By Shelly Weatherly, JD, Vice President, Risk Education and Evaluation Services, SVMIC
A review of SVMIC Urology claims from 2009 – 2015, where there was a paid loss on behalf of an insured, reveals that failure to timely diagnose and improper performance of a procedure were the most common noted misadventures. Most often, the diagnostic errors were not the result of lack of knowledge, skill or diagnostic ability on the part of the physician, but rather, as the graph below illustrates, were a product of inadequate documentation, communication breakdowns and poorly designed or ineffective systems.
DOCUMENTATION ISSUES: The importance of maintaining a well-documented medical record, from both a patient care and a risk management standpoint, cannot be overstated. As the graph above illustrates, documentation issues were a factor in 53% of claims paid in Urology. Of those, 75% involved inadequate documentation, which can have a negative impact on the defensibility of the care provided to a patient. The cases reviewed involved:
EHR documentation issues were also present in the reviewed cases. In one case, the physician, over the course of several office visits, incorrectly carried over erroneous documentation suggesting a positive study for an enlarging renal mass, which was the basis for a radical nephrectomy. The post-op pathology report revealed no such cancer. During the deposition, the physician admitted to the documentation errors that were the result of the “copy and paste” function of the EHR system. While the physician’s failure to review the study prior to taking the patient into surgery was difficult to defend, the documentation errors called the entire record, as well as the physician’s credibility, into question.
COMMUNICATION ISSUES: Effective communication is essential in establishing trust and building good patient rapport, which in turn plays a role in a patient’s perception of the quality of care. Communication breakdowns occurred in 47% of the reviewed claims, and the majority of these involved physician-to-patient situations. Examples include:
SYSTEMS ISSUES: Effective systems and processes help reduce adverse events and claims by decreasing reliance on memory or informal mechanism alone. Systems failures were an issue in 42% of the analyzed claims. Failure to track and act on test results and missed appointments were a common theme.
In one case, a patient presented to the ED with flank pain, nausea and vomiting. The CT scan was originally read as normal by the emergency physician who referred the patient to a urologist for admission. Thereafter, a radiologist over read the CT scan and found a 2x3 cm kidney lesion, which he reported to the emergency physician. The admitting urologist was unaware of this information. He noted in his admission history & physical that the CT scan revealed “no obstruction or stone” and listed the diagnosis as “patient passing a kidney stone”. The patient was discharged, never having received information about the abnormal CT scan. Two years later, he underwent a radical nephrectomy for renal cancer.
Another example involved a patient who underwent a cystourethroscopy for complaints of hematuria. Urine cytology was collected which revealed malignant cells. However, the report was not transmitted to the office, nor did the lab call the office to report the critical finding. There was no internal tracking in place to alert the physician of the missing test result. A return visit in six months was scheduled, but the patient failed to keep his appointment. Again, the office had no system to follow-up on missed appointments. Nearly a year later, the patient self-referred to another urologist who diagnosed bladder cancer with brain metastasis.
Also observed in the cases reviewed were wrong site procedures. One case involved a urologist removing the wrong kidney. Instead of reviewing the CT films prior to the nephrectomy, the surgeon relied on the radiology report that incorrectly cited the lesion on the right kidney instead of the left. Another case involved a wrong side ureteroscopy with stent placement. A review of the events revealed that there was no time out, the site had not been marked, and the wrong CT scan was on the screen.
Shelly Weatherly is Vice President, Risk Education and Evaluation Services for SVMIC. Ms. Weatherly graduated from the University of Tennessee School of Law, is a member of the Nashville and Tennessee Bar Associations, and has been with SVMIC for 26 years. Prior to joining SVMIC, Ms. Weatherly served as Law Clerk on the Tennessee Court of Appeals for the Honorable William C. Koch, as well as on the U.S. District Court for the Middle District of Tennessee under the Honorable Charles Neese. Ms. Weatherly leads SVMIC's Risk Education and Evaluation Services. Prior to 2015, she developed and administered the company's Risk Evaluation Services and earlier served as a Claims Attorney. She is a frequent speaker on risk management, liability assessment, and professional liability topics at medical professional association meetings, medical schools and residency programs, and industry seminars.
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