Malpractice Tips
RISK MANAGEMENT TIPS
Risk Management Tips provide guidance to support our physicians and facilities in their ongoing efforts to improve the quality of patient care and reduce liability exposure in the practice of medicine.
Please e-mail our Risk Management Department for guidance regarding your specific situation.
Tip #1: Maintaining Patient Confidentiality
Tip #2: Tracking Test Results
Tip #3: Prescription medications and patient safety
Tip #4: Failure or malfunction of office equipment can lead to patient, staff or provider injury
Tip #5: Following up missed or cancelled appointments.
Tip #6: Managing medication samples
Tip #7: Safely caring for obese patients in the office practice setting.
Tip #8: Management and documentation of after-hours telephone calls from patients.
Tip #1: Maintaining Patient Confidentiality
The Risk: Inadvertent breach of patient confidentiality.
Recommendations:
Office staff must be aware that routine office practices, such as discussing patient information within earshot of other patients, can breach patient confidentiality.
1. Educate your staff periodically to reinforce the need to maintain patient confidentiality and to never discuss patients outside the office.
2. Every year, have your staff sign a confidentiality agreement.
3. Assess your physical premises to determine the flow of patients through the office and how best to ensure that confidential patient information, written or spoken, is kept private.
4. Assess staff work areas to determine patients’ accessibility to computer screens and patient information. How quickly are computer users logged off the system when data entry stops?
5. Set up your office in such a way that staff conversations can not be overheard in the waiting area.
6. Obtain written consent from patients so that minimal information can be left on telephone answering machines.
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Tip #2: Tracking Test Results
The Risk: Tests may not have been completed or results may be lost, overlooked, or not received.
Recommendations:
Follow-up procedures are important to ensure that patients receive the necessary testing, as ordered, and that results are returned to the office and properly reviewed.
1. Educate patients about the need for the testing, and document this conversation.
2. Implement a follow-up system in your practice to ensure that patients have undergone the recommended testing and that the results are returned to the office.
3. The follow-up system should include the patient’s name, the date the test was ordered, when the results were received, and when the patient was notified.
4. The physician should review, initial, and date the reports before they are filed in the medical record.
5. Attempts should be made to contact patients who have not undergone the recommended testing. These attempts should be documented in the medical record and, once the patient has been reached, he/she should again be urged to obtain the requested testing.
6. Include a process in your follow-up system to verify that consultations were obtained.
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Tip #3: Prescription medications and patient safety
The Risk: Patient injuries and malpractice claims can result from known risks and side effects, allergic reactions, drug interactions or errors in prescribing.
Recommendations:
1. Since there are significant risks and side effects associated with prescribed drugs, physicians must discuss this information with their patients and document these discussions in the medical record.
2. The patient’s allergic history must be reviewed before a new drug is prescribed. Known allergies must be documented and flagged in a prominent, easily viewable place in the medical record.
3. Medication updates, including dosage changes and refills, and the use of any over-the-counter drugs, must be clearly documented in the medical record. A medication flow sheet can be used to monitor and track current and past medication usage, as well as allergies.
4. Any specific instructions provided to patients regarding the medications must also be written in the record.
5. There must be written confirmation that the laboratory and/or diagnostic tests necessary to monitor certain drugs for their effectiveness or side effects are ordered, as recommended by professional guidelines, and the test results viewed and necessary adjustments made.
6. The rationale for the discontinuing a medication must be documented in the medical record.
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Tip #4: Failure or malfunction of office equipment can lead to patient, staff or provider injury
The Risk: More procedures are being performed in the office practice setting than ever before and more physicians own or lease office equipment. Therefore, providing for the safety of patient, staff and providers by performing necessary inspections and maintenance of equipment is an important part of office practices today.
Recommendations:
1. Written policies and procedures must be developed to define the use and maintenance of office equipment. The manufacturers’ directions for use and their recommended schedules for preventative maintenance must be followed.
