Central Florida Society of Optometric Physicians



Prevention of Medical ErrorsBrian P. Den Beste, O.D., F.A.A.O.COPE Course ID: 65702-EJCE Broker Number: 20-678761Medical errors definedA preventable adverse eventTypes of medical ErrorsDiagnosticTreatment MedicationWrong site treatment or surgeryCommunicationIncidence106,000 patients die annually from wrong meds or side effect80,000 die from hosp. infections20,000-40,000 die from hosp. errors225,000 deaths annually from errors of some nature Risk ManagementIn context of medical profession: those measures taken to prevent medical errors, and prevent patient injuryIn context medical mal practice: the study to avoid litigationThe study of root cause analysisThe 5 whys technique for patient care and safety. Should be used whenever there is a medical error. Example Why wasn’t Mrs Jones seen yesterday for her corneal ulcer? Because Jean didn’t call her back to change her appt time. Why didn’t she call her back ? Because Jean asked Joan to call her back. Why didn’t Joan call her ? Because Joan left suddenly for an emergency at home. 17 years of malpractice data. MDs 232,727Dos 17,322Dentists 40.261Podiatry 4,616ODs 580What is Malpractice?Bad outcome doesn’t necessarily mean Malpractice Law 101, review of the processThe usual cause is negligence , the plaintiff has to prove 4 thingsLegal duty, you were the one who examined and treated the pat.Breach of duty…..standard of care.Causation…what you did caused the outcomeDamages…what you did resulted in damages, loss of visionDuzak paper on OD outcomes and payoutsAbout a 1 % chance of being sued annuallyMean payout 190,000 dollarsMost (55%) were due to wrong diagnosisCommunication the key to preventing errorsCarroll article in NY timesKey to not being sued: talk to your patient and don’t rush themIncident reports within your office Three tips from an attorney to avoid malpractice: 1.Get a system, 2.Get perspective, 3. Get “clean”… Heather Hansen JD . Patient types that are at riskSlow loss of visionUnexplained acuity lossLow tension glaucoma , chronic angle closure glaucomaPleasing patients or limiting the care that is needed because of financial limitations. Cases and examples of litigated cases.35 yr. old white female treated for glaucomaHer vision progressively worsens despite normal IOPs.She has a difficult time with visual fields and it is blamed on her treated schizophreniaIn light of the worsening vision she is referred by her optometrist to a retinal specialist who routinely sees 80-90 patients a dayHe feels she is malingeringHer vision continues to decline to the count fingers level and she seeks another opinion. Optic nerve pallor is noted and a CT scan is ordered which shows a large pituitary adenoma.Both the OD and MD are suedThe OD is found innocent Surgery is performed but patient left with count fingers acuityA review of the Visual fields shows classic bi-temporal hemianopsiaLessons to be learned include, simple confrontations can be more reliable than formal threshold fields especially for younger patients or patients with mental or senile issues. Listening to patients is sometimes difficult when they seem to be “crying wolf” but key if indeed a problem exists. More common to see this with patients and floaters. “ They are worsening” but you don’t see any new opacities….may be best to get another opinion. 28 yr. old female with redness, blurred vision and a corneal infiltrate Assoc with EW sclsNot an uncommon scenarioChart described Peripheral sterile lesion less than a mm in sizeOptions include stopping the lens and seeing patient back, stopping lens and rxing an antibiotic, stopping lens and rxing a antibiotic/steroid ( most common), stopping lens and rxing a steroid.All of these could be easily defended …with appropriate followup . The DR. worked at mult offices and would not be back to this office in a wk and that was when she was told to return. In this case the pain increased and she was seen elsewhere with a true infection, since it was peripheral it didn’t result in a permanent loss of vision and the case was settled.50 yr old white female followed by several different Drs in the same practice for moderately severe diabetic retinopathy The patient was dilated on one occasion as she was complaining of new floaters and blurred vision. A large choroidal melanoma was noted near the equator and pars plana. Her eye was subsequently removed. The entire practice was sued. How long had the lesion been there? If it was found sooner, perhaps could have had radiation.wasn’t it seen sooner? How fast can they grow. Case was settled out of court. Lessons: patient was obese and difficult to examine and not able to get into the exam chair. She was examined while in a wheelchair. Noone expects to have patients with multiple problems…diabetic retinopathy and choroidal melanoma. Remember sick eyes can have multiple issues….35 yr old female seen complaints of blurred vision for two days.Patient with normal IOP and increase in myopic correctionA few days later seen at another office for pain and blurred visionShe was noted to have angle closureLessons: a few days before she was placed on Topamax ….that was not noted in the medical history. Noted to cause myopic shift in refraction and angle closure. IOP was documented as being normal at the initial exam. This case was settled. 70 yr. old male who underwent glaucoma surgery with a Baerveldt tube.OD on call spoke to the patient 4-5 days after surgery with complaints of blurred vision and some tears with blood.Patient was offered a visit that evening, but said he couldn’t make it at the time offeredThe patient was told to come in the next day if no betterDisagreement on what was said on the phone call. “he said she said”A note about the weekend call was lost and never made it into the chartPatient called 4 days later asking about the gtts and states he complained of worse vision, the on call tech said he did not mention any worsening of vision. The surgeon signed off on the note and advice given to the patient.A few days later at his scheduled 2wk follow up his vision was LP with Endophthalmitis ( pseudomonas) and a poor outcome.Surgeon was not sued ……the OD and the practice (answering service) , despite the OD never saw the patient and only spoke to the patient on one occasion. Case is ongoing.Lesson: enter info after a conversation. Teach your techs well !!! Any worsening of vision during a postop visit or an increase in pain should be referred back to surgeon or brought in for evaluation. ................
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