The following review process is offered to assure that the data entered in the Anesthesiology Report is concordant with the data entered in the medical record and the operating room log, so that the Anesthesiology Report may be used to fully support and defend these highly educated, experienced and caring healthcare providers.

ANESTHESIOLOGY REPORTS

Issue: Contradictory statements appearing on anesthesiology records.

Solution: In all operating rooms the Anesthesiologist (or Nurse Anesthetist, with oversight by the Anesthesiologist) is expected to complete an Anesthesiology Report with certain data being entered on a periodic basis. The primary goal is to assure that the data being entered in the Anesthesiology Report is concordant with other data being entered in the medical record and the operating room log.

Review Procedure: 1. Obtain a listing of 30 patients recently discharged from the hospital after an operating room event. 2. Secure a copy of the Anesthesiology Report from each of the medical records and, with the assistance of the medical records librarian, review each report for the timing of the data entered – such as the start of the operation, the end of the operation, or the point at which a significant clinical event began. 3. Also review other possible details, such as the signature of more than one Anesthesiologist or Nurse Anesthetist, the comments of the circulating nurse, and the timing of such things as the start of the operation, the end of the operation and the administration of blood, all of which may be mentioned in the operating room log.

Actions to Be Taken: 1. If all is in order, so notify the Medical Executive Committee and the medical staff at the next meeting. 2. If problems exist, devise a solution with the cooperation of the hospital risk manager or administrator, implement it, and re-audit the issue after approximately six months. Report the results of your re-audit to the Medical Executive Committee and medical staff.

Added Point of Emphasis: I have handled dozens of cases over the last 38 years where the data in the Anesthesiology Report did not match the data in the medical record or in the operating room log. These conflicting data entries create an unnecessary negative in the defense of the medical malpractice claim. It is usually something innocent, such as an incorrect time entry based on a wristwatch that was not reset that morning to daylight savings time; or a piece of data that has been hastily written on a paper towel, only to be lost before it can be recorded. The primary point is that the creation of doubt over the accuracy of the data entries causes cases to be settled when, with concordant data, they could have been fully defended.

One month later a lawsuit is filed and the recording of Dr. X’s candid statements will now be used against him. Dr. X has learned, too late, that the attorney was originally on a fishing expedition to set up the doctor for a lawsuit, that he does not have the doctor’s interests at heart, but is instead interested in the doctor’s wallet!

Dr. X should have said that he would be most willing to discuss the facts of the case, but only after contacting his insurance company’s claims manager or risk manager for guidance. If Dr. X had contacted his insurer first, he would have received help to avoid making careless statements that later could be taken out of context and used against him. It is human nature to feel you may have been able to do better. Because of these feelings, and the innate vulnerability of Dr. X in this situation, he needs the assistance of an individual experienced in managing these inquiries.

I recommend that you consult your claims manager or your risk manager before complying with any request by a patient’s attorney to discuss, or provide a written report concerning professional services rendered.

In the investigation of a formal claim, all too frequently we find evidence that an attorney or investigator has contacted the doctor, or worse, a member of his office staff, who then engaged in a prolonged discussion of the treatment being questioned. Any such unprotected statements will certainly come back to haunt the doctor. As we all know, preventive medicine is the best medicine, and it may be too late for a cure if you give a statement before seeking the advice of your claims manager or risk manager.

If a healthcare provider orders a test, that same healthcare provider is fully responsible for ascertaining the results of that test, and for acting on those results. Most of the lawsuits have arisen from the test results simply being filed in the patient’s chart, with the intent of having the physician review the test results at the next scheduled visit of the patient; only to have the patient move across the country before that next scheduled visit. The adverse result is diagnosed years later, with increased risk of harm to the patient. A lawsuit is then filed against the original healthcare provider who ordered the test, usually resulting in a large settlement.

All of this can be avoided by simply assuring systems are in place that guarantee the test results actually get to the healthcare provider who ordered them in the first place. Not at the next visit, not at the next grand rounds, but immediately upon receipt of the actual test results. And if the results are not timely received, a system must be in place that will trigger the staff to actually pursue the results.

OUTSIDE LABORATORY REPORTS

Issue: Failure of healthcare providers to determine what has been reported to their practice/clinic/hospital by outside laboratories.

Solution: In all physician offices, clinics and hospitals, assure that any and all outside laboratory reports have been received and are carefully reviewed before filing.