2. A written log of all maintenance activities must be maintained and retained.
3. A specific staff member must be designated to be responsible to confirm that all required inspections and maintenance of equipment have been performed at the proper intervals.
4. All patient care equipment must be inspected on an annual basis at a minimum, or more often if recommended by the manufacturer
5. All patient care equipment must be tagged to reflect the inspection date, the initials of the inspector, and the date the next inspection is due.
6. All staff must be properly trained in the use of all equipment. Documentation of training and education must be maintained in their personnel files.
7. Equipment must only be used by an employee if it is within the applicable scope of practice for that employee. This includes licensed professionals. This must be determined prior to the employee being trained and/or using the equipment.
8. Every piece of equipment that malfunctions must immediately be removed from service, and labeled as defective. The written office policy must contain a provision to sequester any piece of equipment which may be directly involved in injury to a patient, staff, or provider. Prompt notification to MLMIC is recommended when an equipment-related injury occurs.
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Tip #5: Following up missed or cancelled appointments.
The Risk: A missed or cancelled appointment, and the failure of a practice to follow up with or contact the patient, may result in a serious delay in diagnosis or treatment and a subsequent risk of liability for the provider.
Recommendations:
A pro-active system to follow up with patients about missed or cancelled appointments allows healthcare providers to promptly assess and respond to clinical situations, thereby maintaining continuity of patient care.
1. Develop policies and procedures in your practice for following up with patients who have missed or cancelled appointments.
2. Physicians should be made aware of all missed or cancelled appointments. The staff should inform the physician(s) of these patients at the end of the day and have the medical records ready for the physician’s review.
3. The physician should assess the clinical importance of the appointment, the severity of the patient’s medical condition, and the risk(s) associated with the missed or cancelled appointment.
4. A reminder telephone call from the office staff may suffice for patients at minimal risk. The time and date of the telephone call and the content of the message or conversation must be documented in the patient’s record.
5. A telephone call from the physician may be indicated for patients at higher risk. The physician should emphasize the importance of follow-up care and the risks inherent in failing to obtain it. This telephone conversation must also be documented in the medical record.
6. If there is no response from the patient or the patient develops a pattern of not keeping or missing appointments, a certified letter, with a return receipt requested, should be mailed to the patient to advise him/her of the risk of non-compliance. A copy of the letter and the signed receipt must be maintained in the patient’s chart.
7. All efforts to contact the patient, either by telephone or letter, must be documented in the medical record. This provides written evidence that the patient was clearly made aware of the importance of continuing medical care.
8. Educate your staff about patient follow-up policies and procedures in your practice. Conduct periodic record reviews to determine staff compliance and to evaluate the effectiveness of the processes you have implemented.
9. Continued failure of patients to keep appointments may be deemed non-compliance with treatment. Consideration should be given to discharging the patient from your practice since patient non-compliance may increase a physician’s risk of liability. The attorneys at Fager & Amsler, LLP are available to assist you to determine how and when to properly discontinue a physician-patient relationship due to patient non-compliance.
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Tip #6: Managing medication samples
The Risk: Medication samples are widely used in physicians’ offices. The proper storage, handling, dispensing, and disposal of medication samples are necessary to prevent medication errors and subsequent patient injuries.
Recommendations:
A pro-active system to follow up with patients about missed or cancelled appointments allows healthcare providers to promptly assess and respond to clinical situations, thereby maintaining continuity of patient care.
1. Develop policies and procedures for storing, handling, dispensing, and disposing of medication samples in your office practice.
2. Store medication samples in a safe and secure location in your office to reduce the risk of theft and unauthorized use. Limit access to licensed staff members. Medication samples must not be kept in examination rooms or areas that are easily accessible to patients and visitors (e.g., in unlocked drawers or on countertops). Follow the manufacturer’s recommendations for storage of each drug.
3. Maintain a log of your supply of medication samples. Assign the responsibility of monitoring and tracking the inventory to one staff member. The log should include documentation of the monitoring of expiration dates.
