The following strategies can help reduce the risk of patient harm and malpractice claims in dermatology practices and when performing dermatological procedures.
Use care in managing patients who require periodic follow-up examination or testing due to risk factors such as prior history. A lack of follow-up with appointments may result in allegations of delay in diagnosis or treatment. The practice must have a follow-up process in place that includes documenting efforts to schedule return visits. If three calls do not result in a patient’s being seen, send the patient a letter from the physician that explains why the follow-up appointment is necessary and outlines the specific risks the patient may incur by not returning. File a copy of the letter in the patient’s medical record and track the patient’s response. If the patient does not respond to a letter, the practice may want to consider formally terminating the patient from the practice.
If the patient refuses a test or biopsy for any reason (including costs) after being advised of its need and importance, document the refusal in the patient record. If, for example, you are concerned about a possible malignancy, document that the patient was advised of the specific risk or concern and include the patient’s comments. Consider asking the patient to sign a specific refusal of treatment form.
Ensure that you have a stringent specimen collection and labeling protocol in place that identifies who does what in the collection and labeling process and be consistent in its use. Use a courier or transport service that is reliable and provides receipts. Create a mechanism to track when specimens are sent and ensure that reports are returned. The provider initials or signs and dates results/reports when they are reviewed so the staff knows that the report may then be filed in the medical record. Advise patients they will be notified of the results of every test and should not expect that “no news is good news.” Document patient notification of results and any required follow-up.
In addition to preventing wrong-side or wrong-site procedures, take precautions against “wrong lesions.” Claims of misdiagnosis or delay in diagnosis have resulted from failure to document the exact location of a lesion and the wrong lesion being excised. Be sure that you and the patient are clear about which lesion is being treated, and document locations carefully when the patient has multiple lesions in a particular area of the body.
Be aware of look-alike, sound-alike (LASA) medications—in particular, those common to dermatology with a LASA medication not typically associated with the specialty. Examples include Accutane and Accupril, Aldara and Alora, or Elidel and Elavil. If using an electronic health record, be mindful of selecting the correct medication and dose from the drop-down list.
The best practice is to avoid verbal orders. If a verbal order is the only option, spell out the drug’s name. Write the brand and generic names on prescriptions, and include the diagnosis or indication on the prescription. Not only does this help a pharmacist in the case of LASA medications, but it also helps a patient to recall the purpose of each medication.
The human eye is more vulnerable to injury than human skin, but both are susceptible to laser injury. Ensure that personal protective equipment appropriate for the type of laser is worn by the user, the patient, and the staff. Practice read back and repeat back with technicians and assistants, especially for laser settings. Whether you own the laser or you use a vendor, the equipment must be maintained according to the manufacturer’s specifications. Keep a log of when maintenance is scheduled and performed. Be clear about the licensure and training needed to operate a laser and verify that staff is properly trained. Maintain evidence of licensure, certifications, and laser training in employee files. Adequate supervision is required when the laser treatment has been delegated to staff other than the physician. Check state law and scope-of-practice requirements for the level of supervision required.
More and more practices are adding cosmetic and aesthetic services. With the advent of these services has come an uptick in claims alleging improper performance of procedures. It is the physician’s responsibility to be fully trained and to validate that staff members performing the services are properly trained and comply with state regulations for that service. The physician should observe staff performing procedures to know that the service is done correctly. Medications used for cosmetic or aesthetic procedures must be stored according to the manufacturers’ specifications. To help prevent infection from the misuse of multidose vials, a vial must be dated when opened and expired within 28 days after opening unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
For staff who have professional licenses, it is the physician’s responsibility to verify that licensure is current and active. Observe staff as they perform specific procedures, and conduct periodic performance evaluations that are documented in employee files. According to state law, the physician may be solely responsible for licensed personnel or held vicariously liable.
Informed consent is required when risks are associated with a procedure or medication. It is the physician’s responsibility to inform patients and provide them with the opportunity to ask questions. A patient must also give informed consent when the proposed procedure or medication is considered off label—used in a way not mentioned in the FDA-approved labeling—such as platelet-rich plasma treatments. (Consider using our sample off-label use forms for devices and prescription drugs.)
Your patient safety risk manager can help if you have questions. Contact us at 800.421.2368, extension 1243, or firstname.lastname@example.org.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.