know in the above scenario whether the nurse’s judgment call that the patient did not have to been seen immediately could have been justified based on the full content of her conversation with the patient. However, with the dearth of documentation and the absence of any independent recollection by the nurse involved, the opportunity to raise such a defense was lost.

An office procedure that includes communicating the ophthalmologist’s findings and plans from the previous examination to staff in a remote office, perhaps via fax or computerized medical records, accessible to both the principal and satellite offices, may have benefited the nurse who triaged this patient. If due to some communication issue, the description of symptoms provided by the patient over the telephone was not clear enough to raise concerns regarding a possible retinal detachment, reference to previous records would have alerted the nurse to the seriousness of the situation.

This case also points out that ophthalmologists should be mindful of what malpractice coverages they have in place for their corporations. Because the nurse was an employee of the corporation, it was the corporation rather than the individual physician who was exposed to liability. At OMIC, coverage for sole shareholder corporations at shared limits with the physician owner is automatically included without additional charge. However, if separate limits are desired, or if the corporation has more than one shareholder, additional coverage may be purchased in order to protect the shareholders against claims directed at the corporation and its employees.