4. Explain the proper use of the drugs to the patients and any special instructions or warnings in the event the patient does not have sufficient reading skills.
5. Record all medication samples dispensed to patients in the medical record. Documentation should include the medication, the amount, the dosage, the frequency, and any instructions provided to the patient.
6. Properly dispose of expired medication samples, when necessary, in accordance with state, federal, and local laws.
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Tip #7: Safely caring for obese patients in the office practice setting.
The Risk: Obesity is a serious health issue of epic proportion in the United States. Physicians’ offices may not be well equipped to accommodate obese patients. Injuries can occur if appropriate equipment is not available to care for these patients. Further, bias or ambivalence by the healthcare team in treating obese patients can negatively affect patient care and lead to poor outcomes.
Recommendations:
Providing a safe environment while optimizing sensitivity to the needs of the obese patient will enhance patient care and minimize your exposure to claims of negligence.
1. Examination rooms and waiting areas should contain appropriate and safe furnishings, such as large sturdy chairs, high sofas, benches, or loveseats that can accommodate obese patients.
2. Diagnostic and interventional equipment that can accommodate morbidly obese patients should be available, if regularly needed. This may include, but is not limited to:
Appropriate scales for patients who weigh more than 350 lbs.
Extra large adult-size blood pressure cuffs
Gowns to accommodate patients weighing more than 350 lbs.
Extra-long phlebotomy needles and tourniquets
Large examination tables
Toilets that can accommodate patients who weigh more than 300 lbs.
Sturdy grab bars in bathrooms
Sturdy step stools in examination rooms
3. The staff must be knowledgeable about the weight limits of their office equipment. Color coded labels can be used to discreetly identify weight limits. Further, the office staff must be educated and trained in the use of safe techniques for lifting and transferring obese patients.
4. While there are many medical complications of obesity, these patients are less likely to obtain preventative care and more likely to postpone or cancel appointments because of embarrassment and/or a feeling of bias on the part of healthcare providers due to their weight. Patient support and follow-up are important.
5. Healthcare providers must address their own potential for weight bias.
Recognize your pre-conceived ideas and attitudes regarding weight. Learn how to give appropriate feedback to patients to encourage healthful changes in behavior. Encourage patients to actively participate in their plan of care and set goals.
6. Educate the staff about the needs of this patient population to enhance their ability to demonstrate understanding, respect, and sensitivity to these patients.
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Tip #8: Management and documentation of after-hours telephone calls from patients.
The Risk: The failure to properly handle and document after-hours telephone calls can adversely affect patient care and lead to potential liability exposure for the physician. Further, should a telephone conversation become an issue in a lawsuit, and it is not documented, the jury is less likely to believe the recollection of the physician, who receives a large number of calls on a daily basis.
Recommendations:
1. Establish a system to respond to afterhours telephone calls. This system should include a consistent process to help ensure that all after-hours calls are responded to in a reasonable time frame and are documented in the patient’s medical record.
2. Medical record documentation of after-hours calls should include the following:
Patient’s name
Name of the caller, if different than the patient, and the individual’s relationship to the patient
Date and time of the call
Reason or nature of the call, including a description of the patient’s symptoms or complaint
Medical advice or information that was provided, including any medications that are prescribed.
3. If the patient’s condition warrants the prescription of medications, it is important to inquire about and document any medication allergies, as well any other medications the patient may be taking.
4. When providing after-hours coverage for another physician’s practice, a process should be in place to ensure that documented telephone conversations are promptly forwarded to that practice.
5. If you use an answering service, it should be periodically evaluated for courtesy, efficiency, accuracy, and proper recordkeeping.
6. The use of answering machines for after-hours calls is not recommended for the following reasons:
There are no safeguards in the event of an answering machine malfunction.
Patients do not always understand that no one will call back, even if this is stated in the message, due to limited English capacity, anxiety, or other impediments.
If, as a last resort, an answering machine must be used, the message must be brief and simple: “The office is now closed. Please go to the emergency department if you believe this is an emergency.”