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Thursday 03 March, 2016 06:06

Chapter 26: Risk management – keeping problems at bay

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Chapter 26: Risk management – keeping problems at bay

"Risk comes from not knowing what youre doing. "

- Warren Buffett.


All doctors today are aware of the risk of being sued. While lawsuits against doctors used to be rare in the past, trends are changing rapidly and we are quite likely to follow the American example where practically every doctor has been sued at least once, and where being sued is considered to be one of the occupational hazards of practicing medicine. While this can be bitter medicine, there is little point in waxing nostalgic about the good old days; we need to come to terms with the new reality.

Learning how to minimize the incidence of adverse events in medicine, and their impact, is called risk management, and this has become a well-established science today. The practice of risk management involves identifying those aspects of problem behaviour on the part of doctors, that cause patients to sue, and then eliminating or controlling them to reduce the likelihood that a malpractice claim will be filed. Unfortunately, most doctors in India are still unaware of this field, and most of us learn about it the hard way.

Risk management is tied to the concept of quality control. The ideal solution to quality control would be to prevent all risks, but unfortunately this is impossible because provision of much needed medical care is unavoidably accompanied by the occurrence of injuries. What can you do to minimize your risks? Risk management focuses on preventing problems, and the most important issues are:

Clinical Competence

Medical knowledge requires maintenance: Keep yourself up-to-date! Do your homework: good doctors can prevent the most serious errors by being primed to recognize and treat them. The sequence of events leading to poor patient outcomes and eventually to malpractice suits can usually be clearly visualized. Failure to perform an adequate clinical assessment of the patient, omission of necessary tests, an improper diagnosis, and failure to treat the patients condition can lead the physician and his patient towards disaster. Fortunately, proper attention to the details of the clinical encounter and an awareness of the most common problem diagnoses can help you to avoid these pitfalls.

Remember, however, that being competent as an individual is not enough. You are in charge of the entire medical team caring for the patient, and you need to ensure that your staff too is competent. They will learn from you, and it is your responsibility to teach them well!

It is important to realize your own limitations, and to ask for consultations and referrals to seniors when necessary. Also, do not criticize other doctors and their care: after all, what goes around, comes around, and your criticism may backfire in the long run.

Communication

This means being able to manage high-risk situations, where the patient is likely to sue. Thus, the patient who has had a poor outcome (for example, the birth of a baby with birth asphyxia: the obstetricians nightmare) is like a time bomb which may explode if not handled with care and tact. The most important skill is that of patient communication: of being able to talk and explain to the patient what went wrong, and why. This is the skill of having a good bedside manner: of treating patients as human beings worthy of your time and attention. For many physicians that goes without saying, but for some it bears repeating. Unfortunately, arrogance seems to be second nature for some doctors in India and, as Tuthill puts it,
"If you act like God youll be expected to perform like God," and thats sure invitation to a lawsuit. Remember, patients who like their doctors and medical office staff, and feel a strong sense of loyalty and friendship towards them are much more inclined to resist the notion of suing even if things do go wrong. For example, if a complication does occur, do not try to hide it. It is best to explain it as some form of biological variation in the patient responsible for an unusual clinical presentation or therapeutic response, for in most cases this is the best tactical explanation.

Fortunately for most doctors, the majority of patients who experience an adverse event or poor clinical outcome because of an error do not sue their doctors. Nonetheless, an adverse event or unexpected bad result can serve as a red flag, warning the doctor that he may be slapped with an allegation of malpractice. The severity of the injury and the degree of patient or family dissatisfaction may be additional "early warning" signs that a lawsuit may be on the way. So what should you do to prevent problems if an adverse event does occur ?
First, remember what not to do - dont lie; dont hide; dont pretend; and dont push off the unpleasant duty of talking to the patient or his relatives to someone else - its your responsibility and only you can do it properly. Dont make a bad situation worse by running away from it ! Unfortunately, the first response is often to bury the error and hide it - but this often makes matters worse.

Junior staff members should report all incidents to their seniors, who can take appropriate steps. After all, with seniority comes experience - and often your seniors will have encountered similar problems in the past, and will know exactly what to do. Their advise and guidance can be invaluable.

 

The first priority should be to attend to the patients medical needs. Take responsibility

for dealing with the problem, ask for consultation and make arrangements for follow-up. Discuss with all staff members the factual details and sequence of what occurred , and attempt to reconcile any opposing perceptions of what occurred. Coordinate your response, to ensure that everyone is going to tell the same story.

