Reviewing Preoperative Test Results
By Marilys Fernandez, RN, JD
Digest, Spring, 1991
ALLEGATION Insured ophthalmologist failed to review a preoperative chest x-ray which was ultimately shown to be suggestive of carcinoma of the lung.
DISPOSITION Settled during trial.
Background
It is customary practice for ophthalmologists to routinely review results obtained from A-scans, visual field tests, fluorescein angiograms and a variety of other diagnostic tools prior to ophthalmic surgery. However, practices in reviewing chest x-rays and lab work routinely ordered preoperatively for patients undergoing surgery can vary considerably.
In a recent review of OMIC claims, reviewers identified a number of cases based on the ophthalmologist’s failure to review non-ophthalmological diagnostic studies. The resulting cases related to claims of missed diagnosis and delay in treatment, often of ailments unrelated to eye disease. The largest payment to date made on behalf of an OMIC insured was over $250,000 for injuries resulting from failure to review a preoperative chest x-ray which was ultimately shown to be suggestive of carcinoma of the lung.
Case Summary
The patient was a 60-year-old male who over the years developed age-related cataracts reducing his vision in both eyes. Cataract surgery was performed on the left eye with good results. Preoperatively, a chest x-ray was ordered by the ophthalmologist to comply with the hospital’s policy that such tests be performed on all surgical candidates over 40 years of age. The x-ray was interpreted by the radiologist as abnormal but was never reviewed by the ophthalmologist prior to surgery.
Four months later, the patient elected to have cataract surgery on his right eye. Another preoperative chest x-ray was performed which showed an enlargening left hilum with a lobulated mass present. The ophthalmologist was informed of the abnormal finding after the patient had been inducted but proceeded with the surgery anyway.
The chest x-ray taken prior to the first cataract surgery was then reviewed and found to indicate the presence of a nodular density in the left hilum. A later CT scan appeared to confirm that the mass had grown significantly in those four months. Following a left thoracotomy and pneumonectomy, the mass was found to be a poorly differentiated adenocarcinoma with four of eight hilar lymph nodes positive for metastatic cancer.
According to a pulmonary oncologist who reviewed the case, the first chest x-ray showed no metastasis to the nodes. Had the patient been treated at that time, he arguably might have had a 50 to 55 percent chance for a 5-year survival rate. With the four-month delay in diagnosis and treatment, the chances for a 5-year survival might have dropped to between 15 and 25 percent.
Outcome
Although there was potential exposure on the part of the hospital, anesthesiologist and radiologist for not being more aggressive in bringing to the attention of the ophthalmologist the results of the first chest x-ray, it remains the attending physician-surgeon’s responsibility to follow up on all tests ordered and to review the results of all preoperative tests.
After OMIC assessed the liability exposure of the case, the claims management staff entered into settlement negotiations with the plaintiff’s attorney and settled the claim with consent of the insured ophthalmologist.
The co-defendants involved, namely, the hospital, anesthesiologist and radiologist, refused to participate in settlement and were later sued by the patient. The outcome of that suit has yet to be determined.
Risk Management Principles and Commentary
This case presents a number of fundamental principles that ophthalmologists can follow to help avoid or reduce diagnosis-related claims. In particular, systems should be developed in the ophthalmic office to assure the efficient processing of all diagnostic clinical information.
Such systems could include:
- A method for ensuring that laboratory results, consultation reports and other pertinent documents are seen by the treating/attending physician before such information is filed.
- A reminder or diary system which ensures that follow-up tasks, such as notifying patients of test results, are undertaken when warranted.
- A formal arrangement whereby test results that are adverse or require immediate attention be reported personally by the consulting physician to the physician who requested them.
Additional suggestions may be found in the publication Risk Management Principles and Commentaries for the Medical Office published by the AMA/Specialty Society Medical Liability Project.
Delayed Diagnosis of Endophthalmitis Following Cataract Surgery
Digest, Winter, 1994
ALLEGATION Insured ophthalmologist allegedly delayed diagnosis of endophthalmitis following cataract surgery.
DISPOSITION Case was settled for $50,000.
Background
Claims against ophthalmologists frequently arise from cataract treatment. Improper performance of surgery is the most common allegation related to the treatment of cataracts followed by failure to recognize and treat a complication of surgery. Careful postoperative evaluation and documentation is crucial for successful defense of these claims.
