The most frequent cause of malpractice litigation is not a clumsy incision or a faulty prescription, but an eminently avoidable omission– Failure to diagnose, as it is known in the medical and legal communities, accounted for 40 percent of all malpractice suits filed in 1997. What’s more, six of the top 10 suits closed in 1996 involved physician failure to identify in a timely manner a variety of serious medical conditions.
Until office practices become part of the curriculum of medical schools, those in the health care community would do well to recognize a need to incorporate practical systems that can simultaneously improve the quality of care and guard against liability. Often, outside assessment of simple office procedures, as provided by a qualified risk manager, reveals a need and an opportunity to implement some simple steps that can drastically reduce a medical practitioner’s exposure to liability.
Seifert Systems Invests in Energy Efficiency to Strengthen Operations
For manufacturers, energy is more than just another operating expense. It plays a critical role…
Learn More
Breast cancer has become the most common cause of failure to diagnose litigation. Researchers estimate that one out of every eight women in the United States will develop some form of breast cancer. If treatment is not received before the cancer reaches advanced stages, death can occur within six months.
Five years ago, the mean age of a breast cancer litigant was 44; today it is 39. This doesn’t mean, however, that breast cancer has become more virulent or doctors are now less attentive than they were a few years ago. The increase is due, in large part, to a greater awareness among consumers of their legal rights.
But statistics show that failure to diagnose is more often caused by faulty administrative procedures than it is by medical incompetence. A system as simple as a “tickler file” kept in a spiral-bound notebook to keep track of pending and active cases could avert both personal tragedy and costly litigation. The following scenario illustrates the problem and suggests solutions.
A physician in solo practice was visited by a patient complaining of abdominal pain. The pain was chronic but not incapacitatingly severe. The physician questioned and probed and, finding nothing obvious, ordered an ultrasound scan of her abdomen.
To this point, the physician had performed his duties correctly; he had developed a comfortable rapport with the patient that allowed her to speak freely about her medical condition; he had conducted a thorough physical examination; and when he determined more information was needed, he scheduled a diagnostic test. But the physician’s failure to establish clear administrative procedures for his office practice proved disastrous.
When the ultrasound report came back to the physician’s office, a secretary recorded its return and then filed it away. The case was forgotten both by the busy doctor and the patient who, although still experiencing abdominal pain, assumed that if the test indicated problems she would have been informed. Four months later the trouble began.
By that time, the patient’s pain had become acute, forcing her to return to the physician’s office. It was only then that the physician reviewed her test results and found, to his horror, that they were positive. They showed clearly that the woman had developed tumors. Subsequently, the woman’s family asked to see the medical records, detected the error and filed a failure-to-diagnose malpractice based entirely on the doctor’s failure to alert the woman about her test results.
As in many cases, earlier diagnosis might have had little impact on the patient’s health. But the absence of clear, written procedures for the operation of the physician’s office reflected poorly on the quality of medical treatment and opened the physician to malpractice liability.
What constitutes an adequate system? Our company has conducted more than 6,000 office system appraisals over the last 20 years, and we have found a wide range of procedures that will pass the legal test of sufficiency. The systems can be standard and simple — a card file, a notebook — or they can be complex computer models tailored to a particular practice setting.
No matter what their ultimate form, good systems contain three essential components: screening procedures; follow-up procedures and referral procedures. These must be clear and in writing, and there must be evidence that they have been communicated to and understood by the office staff.
Screening procedures: The physician should establish a rapport with patients so they will feel comfortable enough to talk candidly about their medical history. Standard forms should be used to update allergies and screen for cancer and hypertension. All forms should be filled out completely, leaving adherence to these procedures beyond question.
Follow-up procedures: Follow-up should not be left to the patient alone. By virtue of their education and training, physicians are in the best position to understand the gravity and implications of a patient’s medical condition. Courts increasingly have held physicians responsible for the follow-up performed, or not performed, on the patient’s behalf
Referral procedures: Physicians must understand the limit of their ability, and know when a patient should be referred to a specialist. Following referral, a system should be in place to monitor the patient’s progress under the consulting physician’s care.
Physicians must understand that record-keeping systems are not simply adjuncts to good practice, but central to it.
Maureen Mondor is Vice President of Risk Management at ProMutual Group, a provider of medical professional liability insurance.
