Missed diagnoses: a breakdown in communication, coordination, compliance, and situational awareness

THE OPHTHALMIC RISK MANAGEMENT

OPHTHALMIC MUTUAL INSURANCE COMPANY VOLUME 25 NUMBER 3 2015

Giant cell arteritis claims are costly and difficult to defend RONALD W. PELTON, MD, PhD, OMIC Committee Member, and ANNE M. MENKE, RN, PhD, OMIC Risk Manager

77-year-old male patient When the patient saw the were delayed for so long and presented for the first ophthalmologist about two weeks easy to erroneously conclude that A time to our insured later, he reported a new symptom, both physicians must have been ophthalmologist to report the a low-grade fever, with ongoing incompetent. The claims investigation sudden onset of intermittent diplopia headache and diplopia. Five days showed instead that these physicians six days prior and a headache over after that—a full three weeks after the had treated patients with giant cell his eyebrows for one day. Noting initial visit to the ophthalmologist— arteritis, knew its signs and symptoms right inferior oblique muscle paresis the patient lost vision in his left well, and understood that emergent but unable to determine its cause, eye. An emergency room physician treatment is needed to prevent and with no neuro-ophthalmologist diagnosed giant cell arteritis and imminent, bilateral vision loss. What, in the region, the eye surgeon began intravenous steroid treatment, then, led these physicians astray? referred the patient to a neurologist. but the patient never regained vision Severe vision loss, costly claims The patient told the neurologist in that eye. The malpractice lawsuit that the headache had actually against the ophthalmologist settled for This issue of the Digest will report on lasted for one month and that he $85,000; we do not know the outcome a study of OMIC claims involving 18 was also experiencing jaw pain. This of the suit against the neurologist. patients diagnosed with GCA additional information prompted Armed with hindsight bias, the between 1993 and 2014. In 12 of the the neurologist to include giant classic signs and symptoms of giant 18 cases (66%), no physician included cell arteritis (GCA, also known as cell arteritis jump out: older patient, GCA in the differential diagnosis. Four temporal arteritis) in the differential vision changes, headache, jaw pain, of these patients were seen only by diagnosis and to order an MRI, CT, and fever. It is hard to imagine how an ophthalmologist; the rest were and lab work. the definitive diagnosis and treatment examined by an eye surgeon and one to three additional physicians. And although GCA was considered by the MESSAGE FROM THE CHAIR ophthalmologists in each of the remaining six cases, symptoms in five TAMARA R. FOUNTAIN, MD, OMIC Board of Directors patients progressed when either the ophthalmologists or other physicians I’m the daughter of an aviator. I spent hours as a child did not follow through to confirm the sitting with my dad on the hood of a ’65 Mustang diagnosis and coordinate treatment. watching planes take off and land at Minneapolis/St. Paul All 18 patients experienced severe International Airport. A former Air Force instructor pilot vision loss, often bilaterally. OMIC had and Northwest Airlines captain, he taught me early on how to settle twice as many of these claims 450 tons of aluminum can become airborne (Newton’s Third Law) and other as OMIC claims overall, and the mean aerodynamic concepts like pitch, yaw, attitude, and angle-of-attack. I still and median payments were both love talking to my father about airplanes and, like cable news outlets, often considerably higher (see table 1). turn to my own resident aviation expert whenever a commercial airliner goes The short window for diagnosis and down. He is nearly always spot on when he predicts a crash was due to pilot treatment and the risk of severe error. Though each accident may have different antecedents, the final, often bilateral vision loss make the high fatal mistake usually boils down to a simple failure of the flight crew to “fly stakes of this relatively rare condition the airplane.” clear. This issue of the Digest will The 2009 crash of Air France 447, an overnight flight from Rio de Janeiro explore the reasons for these poor to Paris, is a classic case study in pilot error. Over the Atlantic, three hours outcomes, the standard to which into a routine flight, the crew started receiving faulty airspeed readings continued on page 2 continued on page 4 EYE ON OMIC Rate decrease and policyholder dividend approved for 2016

