An Ounce of Prevention

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Examining the Provider’s Role

by Arlene Luu, JD, RN, Regional Patient Safety Risk Manager, and William J. Oetgen, MD, MBA, FACC, Clinical Professor of Medicine, Division of Cardiology, Georgetown University, Washington, DC

^{Robin Diamond, MSN, JD, RN}

As a follow-up to Dr. Troxel’s article, Arlene Luu and Dr. Oetgen examine the consulting provider’s role and the risk management and patient safety issues brought to light by the case. 

—Robin Diamond, JD, RN; AHA Fellow–Patient Safety Leadership; Senior Vice President, Department of Patient Safety 

According to a 2008 Physician Insurers Association of America (PIAA) report, the most prevalent misadventures* for cardiovascular specialists include errors in diagnosis, improper performance of a procedure, failure to supervise or monitor a case, and medication errors.¹ In the preceding Director’s Forum article by Dr. Troxel, “A Patient with Chronic Atrial Fibrillation,” the highlighted case primarily presents the issue of failure to properly supervise or monitor the care of a patient^†  with the chronic and long-term medical condition of atrial fibrillation.

The case also presents the issue of a consulting provider’s role in the management of a patient’s medical condition. A consulting provider can be involved in the care of a patient for short-term, acute, or episodic management or for long-term management of a chronic condition.

Whatever the level of involvement, the provider must be aware that, once he or she has entered into the physician-patient relationship and there is no evidence that the relationship has ended, he or she owes a duty to the patient to provide care that is within the accepted standard of practice. Moreover, the relationship will continue to exist as long as the patient has a reasonable belief that the physician will provide the necessary medical care to the patient.²

The American Medical Association’s Council on Ethical and Judicial Affairs opined that with regard to the physician-patient relationship, “the physician is required to use sound medical judgment, holding the best interest of the patients as paramount.”³ For the stated reasons, it is imperative for physicians to be clear to their patients regarding the status of their relationship. The case highlighted by Dr. Troxel also raises a number of risk management and patient safety issues that merit attention. These issues include adherence to accepted practice standards, appropriate monitoring and follow-up, documentation, and communication.

Adherence to Accepted Practice Standards 
In the prior case, Dr. Troxel noted that the patient was assigned an inaccurate score for the stroke risk, which could have contributed to the provider’s decision not to place the patient on anticoagulation therapy.

As a general rule, providers should stay current with accepted standards of practice for their respective specialties. Membership in the American College of Cardiology and participation in ongoing continuing education programs assist providers in staying current.

Appropriate Monitoring and Follow-Up
Once the physician-patient relationship has been established, the physician owes a duty to the patient to exercise reasonable care in the treatment of the patient. A breach of duty can be alleged where there has been improper monitoring or follow-up of a patient’s care.

In this case, it could be alleged that our physician failed to properly monitor and follow up with a patient with a chronic “unstable” atrial fibrillation as evidenced by the fact that there was an over four-year gap between visits. He saw the patient in October 2001 and did not see her again until March 2006.

The inherent patient safety implication is that the physician may no longer be familiar with the patient or the patient’s interim medication and treatment plan. The practice of continuing to treat a patient after an extended absence can also result in allegations of delayed or missed diagnosis when the patient reappears with a worsening condition or a condition that the physician originally failed to detect.

To avoid such issues, it is advisable for a provider to terminate the relationship with the patient if the patient repeatedly fails to follow up for care, has a long history of noncompliance with treatment recommendations, or after an extended period of time has elapsed.

Documentation 
The importance of thorough, accurate, and objective documentation cannot be overstated for the defense of a case and in ensuring that the patient receives safe care. As one physician stated aptly, “Write every note like it’s eventually going to be read by the patient and many other people… including a 12-member jury panel.”⁴

The standard of care does not require that a provider follow every treatment recommendation for a particular condition; thus, thorough documentation regarding the physician’s rationale for proceeding with a particular course of action is crucial. In addition to thorough treatments and plan of care notes, all conversations (by phone or in person), failed appointments, noncompliance with care, education provided, and follow-up plans should be documented.

Communication
Poor communication is at the heart of a significant number of medical errors. For this reason, it is imperative that physicians continually strive to improve communication with patients and with other providers as a necessary patient safety strategy.

In the highlighted case, one or more communication breakdowns could have contributed to the patient’s injury. First, communication between the primary and multiple consulting physicians appears to have been inadequate. The lack of documentation and information exchange among the multiple providers could have led to the poor monitoring of the patient’s atrial fibrillation and ultimate poor outcome. In addition, having accurate and thorough information about the patient’s present and prior course of treatment and medication history could have helped our insured physician in making the most appropriate treatment recommendations.

Likewise, effective communication between the provider and the patient is an important patient safety strategy. Good communication with the patient can have a dramatic result. It can even lead to a patient’s decision not to sue the physician despite a bad outcome.

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