The Ten Commandments Of Risk Management

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

The Ten Commandments Of Risk Management

Dr Paul Nisselle AMSenior Consultant, Educational Services

MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE

Ten Risk Management Commandments

1. Keep good records2. Document all discussions with patient3. Don’t alter records4. Follow up referrals and test results5. Check the history before writing a prescription6. Don’t diagnose and treat over the phone7. Show patients you care8. Give patients “enough” time9. Manage adverse events pro-actively10.Talk to your medical defence organisation


All “Rules” exist to be challenged!

“Rules are for the obedience of fools….…and the guidance of wise men”

Douglas Bader

“Rules are there to make you think before you break them.”

Anon


1. Keep good records

A medical record should be able to be read with understanding by another doctor.

WHY?So another doctor can read your notes and understand:• how you came to make the diagnosis; • what treatment you suggested and why; • what information you gave about the diagnosis &

treatment; • what arrangements were made for follow up.


1. Keep good records

A medical record should be able to be read with understanding by another doctor.


2. Document discussions

• A signed consent form is advisable, but it is not a substitute for a detailed and documented discussion with the patient about risks, benefits, etc.(Consent –v- Informed Consent)

• It is as important to record a brief summary of that discussion in the notes as it is to record the history and findings on examination.

• Document ALL discussions


3. Don’t alter records

Good Records = Good DefencePoor Records = Poor DefenceNo Records = No Defence

Altered Records = No Defence

• Review your records to check for mistakes or omissions;• Do not alter a record. You can add to it, if indicated, but

should indicate the date and time of the addition;• If the new entry significantly contradicts the original entry,

add an explanation.


3. Don’t alter records


4. Follow up referrals and test results

“But I told the patient to see the specialist; it’s their fault if they didn’t go!”

The doctor has a duty:

• to convey clearly the reason for referral and the possible consequences of not attending the specialist.

• to have a system to detect, from tracking whether a letter has been received back from the specialist, that the patient attended.


If you give a patient a note to go for a blood test or X-Ray, they might choose not to attend. If they were properly advised at the time the test was suggested, that’s their choice.

But would you know• if they did go, but the report has gone astray? • if the report was received but was filed without you seeing it?

4. Follow up referrals and test results


5. Check the notes before writing scripts

a) Never write a script from memory Never just sign a script

• Always call up the patient’s record and check it is the right drug, in the right formulation, at the right dose, etc., etc...

b) Never write a script without recording in the notes that you have

• Always carry a “Post-It” pad


5. Check the notes before operating


6. Don’t prescribe/treat over the phone.

• Yes, there’s exceptions to every rule.

• But think carefully before making a clinical decision having denied yourself the opportunity to examine the patient.

• Are you REALLY sure it’s safe, not just convenient?

• Are you sure you know to whom you’re talking?


7. Show patients you care

"The most important factor… besides the injury itself, is the quality of the patient's relationship with the doctor. I've never had a client say, 'I really like this doctor, and I feel terrible about doing it, but I want to sue him.’People just don't sue doctors they really like.The best way to avoid getting sued is to establish good relationships with your patients, and to treat them with respect. That requires taking time to talk with them - and more important, to listen."

Alice Burkin, a plaintiffs' lawyer in Boston


8. Give patients “enough” time

Available Time ÷ # of Patients = Av Cons Time

WRONG!WRONG!

• Work out how much time, on average, you need to see patients properly, and work at that speed.

• The same applies to procedural medicine. If squeezing another ‘emergency’ on to a list means all the patients on the list get shorter shrift- that’s bad medicine.


9. Manage adverse events pro-actively

What do patients want after an adverse outcome?

•To know what happened– and why/how it happened•To receive acknowledgment•To receive an apology•To be assured that you have learnt from what happened to them



60% sued because: Failed to receive an explanation of the error Felt ignored or neglected by their doctors.

30% of these said an explanation, apology or honesty may have prevented litigation.

Vincent, Young & Phillips Why do people sue doctors?

The Lancet Vol 343 June 25th, 1994 1609-1613



Apology of Sympathy“I’m sorry this happened to you”

-v-

Apology of Responsibility “I’m sorry I/they did this to you”



The Components of Apology

• Acknowledge the harm • Take responsibility for it • Explain what happened• Show remorse• Make amends

“On Apology”: Prof Aaron Lazare

(OUP2004)


Apology of Sympathy or Responsibility?

"The Gulf of Mexico explosion was a terrible tragedy for which – as the man in charge of BP when it happened – I will always feel a deep responsibility, regardless of where blame is ultimately found to lie.”

Tony Hayward CEO BPResignation Statement 27 July 2010


10. Talk To Your MDO

“I only talk to them when I’m hit with a writ. If I tell them about every damn thing that happens, they’ll put up my premium”

WRONG!!


Ten Commandments

1. Keep good records2. Document all discussions with patient3. Don’t alter records4. Follow up referrals and test results5. Check the history before writing a prescription6. Don’t diagnose and treat over the phone7. Show patients you care8. Give patients “enough” time9. Manage adverse events pro-actively10.Talk to your medical defence organisation


Two Commandments

1.1. Care for your patientsCare for your patients

“Patients do not care how much you know until they know how much you care” Scherger JE. What patients want. Journal Fam Prac. 2001; 50 (2):137

2. Document that careDocument that care

“Claims were twice as likely to be successfully defended if documentation was judged to be adequate” Kelsay loss control bulletin, Chicago, CNA healthpro quoted in

Bunting RF et al. Practical Risk Managements for physicians. J Health Risk Management. 1998 Fall; 18(4):29-53

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

The Ten Commandments Of Risk Management

Dr Paul Nisselle AMSenior Consultant, Educational Services


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