The Ophthalmic Risk MIC’s Board of Directors is pleased to dividend credits totaling more than $65 million, Management Digest is published quarterly by announce a nationwide rate decrease leading peer companies by a wide margin. the Ophthalmic Mutual O and a 20% policyholder dividend for Issuance of dividend credits is determined Insurance Company, a Risk Retention Group insureds effective January 1, 2016. each year after careful analysis of operating sponsored by the After a favorable year buttressed by excellent performance. OMIC remains committed to American Academy of Ophthalmology, claim results and lower than expected operating returning premium above what is necessary to for OMIC insureds expenses, OMIC is experiencing one of our best prudently operate the company and to do so at and others affiliated with OMIC. years ever. In recognition of this development, the earliest opportunity. OMIC, not the we are implementing a rate decrease in all states Issuance of the dividend requires that an Academy, is solely totaling approximately $6 million nationally. The active 2015 professional liability policy be responsible for all insurance and business amount will vary by coverage area and insureds renewed and maintained throughout the 2016 decisions, including will be notified of the decrease in their territory. policy period. Mid-term cancellation would result coverage, underwriting, claims, and defense Since 2005, OMIC has lowered rates by in a pro-rata dividend. Dividends appear on your decisions. an average of nearly 40% nationally. OMIC policy invoice as a credit to either your annual OMIC owns the continues to outperform competitors by making or quarterly billing installment. OMIC issues copyright for all material published in the Digest fewer and lower average indemnity payments dividends as a credit toward renewal premiums (except as otherwise than the multispecialty industry average. for two reasons: premium credits offer favorable indicated). Contact OMIC for permission to OMIC will also apply a policyholder dividend tax implications for policyholders and allow for distribute or republish for all physician insureds in the form of a 20% easy and efficient distribution of dividends, which any Digest articles or information. The credit toward 2016 renewal premiums. Since keeps operating expenses as low as possible. general information the company’s inception, OMIC has announced on medical and legal issues that OMIC provides in the Digest is intended for MESSAGE FROM THE CHAIR This issue of the Digest is dedicated to educational purposes missed diagnoses, the medical equivalent of only and should not continued from page 1 be relied upon as a “forgetting to fly the airplane.” By one estimate, source for legal advice. while entering a thunderstorm. Onboard failure to diagnose kills over 40,000 people OMIC will not be liable 1 for damages arising computers, recognizing the erroneous airspeed annually in American ICUs alone. That’s the out of the use of or was inconsistent with all the other normally equivalent of three Air France crashes every reliance on information published in the Digest. functioning flight indicators, kicked off the week. Plaintiffs alleged a failure to diagnose autopilot. Forced to fly manually and distracted in 13% of OMIC’s 4,500 closed claims. It’s not OMIC 655 Beach Street by the faulty airspeed, the crew (incorrectly) the “zebras” we overlook; retinal detachment, San Francisco, CA pulled the nose up, slowing the plane down glaucoma, and intraocular foreign bodies 94109-1336 and precipitating a stall. This error was further are among the top diagnoses we miss. The PO Box 880610 same factors contributing to pilot error— San Francisco, CA compounded when, in a departure from 94188-0610 standard cockpit procedure, the pilots failed to conflicting information, distraction, lack of P 800.562.6642 monitor and call out loud the plane’s altimeter communication, departure from preferred F 415.771.7087 practice patterns—are at work in our clinical [email protected] readings (how far up in the air the plane is). www.omic.com Recovering from a stall is as instinctive to an environments. Like those Air France pilots who Editor-in-Chief aviator as putting one’s hands out to break a failed to execute a successful recovery from Timothy J. Padovese fall: point the nose down, build up air speed, their stall, we ophthalmologists usually have all Executive Editor the clinical information we need to make the Paul Weber, JD, ARM restore lift to the wing (Bernoulli’s Principle), and pull out into level flight. The crew had at correct diagnosis, even when we fail to do so. Managing Editor Anne Menke, RN, PhD least two minutes during their free fall to safely Maintaining situational awareness in high stakes, Senior Editor execute this maneuver but lost situational high stress situations—Why is this patient Kimberly Wynkoop, JD awareness of where they were in the air. Trying deteriorating? What could I be missing?—helps Contributors to troubleshoot the various alarms, confused us to better connect the dots. Now sit back, Hans Bruhn, MHS Ryan Bucsi and panicked by conflicting information, the relax, and read on for tips to keep you and your Betsy Kelley pilots of Air France 447 literally forgot to “fly passengers, I mean patients, safe. Linda Nakamura Michelle Pineda, MBA the airplane.” In under four harrowing minutes, 1. http://qualitysafety.bmj.com/content/early/2012/07/23/ Robert Widi the Airbus 330 dropped 38,000 feet from the bmjqs-2012-000803.abstract Production Manager nighttime sky killing all 228 aboard. Linda Radigan