Review Procedure: 1. Obtain a listing of 30 patients who had laboratory tests performed outside the office/clinic/hospital (i.e., sent to another laboratory); obtain the number of the chart and, from it, the name of the physician involved. 2. Have the medical records department pull each of the charts to determine if the laboratory result has been received and has been documented in the chart. Hospitals and larger clinics may verify the findings via the laboratory’s log. 3. Contact the attending physician and/or their office to ascertain whether the physician actually learned of the results; determine how the information was transmitted.

Actions to Be Taken: 1. If all is in order, so notify the Medical Executive Committee and the medical staff at the next meeting. 2. If problems exist, devise a solution with the cooperation of the practice manager or administrator, implement it, and re-audit the issue after approximately six months. Report the results of your re-audit to the Medical Executive Committee and medical staff.

Added Point of Emphasis: Many settlement and verdicts in excess of $1 million have resulted from this allegation of “failure to notice” abnormal laboratory results. It is well worth your time to assure you have systems in place to prevent this allegation being directed against you or your staff.

And on the other side of this equation, it is my opinion that it is equally important to advise your patient if the result is negative (i.e., normal). Your patient is nervously awaiting your contact to advise the results of the test, and it just seems to be the “best practice” to not only advise this patient of abnormal results, but also to advise of normal results as well.

Issue: Conflicting, competing and incompatible drug orders written by multiple healthcare providers for a single patient.

A study done in the 1980’s expressed great surprise to find that as many as nine different physicians were involved in writing orders for one patient during a single 24 hour period. In today’s medical environment, this behavior has multiplied exponentially as other healthcare providers — such as nurse practitioners, physician assistants, nurse anesthetists, nurse midwives, and more — write orders in the medical record.

Solution: Minimize – not necessarily eliminate – multiple healthcare provider orders in the medical record.

Review Procedure:
1. Obtain a sample of 50 charts of recently discharged patients, preferably including at least 10 patients who have been in the Intensive Care Unit (ICU) or the Coronary Care Unit (CCU).
2. Review the order sheets – no more than three pages per chart – for the total number of healthcare providers who are actually writing orders, as well as the total number of orders written.
3. Calculate the mean (i.e., the average!) number of healthcare providers per chart and the total number of orders per chart, then calculate the number of orders per healthcare provider.
4. Review all of the charts for potentially conflicting orders where more than three “authors” have contributed, or where the average number of orders per “author” is less than five.

Actions to Be Taken:
1. If all is in order, so notify the Medical Executive Committee and the medical staff at the next meeting.
2. If problems exist, devise solutions and discuss them with your Medical Executive Committee and the medical staff. After a consensus has been achieved, implement the solution, with appropriate publication to the people who will be affected by it. As always, re-audit the issue within a given time frame and report to the Medical Executive Committee and the medical staff with your updated status report.

Added Point of Emphasis: The old rule concerning the etiology of medical malpractice lawsuits still applies: 50% arise from communication problems between human beings, 30% arise from system errors and 20% arise from actual clinical malpractice. By simply minimizing the number of authors in the medical record of a single patient, the frequency and severity of iatrogenic injury — and the subsequent medical malpractice litigation — can be decreased.

Altered records continue to prompt significant monetary losses, even though risk managers have educated practice managers for decades on this vital issue. When it’s discovered that records have been altered, even if the alteration was unintentional, risk managers know there is simply little to no defense for the physician, said Timothy R. Bone, president of Florida-based MedMal Direct Insurance. “I have enough stories to fill an entire book on the subject of altered records,” said Bone, who has handled thousands of medical malpractice claims during his 35 years in the medical malpractice insurance and healthcare risk management industry. “It appears to be simple human nature, especially for the highly intelligent, to think it’s possible to alter or recreate an earlier created document so that the information in it supports the decisions made by that highly intelligent person. Though we’re very fortunate to have the finest physicians practicing the best clinical medicine in the world, we also live in one of the most litigious societies in the world; and physicians are both highly intelligent—and very human.”

It’s even easier to document alterations in an electronic format than it was “in the old days” with a paper record, Bone pointed out. “Every single keystroke or mouse click is recorded, dated and time-stamped in some backup database, which is being backed up by another backup database every 15 minutes,” he said. Especially with the advent of the electronic age, which makes data recording even easier, “old-fashioned principles still apply.” The methodology for the issue of altering records should involve risk management, clinical staff, and information technology staff. The solution is to eliminate the practice of “altering” as opposed to “correcting” records.

The review procedure involves:
• Obtaining a sample of 50 medical records of recently discharged patients.
• Appointing an ad hoc committee of a physician, a nurse, a medical records staff member, and an information technology staff member to review each medical record separately for progress notes, consultation reports, order sheets and, if applicable, operative reports.
• Checking for the presence or absence of entries that would appear to suggest an “altered” or “incorrectly amended” record.
• Tallying the total number of items reviewed and the total number of possible “alterations” for each member of this ad hoc committee; and then tallying the totals of the committee itself.

