We can assume that health care providers make fewer mistakes on those days when they are not overly busy, easily distracted, constantly being interrupted,
stressed, or dealing with personal issues, a leaky water heater, or
their car’s check engine light. You know those days, right?
Of course, health care providers generally do function safely and
effectively under challenging conditions. From the relative “quiet” of a
private practice to the more frenetic pace of EDs, L&D units, ORs,
understaffed labs, and overbooked imaging suites, health care delivery
is carried out in an environment that would likely immobilize many
non-health care professionals. Physicians and nurses, however, learn
how to filter out numerous everyday distractions and navigate around
routine diversions without compromising their vigilance to the patient’s
care and safety.
Almost all of the time.
But even those of you who thrive amidst organized chaos can become
preoccupied with a nagging concern, take on one task too many, or let
down your guard. Of course, this is when you are most vulnerable to
making errors, or to not catching your mistakes quickly enough to rescue
the situation. This is when you need an extra ounce of vigilance to
prevent patient harm and, perhaps, an allegation of malpractice. So what throws you off your game?
A new piece of equipment, new software, a new form to be filled out?
A schedule snafu, a change in team members, a workplace dispute?
A patient who reminds you of a loved one…or resembles a crabby neighbor?
The day before or after vacation, or the first or last day of being on service?
A pending malpractice case or a near miss?
Traffic, a fight with your spouse, too many meetings?
Something in the mirror that doesn’t look right, or a new and undiagnosed pain or ailment?
Many adverse events stem from seemingly small missteps in the
patient’s care. Self awareness of what might set you up for a
substandard performance is an important step in developing strategies to
compensate and perhaps avoid those little mistakes that can have big
consequences.
Could you miss a colorectal cancer? Our data
show many do. Test your skills with our short private quiz that is based
on a closed malpractice case.
Test your own knowledge by taking our private quiz. The scenario below
is taken from a CRICO closed malpractice case. The case outcome with the
application of CRICO's decision support tools, appears at the end of
this quiz. Take the quiz on the CRICO website. How did you do? Leave a comment here and let us know how you did.
For all the good they promise for health care, electronic medical
records (EMRs) have yet to demonstrate a profound impact on patient
safety. Health care providers who resist
or merely tolerate paperless systems are unlikely to capitalize on
secondary components that could alert them to hidden risks. But even for
clinicians who embrace their EMR, the benefit of reducing errors, and
by extension patient harm, remains elusive. Nevertheless, patient safety
experts see enormous potential in both the point-of-care opportunities
for avoiding errors and the broader value of data aggregated from
appropriately designed systems.
Today, the EMR that some envision
may be mere fantasy, but physicians, patient safety experts, and
patients need to put forward ideas that will enable designers to meet
that potential. Ideally, an EMR should help the clinician in the office
or at the bedside focus on the immediate concern while keeping him or
her fully apprised of the patient’s history. And rather than dictate the diagnostic process or care plan, an EMR should support the clinician’s decision-making:
linking to evidence-based guidelines and protocols
identifying potential risks
ensuring that critical patient information is communicated, received, and acted upon
Behind the scenes, an EMR designed to reduce the risk of patient harm
should enable health care leaders and researchers to mine the database
for trends that signal the need for education, training, or systems
adjustments.
Certainly that is a tall order. Commercial vendors need to see a return
on investment; providers want ease of use; and, more and more, patients
expect to be engaged
with both their physician and their medical information. CRICO and its
constituents have stepped up the challenge through a provocative video
and a series of demonstration projects currently underway that should
influence this evolving technology. But we expect that the best ideas
will come from everyday EMR users who want a better EMR in their future.
While Obamacare is the ultimate political Frisbee, a different set
of laws—about breast cancer screening —may soon have physicians’ heads
spinning.
To date, five states1 have enacted some form of legal requirement that the significant percentage2
of women with dense breasts be apprised of the limitations of
radiographic mammography and informed of alternate or adjunct imaging
options. Now, in addition to having to help patients navigate
conflicting studies about the when of screening, providers also have to
guide patients through the how. Even in states (including Massachusetts)
where such laws are not in place, physicians should be prepared to
address this emerging aspect of breast care with an eye toward patient
safety.