2 V25 N3 2015 Ophthalmic Mutual Insurance Company POLICY ISSUES National Practitioner Data Bank reporting KIMBERLY WYNKOOP, OMIC Senior Legal Counsel

hen OMIC settles a claim or payment for damages. This could reports must be submitted for pays a judgment against an be a letter from a patient alleging each insured. If it is impossible to W insured, policyholders often a botched surgery and demanding determine the amount paid on behalf wonder if the payment will be reported compensation (a specific dollar of each insured individually, the total to the National Practitioner Data amount need not be requested). amount and the total number of Bank (NPDB). This article will describe Conversely, payments based solely on practitioners must be reported on under what circumstances federal law oral demands are not to be reported. each submission. If payment can be requires such reporting. For example, if a patient calls or apportioned, OMIC must report the The NPDB Guidebook states that comes in person to the office and actual amount paid for the benefit of a payment made by an entity for the demands a refund for what he or she each practitioner on their respective benefit of a healthcare practitioner considers poor treatment, payment of reports. If multiple payers contribute to satisfy a written claim or judgment the refund would not be reportable. to the settlement or satisfaction of for medical malpractice must be For reporting purposes, the claim a judgment for the benefit of one reported. This sounds simple enough, must be based on a practitioner’s practitioner, they each must submit a but breaking this requirement down provision of or failure to provide report. For example, if OMIC and a shows that there are situations where healthcare services; the NPDB patient compensation fund each pay the requirement to report is not interprets this broadly. For instance, if a share of an award, they report their always clear. a suit is brought against a practitioner respective payments to the NPDB. First, what is “making a payment”? alleging medical malpractice and other OMIC is also required to submit The NPDB considers making a torts, and the medical malpractice a copy of the NPDB report to the payment to be the exchange of counts are dropped, if the insured appropriate licensing board in the money. A fee refund is considered is still named in the suit and OMIC state where the act or omission that “making a payment.” A waiver of a makes a payment on behalf of the was the basis of the claim occurred. patient’s debt, on the other hand, is insured practitioner, OMIC must report Generally, OMIC does not supply any not considered “making a payment” the payment. The narrative portion further information on the claim to and therefore should not be reported. of the report can be used to explain any state administrative body unless What if the payment is made for the why the payment was made, that the it is necessary to coordinate payment benefit of an entity, not for the benefit medical malpractice allegations were with a patient compensation fund. of a healthcare practitioner? A medical dropped, or any other relevant data. As a reminder, the NPDB was malpractice payment made solely for A report is only required if the created by Congress as an electronic the benefit of a corporation, such as practitioner is named, identified, or repository of information on medical a clinic, group practice, or hospital, otherwise described in both (1) the malpractice payments and certain should not be reported. However, a written complaint or claim demanding adverse actions that authorized payment made for the benefit of a payment and (2) the settlement organizations can access to make business entity that consists of only release or final adjudication, if any. licensing, credentialing, privileging, a sole practitioner must be reported. So if a practitioner is named in the or employment decisions. The reports In other words, a payment made release but not in the demand or are confidential and not available to for the benefit of a sole shareholder lawsuit, that practitioner need not be the public, though the subjects of corporation is considered a payment reported. If a practitioner was named these reports have access to their own made for the benefit of the individual in a lawsuit but is later dismissed and information. Federal law makes clear sole practitioner. is not identified in the settlement that reporting a medical malpractice What constitutes a reportable release, a payment need not be payment is not an admission that claim? Only medical malpractice reported for that practitioner unless the practitioner did anything wrong. payments resulting from a written his or her dismissal resulted from a The law states that a “payment in complaint or a written claim condition in the settlement or release. settlement of a medical malpractice demanding monetary payment are Even if several ophthalmologists action or claim shall not be construed to be reported. This includes tort are insured under one policy, a report as creating a presumption that medical actions brought in state or federal is made to the NPDB only for the malpractice has occurred.” The NPDB court or before another adjudicative individual practitioner for whose recognizes that some claims are settled body, such as a claims arbitration benefit a payment was made. If OMIC for convenience and are not a reflection board, and any form of pre-litigation makes a payment for the benefit of of the professional competence or written communication demanding multiple insureds due to one claim, conduct of a practitioner.

