Saturday, December 16, 2017

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Each issue of The Doctor’s Practice features a new article or video in a simple, one-click e-mail. These articles feature expert tips to help you reduce malpractice risk, avoid claims, and make the practice of medicine more rewarding.

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The insightful content in The Doctor’s Practice is part of The Doctors Company’s commitment to defending, protecting, and rewarding the practice of good medicine.


The Doctors Company Risk Tip: Including Risk Management in Your Vacation Planning Allows You to Relax

Because liability never takes a holiday, your vacation plans should include medical coverage arrangements for your practice, particularly when you use locum tenens. The following tips will help reduce risks in your practice and promote the safety of your patients as you plan your vacation:

  • Review managed care contracts for relevant coverage requirements. Some managed care contracts contain very specific language on this topic and many contain indemnification clauses that could expose you to the liability of the covering physician (as well as breach of contract). 
  • Whenever possible, make secondary coverage arrangements. Confirm coverage arrangements via e-mail or fax with the locum tenens who are covering your practice in order to avoid misunderstandings, possible uncertainty of dates or time frame, and exposure to abandonment.
  • Ensure that the practice coverage arrangements include an understanding about patient billing practices in conjunction with any managed care contracts or plans. 
  • Choose covering physicians who share your medical specialty and have privileges at the same hospitals that you do. 
  • Determine if covering physicians carry professional liability coverage and the limits of such coverage. While asking these questions could be awkward, you may be required to ask under certain managed care plans, provider agreements, and hospital bylaws.
  • Before leaving on vacation, prepare a list of patients who are hospitalized or are in the midst of diagnostic work-up, or who have special medical problems or needs. Give this information to the covering physicians and document any specific advice you provide. 
  • Inform the attending physicians or hospitalists of any hospitalized patients you are following about your coverage arrangements, and document the hospital chart to reflect these conversations. 
  • Advise your patients of the coverage arrangements and give them the covering physicians’ names.
  • Make each hospital where you have on-call responsibilities aware of the dates of your unavailability and the identity and phone numbers of the covering physicians. Give similar notice to your answering service and office staff.
Upon returning from vacation, promptly confer with all covering physicians. Document what you were told by the covering physicians about any significant developments in patients’ clinical course or treatment while you were away. 

Consider implementing these fundamental loss prevention measures for even brief periods when you are unavailable, such as observance of religious holidays, attending medical conferences, personal illness, or a long weekend. Unfortunately, vulnerability to claims is not diminished on these occasions. 

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

The Doctors Company Risk Tip: Undiagnosed Heart Disease in Women

Differences in the early symptoms and signs of an impending heart attack in women may make diagnosis more difficult compared to men. 

In a study of closed medical malpractice claims involving undiagnosed heart disease in women, The Doctors Company found that in 61 percent of claims the patient died when her heart condition was not correctly diagnosed and 33 percent had heart muscle damage from myocardial infarction. 

In the following case, failure to diagnose acute myocardial infarction resulted in death:

A 47-year-old obese woman presented to her PCP complaining of a burning sensation in her chest after eating. The patient reported a similar episode the prior day after eating lunch as well as increased heartburn over the last few weeks.

A review of the medical record reflected elevated blood pressures over the past six months and an elevated cholesterol level of 237 (mg/dl). On the day of the exam, her blood pressure was 160/90. She smoked, drank alcohol socially, and was unaware of a family history of coronary artery disease. A heart exam revealed normal rate and rhythm. The physician noted that the patient appeared diaphoretic; however, she wasn’t in acute distress and was pain-free throughout the examination. An ECG revealed a left bundle branch block. Prior ECGs were not available for comparison. Suspecting reflux esophagitis (heartburn), the PCP advised the patient to take an antacid and to return if the symptoms continued.

Two days later, the patient called her PCP’s office stating that her chest burning sensation continued. The nurse advised her to continue taking the antacid and scheduled an office appointment for the following day. The nurse advised the patient to go to the ED if she developed chest pain. 

That night, the woman awoke with chest pain, nausea, and vomiting. She was taken to the ED for emergeny coronary angiography, but died shortly after arrival. 


To avoid such risks:

 

  • Rule out myocardial infarction before arriving at a GI-related diagnosis such as gastric reflux as the cause of chest pain or discomfort. 
  • Consider cardiac risk factors such as obesity, smoking, hypertension, and hyperlipidemia. 
  • Offer patients same-day appointments when they complain of continued symptoms for which they were recently seen. If this is not possible, send them to the ED and document this in the medical record.
  • Develop a written chest pain protocol. 

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.


