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

2. 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

3. 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

4. 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.

5. 1. Keep good records
A medical record should be able to be read with understanding by another doctor.

6. 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

7. 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.

8. 3. Don’t alter records

9. 3. Don’t alter records

10. 3. Don’t alter records

11. 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.

12. 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?

13. 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

14. 5. Check the notes before operating

15. 5. Check the notes before operating

16. 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?

17. 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

18. 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.

19. 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

20. 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,

21. 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”

22. 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)

23. 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

24. 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!!

25. 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

26. 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 Fall; 18(4):29-53

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

28. Other education available from MPS
Risk management workshops
Clinical risk self assessments for general practice
Presentations, seminars and workshops on medicolegal principles
Web based education
Publications