Ophthalmic Mutual Insurance Company Ophthalmic Risk Management Digest V25 N3 2015 3 Giant cell arteritis claims are costly and difficult to defend continued from page 1

medical experts hold physicians who 1. INDEMNITY PAYMENTS MADE TO SETTLE GCA CASES treat these patients, and the measures ophthalmologists can take to improve GCA Claims All OMIC Claims the likelihood of a correct and timely Closed with a payment 44% 21% diagnosis. Patients presenting with only Mean (average) payment $203,250 $165,282 visual problems Median (middle) payment $335,000 $81,875

Giant cell arteritis, a systemic Highest payment $450,000 $3,375,000 inflammation of the blood vessels that restricts blood flow causing organ and tissue damage, most In one, the ophthalmologist noted our study exhibit? Consistent with commonly affects patients over papilledema in an 81-year-old who GCA’s usual appearance in patients the age of 50. In addition to the presented with sudden vision loss, but over 50 years old, those in this symptoms noted above and scalp he did not work up its cause. The case study ranged from 62 to 86. As part tenderness, varied and non-specific settled for $275,000. In the other, the of a claims investigation, defense constitutional symptoms, such as ophthalmologist was criticized for attorneys obtain and review all of fatigue, malaise, and weight loss, not clarifying the nature of the visual the patient’s medical records. These may develop over time. It can be complaint. The 82-year-old patient reviews revealed that 15 of the 18 difficult to diagnose GCA when had written on the history form patients (83%) were experiencing the only symptom is a change that her vision “blacked out.” The GCA symptoms other than vision in vision. Four of the 18 patients surgeon did not read the form and changes at the time of their initial visit presented this way. In two of these documented only “blurry vision” and to the ophthalmologist. Of these 15 cases, defense experts supported diagnosed her with visual migraine. patients, 12 reported headaches and the ophthalmologists’ care and the The case settled for $350,000. 7 of the 12 had additional symptoms claims closed without payment, even Problems eliciting a thorough (see table 2). The ophthalmologists, however, though the insureds did not diagnose and accurate history GCA or such diagnosis was delayed. failed to elicit the non-vision-related In one case, a patient with dense Exploring the precise nature of the symptoms in 10 of the 15 patients cataracts that explained her vision vision change would have helped (66%) who were having them. Defense loss was appropriately referred for another ophthalmologist entertain experts opined that this inadequate work-up of a choroidal mass; the jury a GCA diagnosis. His patient history contributed to the delay in returned a defense verdict. In the complained of a headache for two diagnosis and was below the standard second case that closed without a days and a “curtain,” which he of care. The ophthalmologist in the payment, a patient who presented understood to be transparent. It was claim described in the beginning with intermittent blurry vision was only during the investigation of the of this article learned only of the diagnosed with amaurosis fugax, a lawsuit that he learned the patient vision complaints and headache, temporary loss of vision in one eye had experienced a “dark” curtain that while the neurologist, who saw the caused by a lack of blood flow to caused frank vision loss. He felt, in patient near the same time, elicited the retina. Because the patient was retrospect, that the combination of the duration of the headache and 79, the ophthalmologist ordered vision loss and headache in an elderly the existence of jaw pain. Ironically, an erythrocyte sedimentation rate patient should have alerted him to the ophthalmologist testified in his (ESR). When the result was normal GCA and agreed to settle the claim deposition that he did not consider at six, he repeated the test and for $100,000. GCA in his differential diagnosis got the same result. He diagnosed While it is important to get since the patient did not complain of GCA six days later when the patient accurate information about the jaw pain. He did not explain why he complained of a shade over the eye complaint, it is crucial to query relied upon the patient to offer this eye and developed a Marcus Gunn older patients about constitutional information instead of asking for it. pupil and visual field deficit. OMIC symptoms. A careful review of signs, Why is obtaining an accurate declined the patient’s settlement symptoms, and systems can help history so difficult? First, patients demand and the case was ultimately distinguish the few patients who could often report their history differently to dismissed. The two other cases where have GCA from the large number each healthcare provider based upon vision change was the only symptom of older patients with eye problems the questions asked and the time were settled when OMIC could not seen daily in ophthalmic practices. spent gathering the information. find supportive defense experts. Which symptoms did the patients in Often it was other physicians who