The Doctors Company Risk Tip: Medical Clearance Does Not Clear the Patient or Physician of Risks

“Medical clearance” is when a surgeon requests clearance from an assessing physician before performing surgery on a patient. Cardiac risk is the number one reason to request medical clearance, but other risks that call for medical clearance include congestive heart failure, pulmonary embolism, anticoagulation, obesity, and high blood pressure. 

Anticoagulants, for example, are often an issue in surgical claims. If the patient is taking anticoagulants, the surgeon and the physician should agree on the best approach for that specific patient. They may discuss changes in medical management that should be made to decrease risk. If they believe the patient is at risk from a respiratory perspective, the focus may be on early mobilization, incentive spirometry, and respiratory treatment.

To avoid malpractice risks, consider the following tips when dealing with medical clearance:

  • Determine which patients need medical clearance. The surgeon should assess the type of surgery and its associated risks and the health of the patient. Healthy patients with no underlying conditions who are undergoing fairly low-risk procedures don’t routinely need medical clearance. 
  • Provide appropriate information. Problems can arise when the surgeon does not provide enough information to the assessing physician about the surgery being proposed. The surgeon should provide information to the assessing physician about the type of surgery, how long it will take, what kind of anesthesia is anticipated, how long the patient will be immobile, what is involved in rehabilitation, and what the recovery period looks like. The assessing physician should take that information into consideration, along with exam results and knowledge of the patient, to determine if the patient is at increased risk.
  • Develop a plan to mitigate risks. The surgeon and the assessing physician should work together to determine the steps to take to mitigate risk preoperatively, intraoperatively, and postoperatively. For example, they should agree about which medications to stop preoperatively and which to continue. 

There is no standard medical clearance process. Physicians should be aware of when a medical clearance would be indicated and have a good process to ensure it’s done.

Medical clearance is a misnomer because it implies that the patient is cleared and there are no risks. No patient is free of risk when undergoing a procedure. The goals of the assessment are to determine the level of risk and to identify opportunities to mitigate risk—with the surgeon and the assessing physician working in concert. The decision about whether to proceed with the operation belongs to the surgeon and the patient.

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.


Malpractice Claims Consume Years of a Physician’s Career

Risk Tip by The Doctors Company

On average, each physician spends 50.7 months, or approximately 11 percent of an average 40-year career, on resolving medical malpractice cases—the majority of which end up with no indemnity payment. That’s the conclusion of a recent study1 by the RAND Corporation based on data provided by The Doctors Company, the nation’s largest medical malpractice insurer. Researchers found that 70 percent of the time physicians spend on claims is spent defending claims that end in no payment to the plaintiff.


Key findings of the study include:

  • Physicians experience additional stress, work, and reputational damage from the time spent defending claims.
  • Fighting claims takes time away from practicing medicine and from the opportunity for the physician to learn from his or her medical errors.
  • The lengthy time required to resolve claims also negatively impacts patients and their families.
The effect of malpractice claims on physicians’ careers is discussed further by Richard E. Anderson, MD, FACP, chairman and CEO of The Doctors Company, in two short videos that can be viewed at www.youtube.com/doctorscompany.

To help prevent claims that can take up years of your career, follow these key tips to promote patient safety:

1.    Communicate with Patients

·         Understand the new vital sign: health literacy.

·         Do not ask patients if they understand—instead, ask them to repeat back the information.

·         Document patient understanding of instructions.

·         Provide the patient with written instructions.

·         Use a translator when necessary.


2.    Document Carefully and Objectively

·         Do not point fingers at other staff or providers.

·         Do not impeach the integrity of the medical record by altering it.

·         Use only approved abbreviations.

·         Review patient information that is automatically populated in the EMR.


3.    Monitor Handoffs and Ensure Follow-ups

·         Establish a formal tracking system for missed appointments.

·         Follow up with patients to reschedule.

·         Document missed appointments in the patient record.

·         Send a letter to patients who repeatedly miss appointments.

·         Explain the importance of follow-up care.

·         Refer the patient to another physician, if necessary.


4.    Avoid Medication Errors

·         Keep prescription pads secure.

·         Document samples in the medical record.

·         Check allergies at every visit and document in the same place in the record.

·         Review and reconcile medications at every patient visit.

·         Be aware of LASA (look-alike/sound-alike) medications.


5.    Follow HIPAA Regulations

·         Avoid unauthorized release or breaches of PHI (protected health information).

·         Safeguard against lost or stolen PHI through laptops or drives.

·         Examine office practices and layout that may compromise confidentiality.

·         Assess your methods to protect electronic communications.

·         Follow federal requirements and know your state regulations, which may be stricter.

 


Reference
1. Seabury SA, Chandra A, Lakdawalla DN, Jena AB. On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim. Health Affairs. 2013;32(1):1-9. 


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