When a serious adverse event occurs, expressing sincere sympathy and compassion to the patient and/or family is often the most important response to help diffuse a potentially volatile situation.
As soon as possible after the event, factually record the incident and medical response and document plans for further follow-up if indicated. Its a good idea to ask the most involved and knowledgeable staff member(s) to record factual statements of the event in the patients record and any follow-up needed or done as a result of the incident. However, do not ever alter ( or allow anyone else to alter) any prior documentation , or insert backdated information. Ill-advised record alterations can render otherwise defensible cases almost impossible to defend. Do not use the medical record to speculate or air grievances about other caregivers, equipment, or administrative processes.

Be accessible for questions from the family and the patient. Repeated requests for an explanation of the event is a common reaction of upset patients and family members - be empathetic and dont get irritated ! Be honest with the patient and family - if you try to wriggle your way out by lying, you may find yourself trapped in a quagmire from which it may be very difficult to extricate yourself later.


Organize a family meeting if several relatives are involved in the patients care or if treatment decisions are complicated. Empathize with the family and offer emotional support. Your goal should be to show compassion for the patients distress, without admitting liability - and this can be tricky, but you need to find the right balance !
Accept responsibility for follow-up of serious complaints, but do not accept or assign blame, or criticize the care or response of other providers.

Should you apologise to the patient if there has been a goofup ? The best approach is a rational one - describe the incident and medical response in brief, factual terms and if additional follow-up is indicated, discuss those plans with the patient. Show concern for the patients condition, but dont criticize yourself or other caregivers for a poor outcome or engage in "thinking out loud" about what happened or why.

If the event involved a medical device or piece of equipment, preserve these materials for
investigation. Do not return defective devices to a manufacturer who may be a possible party to a claim. Electronic fetal monitoring strips, X-rays, and pathology slides are examples of other important data to preserve following an adverse event.

Today patients have higher expectations of the medical care they receive, and they expect their doctor to have excellent technical skills and to apply his medical knowledge expertly to their problems. They expect value for the money they spend on medical services, and they also demand to be treated with respect, courtesy, and caring. When they find their expectations belied they turn into critics, and even plaintiffs.


Insurance

Ensure that you are covered and have adequate professional liability insurance. Indeed, it would be foolhardly for any doctor today to practice without taking out comprehensive coverage for malpractice insurance, and fortunately insurance premiums in India are still reasonable. While coverage will not prevent you from being sued, it will help to mitigate the possible financial impact on your resources.

Documentation

It has been said that the medical record is a defendant physicians only friend, or foe. In every malpractice case, attorneys for both sides scrutinize medical records carefully, looking for specific types of evidence that will bolster their respective cases. Every medical record has a potential for legal scrutiny, and it serves as a legal record of the care provided to the patient. The rule is simple: if it is not documented it did not happen! Absent data, poorly integrated information, or diagnostic conclusions that are not logical or are not properly recorded, leave an impression of sloppy practice and poor physician judgment. In fact, keeping accurate medical records is so important, that we have devoted a complete chapter to this.

If you want to reduce your risk of getting sued for malpractise, follow these simple suggestions.

1. Be a nice person. Be pleasant to be around. Be agreeable. Be friendly. While being nice is no guarantee that a patient or family is not going to sue , they are far more likely to sue you if you are unpleasant, obnoxious and rude. So be nice.

2. Be honest. Don’t make promises you can’t keep. And when you make a mistake, admit it. Promptly. The reason for this is that when we lie, we send off signals that something’s not right. And most people can spot that a mile away. If you are honest and forthcoming with patients and family, they are more inclined to like you, and far less inclined to sue.

3. Be open. Make it a point of being available and easy to reach, both in a physical sense, and in a psychological sense. If something doesn’t make sense, say so. If you don’t understand something, tell the patient. And if you don’t have all the answers, tell the patient that, and say that you will find someone who does have the answers. And do it.

4. Be accessible. Don’t hide from your patients. Don’t avoid them. Again, I’m not suggesting that you be there for them 24 hours a day. But when you are there, be there. And if you have other patients to care for, tell your patient honestly that you have other patients at the moment, but you will be back with them as soon as you can.

5. Keep up to date professionally, and not do things that you are not competent to do. This is just a part of being honest with yourself. Know what you can do, and do it. Know what you can’t do, and don’t do it.

Life is full of the unexpected, and this is especially true in an inexact science like medicine. No matter how competent and careful you are, problems are bound to occur. If you are prepared for these, and have a plan of action to deal with them, you will be able to cope much better when they do crop up.

 

Read 11439 times Last modified on Monday 15 August, 2022 11:06

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