4 V25 N3 2015 Ophthalmic Mutual Insurance Company GCA Chart Supplement Ocular history/symptoms? (see new patient form) Onset of symptoms: weeks History: months years Hx of acute visual loss?: N Y OD OS OU Symptoms: Any visual disturbance or vision loss? Temporal pain? Scalp tenderness? Hearing loss? N Y Drooping lid? N Y Jaw pain (w or w/o chewing)? N Y obtained a more thorough history, be found at www.omic.com/ Fatigue? N giant-cell-arteritis-checklist/ Fever? N Y but in two of our claims, the . Y Loss of appetite? N ophthalmologists’ staff members Y N Missed opportunities Y obtained and documented the N Y presence of GCA symptoms. Not only So what happened in the first case? N Y did the ophthalmologists not get the While the ophthalmologist did not was again normal. The same information when questioning elicit a thorough history or include ophthalmologist advised the patient the patients a few minutes later, they GCA in his differential diagnosis, to keep his follow-up appointment also did not review the notes made the neurologist to whom he referred with the neurologist in four days by their staff members. This lapse was the patient did ask the appropriate time. Experts who reviewed the criticized by defense experts and questions. The combination of claim felt that four opportunities for contributed to the decision to settle diplopia and pain in the temporal an earlier diagnosis that would have these claims. Second, patients mandibular joint led the neurologist preserved the vision had been lost: presenting with eye complaints often to a robust differential diagnosis, when the lab did not perform the first do not think that it is important or which included right fourth nerve ESR ordered, when the patient did pertinent to tell their ophthalmologist palsy versus right inferior oblique not go back to get the ESR lab test about non-ophthalmic problems they paresis, brain stem ischemia, done, when the neurologist did not are experiencing. More than in most myasthenia gravis, and vasculitis. follow up to ensure it was done, and diseases, however, prompt diagnosis He appropriately ordered an MRI, when the ophthalmologist failed to of GCA depends upon the CT scan, and laboratory work, note the lack of ESR results. Had the thoroughness and accuracy of the including an ESR. About a week ophthalmologist asked the patient, health history. In each of the 15 after he examined the patient, the he would have learned that no ESR claims where patients had more than neurologist realized that the lab had had been done. This information, just visual symptoms, the plaintiff mistakenly not performed the ESR. combined with the new symptom of expert alleged that the diagnosis He mailed the patient a prescription fever, could have prompted him to could have been made earlier if the to have it done the next day but the consider GCA and order a stat ESR. ophthalmologist had obtained a more patient never went. Six days later, thorough history. Ophthalmologists the patient brought the results of the Preventing vision loss MRI, CT, and lab work (minus any examining older patients, especially This constellation of incomplete ESR results) to his second visit with those with vision changes and history, poor coordination of care the ophthalmologist, who skimmed headache, need to take a more active among physicians, and problems with the report, which discussed the non- role in obtaining the history. Dr. Ron patient adherence occurred in many specific MRI and CT results and the Pelton, a practicing oculofacial of the claims, including the one in the normal lab results. He failed to notice surgeon who serves on OMIC’s Closed Claim Study. This article that the lab had not performed the claims and underwriting committees, provides information on actions ESR. While he did see that the patient has developed a GCA checklist to ophthalmologists can take, such as had been given a prescription to have prompt ophthalmologists to ask proactively obtaining a more the ESR repeated six days prior, he key questions and document both thorough history, to improve the assumed the test had been done and positive and negative findings. It can likelihood of including GCA in the differential diagnosis when older patients present with vision changes. 2. SYMPTOMS EXPERIENCED IN 18 PATIENTS WITH GCA The checklist created by Dr. Pelton 18 can prompt such questions and help track the completion of key tests and 15 consults. A robust appointment and test tracking system plays a pivotal 12 role in preventing diagnostic error 9 (see “Test Management System is Key to Prompt Diagnosis” and 6 “Noncompliance” at www.omic.com for advice on how to implement one). 3 The Hotline article in this issue provides recommendations on ways 0 to improve communication with other vision change headache jaw pain scalp fever weight loss tenderness physicians and your staff.