Case Summary
The patient was an elderly male who presented to the insured’s office for decreased vision in the right eye. V.A. was 20/80 OD with correction. The patient was scheduled for a cataract extraction OD with insertion of a posterior chamber IOL. Surgery proceeded without complication although toward the end of the procedure the ophthalmologist noticed a rent in the inferior posterior capsule. Maxitrol and Pilocarpine drops were instilled.
The patient was doing well on the first day post-op. The record for this visit noted that the vitreous had moved forward to occupy 3/4 of the anterior chamber. The patient was continued on Maxitrol TID and scheduled for another visit in six days. There was no record of visual acuity or a fundus examination on this date. On the third day post-op, the patient called the insured’s office complaining of a very severe sharp pain in the right eye. No record was made of the call. The following day, the patient came to the office complaining of increased discomfort and decreased vision. V.A. was 20/200 OD. 2+ cells and a cloudy vitreous were noted. No fundus examination was documented. The patient was scheduled for another exam the next day by which time the cells had increased to 3+ and were described as being deposited on the posterior cornea. The insured documented a “faint red reflex.” No visual acuity or fundus examination was recorded. When the patient was seen on the sixth day, the record noted that a vitreous tap had been scheduled for the following day. But again, there was no description of an examination or findings to explain why the tap had been scheduled. The insured attempted the vitreous tap but was unable to aspirate despite trying several size needles. Findings in the record noted substantial membranes within the vitreous cavity.
Eight days after the initial surgery, the patient was referred to a retinal-vitreal specialist who diagnosed an endophthalmitis that already had created permanent and extensive damage to the retina.
A culture indicated a bacterial strain sensitive to multiple antibiotics. Although the retinal specialist was able to preserve the eye’s structure, the infection had caused functional loss of the retina. One year after the cataract surgery, the patient’s vision was count fingers at two feet OD.
Outcome
This case presented documentation issues that made it difficult to defend. The insured’s medical record was replete with questionably substandard examinations, inconsistencies and incomplete descriptions of findings. Notes were in the form of computer billing printouts and did not follow chronologically. The insured was criticized by defense experts for not doing a more thorough examination when he noticed the vitreous had moved to occupy 3/4 of the anterior chamber, and in the presence of cloudy vitreous and a “faint red reflex.” Furthermore, the ophthalmologist failed to record visual acuities and to explain why he decided to “proceed with vitreous tap.” When the vitreous tap was unsuccessful, the insured was criticized for not referring the patient immediately to a retinal specialist and for not administering a proper dose of antibiotics in the meantime. Another 24 hours elapsed before the patient was seen by the retinal specialist. Earlier intervention with antibiotic therapy may have saved the eye.
Risk Management Principlesand Commentary
When a claim arises related to a post-op complication, the experts reviewing the case have only the patient’s record to assist them in evaluating whether treatment of the patient was reasonable. An ophthalmologist often will be given the benefit of the doubt by a reviewer if there has been documentation of the reasoning behind certain judgments at critical decision points. Careful documentation alone may not be enough to overcome claims of a delayed diagnosis; however, patently inadequate documentation is likely to raise doubts about whether the treatment met the applicable standard of care.
Wrong Power IOL Inserted During Cataract Surgery
By Randy Morris, JD
OMIC Claims Associate
Digest, Summer 2000
Allegation
Wrong power IOL insertion led to complicated lens exchange surgery.
Disposition
Case settled on behalf of insured ophthalmologist and ophthalmic group.
Case Summary
A 59-year-old female patient presented to the insured with complaints of glare and significant decrease in her visual acuity OS. Corrected VA was 20/20 OD, 20/25 OS. Glare testing showed decreased VA of 20/80 OD and 20/100 OS. After a discussion with the patient, the insured performed what he thought was an uncomplicated cataract surgery OS. One day post-op, VA with pinhole was 20/150. Anterior chamber showed 2+ cells. The patient was started on Tobradex four times daily and told to return in one week. Later that day, the operating room nurse informed the insured that the wrong IOL had been delivered into the field. The insured had inserted a 17.0 diopter lens instead of a 20.5. The insured contacted the patient to explain what happened and suggested a lens exchange.