Radiologists and primary care physicians (PCPs) are trying to
determine what to write and what to say to patients that is both legally
compliant and reflective of appropriate care. The biggest challenge is
the lack
of clinical evidence that screening alternatives for women with dense
breasts, i.e., whole breast ultrasound and MRI, are beneficial.
Providers have to convey to patients both sides of the potential consequences
of additional screening without increasing their own risk of being
deemed liable for a missed or delayed breast cancer diagnosis.
Given that patients—especially women who have a screening
mammogram—have increased access to their medical records and reports,
radiologists and PCPs will do well to coordinate their breast density
messaging. Wording
the information about density in the mammogram report to help the PCP
frame the patient discussion (about screening options) will reduce
tension between providers. Along with the foundation of evidence-based
care, clearly documenting what was discussed, and the patient’s
expressed plan (if any) for subsequent imaging will be a strong defense
for PCPs whose standard of care is later questioned.
While the breast density issue has received considerable attention,
malpractice cases related to breast cancer more frequently involve the
mismanagement of symptomatic patients than insufficient screening.3
Capturing and updating patient and family histories, and following
breast complaints to resolution will best position physicians to provide
optimal care that can be defended against allegations of diagnostic
missteps. To that end, CRICO’s Breast Care Management Algorithm offers PCPs a clear course of best practices that balance evidence-based care with practical risk management recommendations.
The shortage of
primary care physicians (PCP) in the U.S., paired with the drive to
lower costs, is challenging access to health care. One idea increasingly
advocated is granting greater responsibility and independence for the burgeoning population of nurse practitioners (NP). Scope-of-practice laws vary widely by state—from tight restriction to full independence. Physicians opposed to full independence argue, however, that that solution will bring the level of care those patients receive below a tolerable standard. Is this just a turf battle or a patient safety debate? Unfortunately, any focus on potential risks posed by mid-level
providers’ (NPs, physician assistants, etc.) detracts attention from
their predominately positive role in patient safety. In conjunction with
increasing access to care, non-physicians are often able to perform
tasks that physicians too short on time simply can’t get to: updating
histories, checking medication compliance, listening to secondary
complaints, providing education, etc. These activities clearly enhance
the quality of care—especially in communities with PCP shortages. Those
interactions also reduce the likelihood of miscommunication, missed
appointments, fumbled test results, unresolved complaints, and myriad
other issues that often presage an adverse event and a malpractice
allegation. Certainly, a patient whose needs exceed the capabilities, comfort
level, or authority of a non-physician should be seen by a physician as
soon as possible. Establishing and enforcing the criteria for such
escalations is essential to protect both patients and providers. Indeed,
those criteria are the focus of the debate about whether or not
expanding the practice scope of mid-level providers increases their
patients’ vulnerability to misdiagnosis or mismanaged treatment. Whatever rules are in place, not all patients will fully comprehend
the capabilities or limits of a non-physician they see in their doctor’s
exam room or the Emergency Department or an in-store
clinic. Quickly and sincerely addressing the concerns of such patients
will help reduce misaligned expectations. Of course, mid-level providers
are not immune to being named in malpractice claims, and those who
supervise them, generally speaking, will also be held accountable for
their care. CRICO’s data indicate that since 2002, 75 malpractice claims or suits
cases named 83 NPs or PAs as defendants,* a rate of about one defendant
per 200 practitioners per year. Analysis of those 75 cases indicates
that inadequate supervision of the mid-level providers was identified in
19 (25%). The average incurred loss for cases involving mid-level
provider defendants was $330,000. Supervising physicians are obliged to know (and share) what risks
these arrangements may pose to their patients and practice. Mid-level
providers without independent access to patient safety-related education
will be reliant on their colleagues and supervising MDs for alerting
them to common hazards and practice-specific concerns. As with most
learning situations, point-of-care guidance and training will have a
longer-lasting impact. Physicians and those they supervise who establish
in situ opportunities to address known or potential risks will likely
fare better than those who leave this to chance or individual
motivation. *Mid-level provider defendants who are employed by a CRICO-insured
organization receive the same level of coverage and full complement of
benefits afforded to CRICO-insured physicians.
Carving out time for patient safety education and training is a
challenge. The pressures of day-to-day practice can detract your time
and attention …until something bad happens—to a colleague, or in your
own practice. Of course, physicians who do find the time to learn how to
reduce their risk of patient harm and an allegation of malpractice, are more likely to avoid those circumstances.