Ophthalmic Mutual Insurance Company Ophthalmic Risk Management Digest V25 N3 2015 5 CLOSED CLAIM STUDY Poor communication between providers delays GCA diagnosis RYAN BUCSI, OMIC Senior Litigation Analyst

Allegation n 85-year-old patient with polymyalgia PMR, which is strongly associated with GCA. Failure to rheumatica (PMR) was being treated He was also criticized for not considering GCA A with steroids by her internist. He given the patient’s age, headache, and diplopia. diagnose and treat giant cell tapered her off the steroids when her symptoms Furthermore, our experts pointed out that the arteritis. were controlled but restarted the drug at a low insured did not take a sedimentation rate, CBC, dose two weeks later when she experienced a CRP, or platelet or fibrinogen levels, nor was Disposition headache. Two weeks after that, the internist there a recommendation that these be obtained suspected giant cell arteritis (GCA) due to by the internist or neurologist. Additionally, Settled for diplopia. He provided two referrals: one to our the insured did not recommend a temporal $50,000 on behalf insured ophthalmologist to evaluate the diplopia, artery biopsy. Our experts’ major issue with the of OMIC insured. and the second to a neurologist to initiate and insured’s care was his failure to communicate Codefendants manage high-dose steroids. The referral slip to the patient, her family, and other doctors later settled for noting the history of PMR and steroid treatment involved in her care the high risk for vision loss $500,000. never reached the ophthalmologist. However, and need for emergent intervention. However, the ophthalmologist’s technician documented the experts felt the internist and neurologist that the patient was on steroids. The insured had greater exposure than the ophthalmologist. obtained a history of chronic headaches and new Fortunately, plaintiff counsel agreed that our onset of intermittent vertical diplopia. He found a insured’s liability was limited and a settlement large left hypotropia as well as moderate macular of $50,000 was negotiated. The internist and degeneration and recorded uncorrected visual neurologist later settled for a total of $500,000. acuities of 20/60 OD and 20/40 OS. The insured discussed the possible causes of diplopia with Risk management principles the patient and recommended that she follow This case highlights the importance of up with her internist and see a neurologist. The communication with other healthcare patient saw a neurologist, who diagnosed GCA, providers. The ophthalmologist, internist, and increased her dose of steroids, recommended neurologist did not effectively communicate hospitalization—which she refused—and with each other and did a substandard job referred her back to the ophthalmologist. The of coordinating this patient’s care. Two of the patient was seen by our insured five days later three physicians suspected GCA before serious (two weeks after the initial visit) and reported that vision loss occurred but did not share this earlier in the day she experienced dramatic vision crucial information in a timely manner with the loss and headache. VA was hand motion OD ophthalmologist. The internist did not provide and 20/400 OS. A dilated examination revealed our insured with an adequate history about the inferior retinal ischemia indicating central retina PMR and suspected GCA, which could have artery occlusion with acute optic neuritis. The assisted the insured in reaching the correct insured concurred with the diagnosis of GCA. diagnosis and increasing her steroid dosage to He explained to the patient that her vision was treat the GCA. The ophthalmologist, moreover, unlikely to improve and advised her to follow missed an opportunity to intervene earlier by not up with her internist and neurologist for steroid reading his technician’s note about Prednisone management. He asked her to return in two use, exploring the reason the patient was on weeks but she did not. Eventually, the patient it, and making the association between PMR ended up with bilateral blindness and required and GCA. The ophthalmologist was in the 24-hour care. best position to know the risk with regard to potential loss of vision and the urgency of Analysis increasing the steroid dosage and obtaining OMIC’s defense experts had mixed opinions a temporal artery biopsy. Furthermore, our about the insured’s care. One felt management insured’s documentation was inadequate. When at the initial visit was appropriate since no the records were reviewed, our expert could not circulatory issues were identified during the understand what the insured’s thought process dilated exam. Others felt our insured could be was and if he passed his thoughts and opinions criticized for not reading the note about the on to the internist and neurologist. patient’s steroid use and eliciting her history of