During the lens exchange surgery, the iris was caught in the scissors when the implant was being cut in the anterior chamber. A slight cut to the iris was noted at 12:00. The next day, VA OS was LP with marked corneal edema. Over the course of approximately two months, the patient’s VA improved to 20/150. The insured referred the patient to a corneal specialist, who performed a corneal transplant. The patient eventually had a VA with refraction of 20/25 OS, although she continued to complain of residual cloudiness due to posterior capsule haze.
Analysis
The insured maintained that responsibility for the incorrect lens insertion lay primarily with the nurse because the insured had performed the correct tests, specified the correct lens in his records, and inserted the lens properly. However, under the “captain of the ship” doctrine, the surgeon is deemed to be the person in charge in the operating room and is ultimately the one held responsible for any complications of surgery, even those caused by the actions of others. While the use of this doctrine is on the decline in many jurisdictions, plaintiff attorneys are still able to use it occasionally in situations such as this. Furthermore, the plaintiff could argue that it is the surgeon’s responsibility to verify that the correct lens is being inserted at the time of surgery. In light of this, the defense team and the insured agreed to settle the case on behalf of the insured ophthalmologist, the ophthalmic group, and the nurse codefendant.
Risk Management Principles
Fortunately, this kind of error does not occur frequently and can be avoided with due diligence and efficient sign-off procedures. Effective communications among surgical personnel, augmented by a system of checks and double checks, can go a long way toward preventing mix-ups. Many surgery centers require that the lens power be checked against the medical record and signed off by two people prior to surgery, then verified again visually and verbally by the assistant and the surgeon when the lens is handed to the surgeon for insertion. While such redundancy may sound inefficient or unnecessary, this attention to detail may well help prevent the captain from going down with the ship.
Disclosures of Risks, Complications, and Adverse Outcomes
By Anne M. Menke, RN, PhD OMIC Risk Manager
Allegation
Loss of vision following cataract surgery.
Disposition
Defense verdict on behalf of insured oph- thalmologist.
Case Summary
A 77-year-old female presented to the insured ophthalmologist with com- plaints of being unable to read, drive, or watch television and vision in the left eye of light and dark sensation only. Visual acuity was 20/25 OD and 20/80 with refraction OS. Past ocular history included peripheral iridectomies OU for intermittent angle closure glaucoma and pseudophakia OD. Medical history was significant for atrial fibrillation treated with aspirin, COPD, and hypertension. The patient had a dense cataract, grade 3-4+. The ophthal- mologist recommended phacoemulsification with IOL placement under topical anesthesia and a clear corneal incision. After removing the extremely dense cataract, the insured detected a large rent in the posterior capsule and per- formed an anterior vitrectomy with removal of the remaining cortex. He attempted to place the IOL in the sulcus but resorted to anterior chamber placement due to instability. No bleeding was noted.
The patient’s postoperative course was com- plicated by the development of a full eight-ball hyphema with loss of vision on day 3; treat- ment consisted of bed rest in a recliner at 30 degrees and 1% ophthalmic Atropine. The ophthalmologist later testified that he recom- mended but the patient refused hospitalization; he did not document this or any pre- or postop discussions regarding the possible effects of the patient’s aspirin therapy. IOP, slightly elevated at 28 on postop day 1 and treated with topical agents, rose to 62 on day 4 when the patient experienced a rebleed, prompting an anterior chamber paracentesis and hospitalization. An anterior chamber washout was needed the next day to control the pressures. Blood staining of the cornea and IOP of 30 was noted on day 13. The retina specialist to whom the patient was referred performed another anterior chamber paracentesis and found no posterior bleeding on B scan. The patient requested a second opin- ion; the consultant explained the treatment options but told the patient there was little chance for visual improvement.
Analysis
The plaintiff’s expert was critical of the insured on several accounts. First, the insured should have considered the impact of aspirin therapy on the development of the hyphema or rebleed and advised the patient to discontinue taking aspirin once bleeding developed. Second, the insured did not recognize the early readings as falsely low in the face of edema and hyphema. Third, had systemic agents been used to control the patient’s elevated pressure, optic nerve damage and the resulting loss of vision might have been prevented. Fourth, the hyphema should have been washed out earlier with care taken to remove the clot.
While noting the insured’s lack of documen- tation regarding aspirin and recommended hospitalization, defense experts supported the accuracy of the IOP measurement and felt he had appropriately recognized and managed the intraoperative and postoperative complica- tions. The jury returned a verdict in favor of the insured ophthalmologist.