Actions to be taken include:
• Notifying the medical executive committee and the medical staff if all is in order.
• Devising a solution, implementing it, re-auditing the issue within a given time frame and reporting to the medical executive committee and the medical staff about both the activity and the outcome—if problems exist.

“Throughout the years, the advice has remained the same: if you need to ‘correct’ a record, pull out a fresh piece of paper or the electronic equivalent, put today’s date on it, and then fully explain yourself,” said Bone. “Otherwise, you may end up in a situation similar to the following actual cases.”
• A patient was being treated over many months by a primary care physician, but the patient absolutely refused to follow the physician’s orders to have blood work done. Unfortunately, this refusal wasn’t noted in the record. When the record request from the attorney was received, the physician went back through the record, adding statements about how the patient refused the recommended blood work. In hindsight, these statements appeared to be self-serving. This case was settled.
• At trial, a plaintiff’s attorney called to the witness stand an expert in the subject of ink used in pens. (Yes, such an expert actually exists!) The expert was able to show that the ink used in the medical record had not yet even been manufactured when the dates of treatment took place. This case was settled shortly after this expert’s testimony.

“Though the process of taking the additional time to clearly communicate via the medical record takes some effort, it has shown, over time, to achieve the stated goal: mitigation of the risk that leads to medical malpractice lawsuits and enhancement of the defense of the case after the lawsuit has been filed,” said Bone. “It’s worth saying one more time: if you need to ‘correct’ a record, pull out a fresh piece of paper or the electronic equivalent, put today’s date on it, and then fully explain yourself.”

FSRs summarize Demotech’s opinion of the financial stability of an insurer regardless of general economic conditions or the phase of the underwriting cycle. FSRs utilize statutory financial data based on insurance accounting principles prescribed or permitted by the National Association of Insurance Commissioners (NAIC).

Tim Bone, President of MedMal Direct, comments: “We are happy to have this independent, third-party opinion of our Company’s financial stability. Physicians across the state are finding out every day just how much our direct-write distribution model can save them. At a time when our healthcare providers are faced with so many unknowns, it’s nice to be able to rely on one certainty: MedMal Direct saves their practice money with an unwavering commitment to service, defense and financial stability.”

To view the online press release click here: http://eon.businesswire.com/news/eon/20111027005237/en

Doctors may purchase an “indemnity only, high deductible” insurance policy from an insurance company that is approved and regulated by the State of Florida. Select a company that is not only financially stable, uses the best defense attorneys and has the best price; but also a company that is willing to provide you with the following specific insurance product: a 250/750 policy, with unlimited defense costs, and a $250,000 deductible that applies to the indemnity limit only. This medical malpractice insurance policy has a $250,000 indemnity limit per incident, but also has a $250,000 deductible on that limit – which you only pay if there is a settlement or a verdict. The policy also provides unlimited defense costs, which is what you truly need. And the cost of this policy is 63% less than if there were no deductible at all. This will be, in most cases, a much lower cost than paying defense-only coverage or paying a law firm a monthly retainer. Plus, the physician is able to utilize the true expertise of the highly trained and experienced claims department of the medical malpractice insurance company, which is retaining the best defense attorneys at hourly rates that are much lower than those which the physician could negotiate on his/her own. For the first year of coverage at my Company, for example, that’s around $2,000 for an Internist and $7,000 for a General Surgeon!

In short, stay within the insurance system; a system that is highly regulated, audited and approved by the Florida Office of Insurance Regulation. But utilize this “indemnity only, high deductible” policy to lower your costs by 63%. This is better than bare. This is a good night’s sleep.

With this treaty, physicians in Florida can now secure medical professional liability limits of up to $1mm/$3mm from the only carrier in the state to exclusively offer its policies on a direct-written basis. These enhanced policy limits – when combined with the most competitive premiums, superior customer service and aggressive litigation management – add yet another element of service and financial stability to the company’s already-unique medical malpractice offering. MedMal Direct is the only medical professional liability insurer in Florida that does not use independent agents or brokers, enabling it to offer all physician practices significant savings on their premiums by buying direct.

Tim Bone, President of MedMal Direct, comments: “We are excited to enhance our product capability, and to provide additional financial stability behind our company. This is another step towards building the most dynamic company in the Florida medical malpractice marketplace and another milestone towards our commitment to Florida’s physicians.”