In Massachusetts*, CRICO’s philosophy is reinforced by the Board
of Registration in Medicine’s Continuing Professional Development
(formerly Continuing Medical Education/CME) requirements, which dictate specific education categories, including risk management study:
Physicians must accrue 10 credits of risk management study
every two years. Four credits must be in Category 1. The additional six
credits may be in Category 1 or Category 2 risk management study.
Risk management study must include instruction in
medical malpractice such as patient safety and loss prevention.
Activities that meet these criteria may include courses in quality
assurance, bioethics, end-of-life care studies, opioid and pain
management, as well as non-economic aspects of practice management. All
of CRICO’s CME activities are designed to be suitable for risk
management study, including our newest publication, Insight and our podcasts. CRICO’s most recent issue, Insight into Communication Challenges,
offers actionable data, expertise, and personal physician perspectives
on this universal area of risk. The Massachusetts Board of Registration
in Medicine has endorsed Insight and our podcasts for Category 1 credit.
As a CRICO-insured physician, you can find help meeting these requirements through our website.
CRICO is proud to be accredited by the Accreditation Council for
Continuing Medical Education. We work side-by-side with a network of
Harvard experts to develop activities designed to help you decrease
patient harm. Of course, the Risk Management or Patient Safety departments at the hospitals and other organizations you work with—or for—also offer opportunities for CME and Risk Management credits.
No matter where you chose to go for quality patient safety and risk
management education and training, it is certain to beat trial and
error.
*Look here for CME and risk management study requirements in other states. Through CRICO Strategies, non-CRICO insured clinicians can gain access to education based on clinically coded malpractice data.
As we encourage patients to be more engaged,
we may also see more who go beyond assertive to demanding care
unsupported by good clinical judgment. Understandably, physicians worry
that saying “no” to a patient increases their risk of being disliked,
dismissed, or even sued for medical malpractice. But the right mix of
clinical judgment, bedside manner, and documentation can help take the
“maybe” out of saying no to a request for unnecessary—or unsafe—testing
or treatment. More transparency in health care means patients are more aware of
options for screening, testing, procedures, and medications—often via
direct campaigns. The advent of social media further expands the spread
of both legitimate and untrustworthy
health care information. Thus, an anxious or desperate patient may ask
for something about which they have heard or read, e.g., an MRI after a
negative mammogram, a better drug for acid reflux, a cesarean section
scheduled for convenience, an experimental procedure “like on House,
MD.” In the face of such requests, maintaining an effective patient
relationship, practicing appropriate care, and heeding the pressure to
control cost—can be a real challenge. If your clinical judgment is to say no, then saying yes—because it is
easier, faster, less of a hassle—may pose hazards to both you and your
patient. Even relatively benign procedures can carry the risk of
unintended consequences. For example: changing a medication regimen can
destabilize a patient's health; a “convenience” delivery before 39-weeks
gestation may violate clinical guidelines
(or hospital policy); experimental procedures (even those from the real
world) are the purview of those physicians working to perfect a new
technique with patients selected via exacting criteria—not just foot
stomping. Explaining to a patient the reasons behind “no” takes time and
patience. But thoughtfully discussing and documenting such requests will
improve your chances of maintaining good rapport and leave you less
vulnerable to an allegation of malpractice than if your refusal is curt,
dismissive, or poorly documented. Listening with respect to what the
patient's aunt or neighbor or favorite blogger has suggested gives you
an opportunity to respond with your own expertise and reasoning. Such conversations
also provide an opportunity to elicit suppressed concerns and a chance
to assure the patient that he or she is part of the process. Noting in
the record a) what the patient requested b) your rationale for denying
that request, and c) what you recommended instead, gives you, the
patient, and subsequent providers context for future requests and
decision making. Of course, crossing your t’s and dotting your i’s after saying no
doesn’t mean a disgruntled patient won’t pursue a complaint—that’s
beyond your control. But if the complaint is in the form of a
malpractice allegation, then your medical professional liability insurer
will have such claims assessed by medical experts
in your specialty. Their opinion will be based on their own experience,
the prevailing standard of care, and your notes. To that end, a
properly documented decision based on solid clinical judgment and
matched by the practice of your peers is the best support for your
decision to say no.
