To Err is Human; to Prevent, Divine: 7 Guidelines to Manage Risk

• 7-Guidelines-Risk.pdf (2,459.8 KB)

Hannah is a 14-year-old female spayed Ragdoll cat presented for surgery. Her front right leg needs to be amputated due to cancer and her owner has elected a complete senior workup consisting of blood work and chest films.

Hannah isn’t calm when she comes to the hospital so Dr. Meanswell completes the diagnostics with her under anesthesia. All the tests are within normal limits and the surgery to remove the right front leg goes as planned. While Hannah recovers in the ICU, the technician discovers that one of her back legs is fractured at the first TPR. The technician quickly checks the medical record. There is no physical exam sticker or any remarks in the record. When did Hannah break her leg? What should the practice tell the client? Could they have predicted or prevented this outcome? Is this malpractice?

Our healthcare teams (HCT) face unexpected situations daily. As veterinarians, we must recognize and manage the negative risks associated with unexpected patient outcomes and train our teams on how to handle them. This way, we can continue to spend our time in the exam room – and out of the court room. Here are 7 guidelines to managing these risks.

1. Keep Top-Notch Medical Records

Good documentation is crucial but is often dismissed as insignificant. Don’t fall into this trap. As a team, review these essential elements of the medical record:¹

• Description of the patient’s condition, as that affects diagnosis and treatment
• Description of the physical exam and/or laboratory results
• Discussion of diagnosis and treatment, including rule-outs and diagnostic codes
• Description of the treatment plan complete with any follow-up needed—record whether the patient received any prescribed medication, the response to it, when the next visit is scheduled, etc

Exercise: Pull 10 records from your practice and check the documentation for all of the above. Discuss your findings with the team. Could the doctors exchange records and understand the diagnosis and treatment choices?

Tip: Request that clients bring all the patient’s medication to the yearly visit or prior to a surgery or procedure. This way you know all the current medication and can check for problems or cross-reactions. Also, see a Patient Information Checklist.

2. Create Double Checks in Your System

Creating systems that double-check procedures, such as hospital rounds, are ideal regardless of whether there is one doctor or 30. Ask these questions in a double check process for medications:²

3. Consider Electronic Medical Records & Automated Dispensing

Medical literature abounds with proven methods for reducing errors such as evidence-based medicine, computerized physician order entry (CPOE), and pharmaceutical bar coding. These can all help to prevent or predict bad patient outcomes.² There are also automated drug-dispensing stations (Medstations and CubeX) that function as ATMs with PIN numbers/biometric access, delivering precise amounts of prescribed drugs.² Additionally, electronic medical records (EMR) can help maintain documentation of Sudit trails and informed consent materials. EMR add 4 main advantages:

• Timely access to medical records
• Improved communication with clients
• Improved communication with other providers
• Positive effects on quality of care³

4. Develop Written Standards and Protocols

Medical Care Plans are typically agreed upon hospital standards of care for patients with certain needs or medical conditions. Doctors sometime consider them to be “cookbook” directives yet these guidelines assist with clear communication and consistent quality of care. Protocols are set by a team to outline rules governing communication. All information communicated to the client or other team members regarding the plan and the expectations must be consistent, legible, and included in the record. Without communication protocols or processes a team is likely to dissolve into chaos and leave team member “anybody” in charge. Effective care plans should include not only what should be done, but also the person responsible for providing the care. Finally, care plans need to include expected cost of treatment and should be signed and dated by the client.

Medical Care Plans are also referred to as Standards of Care Plans or estimates.

5. Establish Informed Consent

Unlike Medical Care Plans, informed consent provides a statement that, “we cannot guarantee a successful outcome.”¹ Of note, the word “routine” is dangerous to use in regards to any procedure because it creates the expectation that there will be no complications. To create an atmosphere for informed consent, use a quiet room for client discussions. The use of visual examples related to the procedure is helpful prior to the client signing the consent. According to Braddock et al, informed consent involves:

• Discussion of clinical issues
• Discussion of options, including pros and cons
• Discussion of uncertainties, such as side effects and aftercare
• Assessment of client understanding
• Exploration of client preferences

It is important to review (and document) possible complications and referral options during the informed consent process. This discussion should be documented in the record. See an Informed Consent handout.

6. Review Discharge Instructions

Discharge instructions must be carefully reviewed with each client. Doctors need to be available especially if expectations about the medical needs of the patient have changed. These instructions must include time lines for follow up, danger signs to watch for, medication to give, and contact information for questions and emergencies. Some computer systems will allow the team to create a macro to speed up the discharge process.

A macro is a set of computer instructions that can be triggered by a keyboard shortcut, toolbar button, or an icon in a spreadsheet. Macros are used to eliminate the need to repeat the steps of a common task.

7. Communicate, Communicate, and Communicate

A veterinary study showed that when faced with an unexpected medical error, 40% of veterinarians would not discuss the error with the client.⁴ In a human medical study, 95% of patients and family members said they would want a full and accurate understanding of the causes of any harm experienced as a result of the treatment.⁵ In addition, there are also studies on medical error and corrective action that focus on the client centered task of communication to disclose information when a patient is harmed. Clients will want to know^5-7:

• What happened?
• How did it happen?
• What are the consequences?
• What can be done now?
• Do you have sincere empathy regarding the situation?
• How will the mistake be prevented in the future?
• Will you be taking any restitution/repair action?

When communicating with clients about an unexpected outcome, set the stage by using a quiet room away from noise and distraction. Keep your sentences short and use nonmedical terminology. Also, make sure to maintain an open body posture, make good eye contact, and face the client. The 5 steps are:

Mistakes happen and handling them is hard. Train your team on what to do when these sentinel events occur. Put standards and protocols in place to prevent them from happening. Then see for yourself how nice it is to have a heavenly day instead of a day from you-know-where. To err is human; to prevent, divine. | EVT 

References

1. How to stay out of litigation. Rourke PT, Hershey KM, The Hospitalist, Jan. 2007.
2. The top ten malpractice claims and how to minimize them. Glabmans M. hospitalconnect.com, 2004.
3. Electronic Medical Record Implementation Guide: The Link to a Better Future. Texas Medical Association. home.smh.com/documents/forPhysiciansDocs/documents/EMR_Implementation_Guide_2nd_Ed.pdf
4. Survey of mistakes made by recent veterinary graduates. Mellanby RJ, Herrtage ME. Veterinary Record 155:761-765, 2004.
5. Risk Management in the Veterinary Practice. Richardson F. Can Vet J 46:655-658, 2005.
6. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Witman AB, Park DM, Hardin SB. Arch Int Med 156:2565-2569, 1996.
7. Understanding customer delight and outrage. Schneider B, Bowen DE. 1999. Sloan Mgmt Rev 41:35-45, 1999.