6 V25 N3 2015 Ophthalmic Mutual Insurance Company RISK MANAGEMENT HOTLINE Clear communication is key to timely diagnosis and treatment ANNE M. MENKE, RN, PhD, OMIC Risk Manager

he claims discussed in the made a mistake and wrote the see his PCP. The lawsuit alleges that lead and Closed Claim prescription for 20 mg daily instead we were told that the pain was also T articles resulted partly from of four 20 mg tablets daily. Now I’m in the temple area and accompanied poor communication among treating being sued for not taking over care by visual disturbances, and that given physicians and staff members. Here of the patient from the OD and not his age, I should have seen him right are some recommendations about adequately supervising the technician. away. Am I expected to speak to each ways to ensure that the necessary What should I have done? patient myself or review each note information is received from and about phone calls? communicated to the appropriate A Optometrists often perform members of the healthcare team. the initial evaluation for patients in A You obviously cannot talk to The scenarios come from actual giant a group practice. However, when every patient who calls, so you cell arteritis (GCA) claims, and some a patient has a serious, vision- need an efficient and effective way of the “advice” is from the defense threatening condition such as GCA to share information. OMIC claims experts who reviewed the claims. that requires urgent treatment and experience makes it clear that making careful coordination of care, an medical decisions on the basis of Q An emergency room physician ophthalmologist should assume the limited information obtained from one of the local hospitals called responsibility. Your practice’s written over the telephone is a risky, albeit me about a patient of mine. I don’t protocols should address this necessary, aspect of ophthalmic take call at that hospital and told (see “Coordination of Care with practice. During the phone call, him to have the patient schedule an Optometrists” at www.omic.com). you and your staff need to gather appointment with me. Now I’m being This optometrist did not have the the information necessary to assess sued along with the ER physician, who legal authority to prescribe systemic the situation and determine the says he informed me that the 72-year- steroids. In addition, while your treatment plan, communicate the old patient had a headache and vision technician may know the names assessment and plan to the patient, loss. The lawsuit says I should have at and dosages of the eye drops you and document the encounter and least warned the ER physician about normally prescribe, she is obviously your decision-making process in the GCA. What was I required to do? not familiar with oral steroids. You medical record. To ensure that you should have written the prescription have the most accurate information, provide staff with a checklist of You have no legal duty to yourself and provided written A questions to ask and instruct them to provide assistance to a hospital instructions to the patient on how document the answers. Review the when you are not on call for it. As an much to take each day and when to contact form when you can give it ophthalmologist, however, you know see her primary care physician (PCP). adequate attention, and document more about the risk of severe vision Finally, you should have conducted a the information you would like your loss from GCA than an ER physician. formal hand-off with the PCP to clarify staff to communicate to the patient. To protect the patient, urge the that the PCP would be responsible for To assist you, OMIC developed a ER physician to contact the on-call ongoing management of the steroids. sample phone contact checklist and ophthalmologist to evaluate the It is helpful to give the patient a appointment scheduling guide called patient. (The claim closed without a referral note that explains the “Telephone Screening of Ophthalmic payment.) reason for the referral and when it should take place (available at Problems” available at www.omic.com. www.omic.com/referral-note-for- Use this guide to develop written Q I work in a practice that employs protocols for telephone screening optometrists. One of them asked patient/). (The claim settled for $350,000.) and treatment that are specific to for my opinion about a 67-year-old your patient population, subspecialty, patient who presented with vision Q A 76-year-old patient called our and staff; train staff in the use of the loss, a headache, jaw pain, and scalp protocols and verify competency; and tenderness. The OD thought the practice and spoke to my technician, who reported the conversation to willingly accept questions from staff patient had GCA. I agreed and told members unsure of how to handle him to start steroids and provided the me. I recall her telling me that the patient had pain in the back of his specific calls. (This claim settled for starting and maintenance dosages. $200,000.) The technician who was scribing neck, so I instructed her to tell him to