Butler Ball, Chief Executive Officer of MedMal Direct, adds: “We are creating a paradigm shift in the market which is having a net positive effect in the entire healthcare industry. I listen to our political leaders on a daily basis debate the myriad ways in which we can reduce the cost of healthcare, from tort reform to health insurance reform. We are reducing physicians’ overhead every single day; we are part of the solution.”

Tim Bone, President of MedMal Direct, comments: “As a core competency of our company, we strive to identify and eliminate the causes of medical malpractice at the grass roots level. The educational opportunities provided by MedMal Direct University will help decrease the frequency and severity of lawsuits, and thus also reduce the financial and emotional costs that medical malpractice allegations bring to medicine.”

Butler Ball, Chief Executive Officer of MedMal Direct, adds: “Every day we hear leaders throughout Florida and our nation express the need for reduction of costs in the delivery of healthcare; and with our emphasis on risk management education, coupled with sound and conservative underwriting and our unique cost-saving distribution model, we are proud to be a part of that solution.”

In the United States, we are very fortunate to have the finest physicians practicing the best clinical medicine in the world. Yet sadly, we also live in one of the most litigious societies in the world that is clearly not hesitant to file lawsuits against these same outstanding physicians. It is in the best interest of all physicians to eliminate, or at least mitigate, the sources of these lawsuits, regardless of whether these sources are clinical in origin.

It is always true that the very best risk management for any physician or healthcare provider is continuing education, which naturally emphasizes the clinical practice of medicine. But we can also significantly reduce the probability of a lawsuit being filed, and decrease the duration of a lawsuit that has been filed, by addressing the non-clinical issues.

It is commonly understood in healthcare risk management that 50% of the medical malpractice lawsuits arise from communication problems between human beings, 30% of those lawsuits arise from system errors and only 20% of the lawsuits filed against physicians arise from actual clinical problems. In this issue, and in the few issues that follow, we will begin to address some of the most common non-clinical problems by objectively approaching each issue and its resolution via the scientific method.

This format identifies the issue at hand, provides an “outcome goal” (or objective) and then offers a relatively simple approach to data-gathering via chart review, observations, or simple surveys. Obviously, each participant can enrich the specific approach if warranted, and can also share outcomes. Though these reviews take some effort, they have shown, over time, that they do achieve the stated goal: elimination or mitigation of the risk that leads to medical malpractice lawsuits.

VERBAL ORDERS – fraught with peril!

Issue: Misunderstanding or misinterpreting verbal orders – including telephone orders.

Solution: Determine what proportion of orders for patients in your hospital (or office) – if any – are verbal orders. Engage in subsequent dialogue to measure the appropriateness of the circumstances surrounding their use. The only total protection is avoidance of verbal orders; since this is not a feasible goal, their frequency should be kept to a minimum and appropriate indications for the use of verbal orders ought to be identified and monitored.

Review Procedure:
1. Obtain 50 charts for a sample of recently discharged patients, at least 10 of whom have spent time in intensive care, coronary care or the labor suite.
2. Review all the orders and tallythe total number of orders written – i.e., either individual or group entries to constitute the denominator. Determine how many verbal orders had been issued and let that number serve as the numerator.
3. Tally the totals in both groups and determine what percentage of the total orders was composed of verbal orders.
4. If the percentage exceeds 5 percent for the total sample, prepare a proposed listing of appropriate indications for the use of verbal orders and submit them to the Medical Executive Committee for their consideration.

Actions To Be Taken:
1. If all is in order, so notify the Medical Executive Committee and the medical staff at the next staff meeting.
2. If a problem exists, devise the recommended list of appropriate indications for your Medical Executive Committee, bring it to them for their action, and, if implemented, re-audit the process six months hence.

Added Point of Emphasis.
1. One hospital, priding itself on the accuracy, legibility, and completeness of its order sheets, was stunned to discover that approximately 14 percent of orders of non-intensive care medical patients were verbal orders. With so many similar-sounding names of medication, such practices are fraught with problems.
2. Another hospital has noted that this problem of accurate verbal communication is also greatly increased in today’s healthcare environment simply because so many physicians and healthcare providers do not speak English as their primary language. Pronunciations of words are different and are easily misunderstood or misinterpreted. It is thus more important than ever that the electronic medical record be used to accurately document all communications.

Summary:
Remember that only 20% of all medical malpractice lawsuits brought against physicians arise from actual clinical error. That leaves an astonishing 80% of all medmal suits that could be avoided through the simple modification of non-clinical procedures. It is worth the small investment in time to perform an analysis of your systems that may greatly decrease the chance of a lawsuit being brought against you.