The Ten Commandments Of Risk Management Dr Paul Nisselle AM Senior Consultant, Educational Services

Ten Risk Management Commandments Keep good records Document all discussions with patient Don’t alter records Follow up referrals and test results Check the history before writing a prescription Don’t diagnose and treat over the phone Show patients you care Give patients “enough” time Manage adverse events pro-actively 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 Defence Poor Records = Poor Defence No 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

3. Don’t alter records

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.

4. Follow up referrals and test results 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?

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

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! 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.

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

Manage adverse events pro-actively 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

Manage adverse events pro-actively Apology of Sympathy “I’m sorry this happened to you” -v- Apology of Responsibility “I’m sorry I/they did this to you”

Manage adverse events pro-actively 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 BP Resignation 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 Keep good records Document all discussions with patient Don’t alter records Follow up referrals and test results Check the history before writing a prescription Don’t diagnose and treat over the phone Show patients you care Give patients “enough” time Manage adverse events pro-actively Talk to your medical defence organisation

Two Commandments Care 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 Document 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

The Ten Commandments Of Risk Management Dr Paul Nisselle AM Senior Consultant, Educational Services

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