Risk Management Principles
The ophthalmologist disclosed the potential complications to the patient and responded each time to the patient’s complaints by promptly examining her, even on Christmas. This responsive care no doubt contributed to the jury’s defense verdict. Like many patients, the plaintiff was angry about experiencing two rare complications and about learning the permanent nature of her vision loss from a con- sultant she herself had asked to see. Had the ophthalmologist explained that she had two risk factors that might lead to rupture of the posterior capsule (the dense cataract and the fragile condition of the capsule), the patient might have been better prepared to deal with her poor outcome.
When anticoagulants are medically neces- sary for surgical patients, the surgeon should explain the need and risks to the patient and choose the most appropriate anesthesia and operative technique. Instructions to stop medications, especially anticoagulants, and recommendations for hospitalization must be documented. When there is significant loss of vision, the patient should be kept informed of treatment options and prognosis for recovery. If a poor outcome is final, the patient should be assisted in adapting to a low vision status.
Negligent Telephone Care of Postoperative Patient
By Anne M. Menke, RN, PhD OMIC Risk Manager
ALLEGATION Delay in diagnosis and treatment of retinal detachment following cataract surgery.
DISPOSITION Defense verdict at trial.
Case Summary
A 58-year-old female with lattice degeneration had uncomplicated cataract surgery. Three months post-operatively, the patient called the surgeon to report seeing branches and black spots of one day duration and was told to come in. She denied seeing flashing lights. BCVA was 20/25, and a dilated fundus with scleral depression examination of the right eye revealed vitreous hemorrhage and floaters. The macula and peripheral retina were flat without holes, tears, or evidence of retinal detachment. The ophthal- mologist prescribed bed rest (with the head of the bed elevated at 30 degrees) and advised the patient to follow up in 1 to 2 weeks or sooner if she developed increasing floaters, photopsia, or a veil/curtain formation.
The patient said she called the office four days later to report that she could barely see through a dark bubble. She claimed to have spoken to the receptionist, who consulted with the ophthalmologist, and was told not to worry. There was no documentation of the call. In deposition, the insured recalled being told only that the patient wanted to know when the floaters would resolve. She believed that she either asked the receptionist to call the patient back and verify the lack of new symptoms or that she called the patient herself. Five days later, the patient called again and said she was coming in. At the visit, she reported fluctuating vision and was noted to have a VA of CF, with both a horseshoe tear and a macula-on retinal detachment in the superotemporal quadrant. The insured spoke with a retinal specialist, who agreed to see the patient the next day; the call was not documented and the specialist had no recall of the conversation. When the patient was seen the next day, the detachment had progressed to macula-off. The patient had a scleral buckle, vitrectomy, air/fluid gas exchange, and endolaser surgery. At the time of trial eight months later, the retina was still attached, with vision pinholed to 20/60; the patient reported multiple visual problems.
Analysis
Plaintiff experts focused on the increased risk of retinal detachment in patients with lattice degeneration and cataract surgery. They doubted the ability to visualize the retina in the presence of vitreous hemorrhage and criticized the delay in referral to the retinal specialist then and when the detachment was diagnosed. Defense experts supported the insured’s examinations and treatment; more- over, they felt strongly that an experienced cataract surgeon, who had explicitly warned the patient about retinal detachment, would never ignore reports of a dark bubble. The lack of documentation, especially of the phone calls with the patient and the retinal specialist, became the focal point of the trial. Jurors who returned a defense verdict later explained that the plaintiff lost credibility when she refused to pursue the recommendations of a blind vocational rehabilitation expert. Nonetheless, they had sharp criticism for the insured’s call screening process and failure to document telephone care.
Risk Management Principles
Telephone screening of eye complaints, especially in postoperative patients, is an extremely risky aspect of ophthalmic practice and a regular feature of malpractice lawsuits. Physicians need written protocols, including contact forms that prompt them and their staff to ask crucial questions and document the responses, as well as guidelines to determine when the patient needs to be seen. Such sample forms and protocols are available online and from OMIC’s Risk Management Department (see cover article). The physician’s screening process is intended to gather the information necessary to develop a differential diagnosis that includes the worst case scenario for the patient’s presentation. In this case, the ophthalmologist clearly identified the risk of retinal detachment, but she could have been more proactive in managing it by making an early referral to a retina specialist to verify her examination in the presence of hemorrhage and by scheduling frequent follow-up visits before the patient left her office.