Ophthalmic Mutual Insurance Company Ophthalmic Risk Management Digest V25 N3 2015 7 655 Beach Street San Francisco, CA 94109-1336 OPHTHALMIC MUTUAL INSURANCE COMPANY PO Box 880610 (A Risk Retention Group) San Francisco, CA 94188-0610

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OMIC continues its popular risk Webinars are available to OMIC management program. Upon insureds at no charge. Contact completion of an OMIC online or OMIC’s risk management PDF course, CD/DVD, or live department for more details. seminar, OMIC insureds receive one risk management premium September discount per premium year to be 25 Diagnostic Errors. Table Rock applied upon renewal. For most Regional Meeting—Arkansas programs, a 5% risk management (AOS),* Kansas (KSEPS),* Missouri Westpark Drive, McLean, VA; Exposition & Convention Center, discount is available; however, (MoSEPS),* Oklahoma (OAO).* 6–9:30 pm. Register with Las Vegas, NV; 9–10 am. You must insureds who are members of a Big Cedar Lodge, Ridgedale, Linda Nakamura at OMIC risk purchase an “ACADEMY PLUS cooperative venture society MO; 8:10–9:10 am. Register management, 415.202.4652. COURSE PASS” to attend this course! (Prior to meeting, pass is (indicated by an asterisk) may with your state society at http:// 15 Diagnostic Errors—The OMIC $225. Onsite fee is $275.) earn an additional discount by www.tablerockroundup.org/ Forum (Special Meeting #15). participating in an approved OMIC registration. American Academy of 17 The Code of Ethics: A Shield of risk management activity. Contact 25 Diagnostic Errors: Lessons Ophthalmology. Venetian Litigation (AAO Instruction Course Linda Nakamura at 800.562.6642, Learned from Closed Malpractice Ballroom AB, Sands Exposition & #710). American Academy of ext. 652, or [email protected], Claims. Indiana Academy of Convention Center, Las Vegas, NV; Ophthalmology. Room Galileo 907, for questions about OMIC’s risk Ophthalmology.* Ritz Charles 2–3:30 pm. Sands Exposition & Convention management seminars, CD/DVD Center, Las Vegas, NV; 2–3 pm. Conference Center, Indianapolis, 16 Medicolegal Aspects to EHRs recordings, or computer-based You must purchase an “ACADEMY IN; 4–5 pm. Contact the IAO That You Need to Know (AAO courses. Courses are also listed at PLUS COURSE PASS” to attend at 317.557.3062 or http:// Course SYM #29). American www.omic.com. this course! (Prior to meeting, pass www.indianaeyemds.com/ Academy of Ophthalmology. is $225. Onsite fee is $275.) NEW! Three Webinars event-1861366. Venetian Ballroom AB, Sands November Exposition & Convention Center, January My Doctor Never Told Me That Las Vegas, NV; 2–3 pm. Could Happen! 9 EHR to the Rescue? Not So Fast: 14 OMIC: Cataract Malpractice Settlements of 2015. Cataract Telephone Screening: Liability Liability Risks in the Electronic 17 Prelitigation Services (AAOE Surgery: Telling It Like It Is! Naples Issues & Guidelines Platform. Northern Virginia Instruction Course #606). American Academy of Ophthalmology. Grande Beach Resort, Naples, FL; Using Checklists to Prevent Patient Academy of Ophthalmology. McCormick & Schmick on Room Casanova 606, Sands 8:30–9:30 pm. Register at http:// Harm www.cstellingitlikeitis.com/. Sign in onsite.