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.