by Leilani Kicklighter, RN, ARM, MBA, CHSP, CHRMP, LHRM, DFSHRM
I started my life-long career as a Registered Nurse. After I worked as a bedside nurse for several years, I transitioned to Infection Control epidemiology, and then to Quality Assurance before finding my niche where I could apply all the knowledge and experiences I’d learned to the field of risk management. I have been a healthcare risk manager for over 40 years in various healthcare settings and responsibilities. I am using this blog to share some of my experiences that still have application to today’s patient care.
I am now self-employed as a risk management, Infection prevention and patient safety consultant in various settings. All opinions are my own.
I AM NOT AN ATTORNEY. THIS IS NOT LEGAL ADVICE. THIS IS TO SHARE MY VARIOUS EXPERIENCES AND THE RISKS I DEALT WITH AS A RISK MANAGER AND IN SOME INSTANCES STILL DO.
UH OH THE SIGNIFICANT RESULTS WERE MISSED – NOW WHAT?
Scenario
Some years ago the multi-facility organization I worked for was buying physician practices and employed the physicians, like many are doing currently. This was before the era of electronic medical records.
One day I got a call from the Senior physician (Dr.X) of one of the recently acquired practice groups, who was very angry. Seems he had seen an elderly established patient for whom he had previously ordered a chest x-ray for a persistent cough. On this follow-up visit Dr. X had just seen the report of the x-ray he had ordered in the previous visit. The report referenced the status of the lung lesion identified on the previous x-ray. Seeing that finding Dr.X reviewed the medical record to find that the ARNP had seen the patient on the visit prior to the visit when the latest x-ray was ordered and had ordered the x-ray referenced by the radiologist. Dr X was livid he wasn’t aware of the positive findings and that follow-up with the patient hadn’t happened and blamed the ARNP.
Note: The patient’s son is an attorney who lived out of town. Disclosure with the family was held. (yes, a lawsuit was filed.)
Risk issues
I advised Dr. X that he was wrong to blame the ARNP for several reasons.
- The ARNP was an employee of the practice
- The ARNP practiced under the supervision of the physician(s)
- Physician/practitioner who is seeing the patient should review the previous visit notes and results of any tests recently ordered
There was no system for ordered test results to be given to the ordering practitioner to review, sign and date to confirm review. Depending on results the medical record should reflect next steps. If the test is part of the differential diagnosis a negative result is important as a “rule-out” and should document the next steps
There was no process/system to log tests, lab, radiology, consults and to monitor receipt of results- When results aren’t received on a timely basis follow-up with the lab, radiology, physician consultant should be initiated.
Loss control or prevention
- Conduct a root cause analysis, including all levels of office staff, to determine why and how this scenario happened and create system(s) to prevent
- Create and implement an incident reporting process as required by the FL law 458 & 459 (and maybe other states have the same rules.)
- Review the CMS reimbursement rules regarding medical necessity documentation. First, there should be documentation of the reason for ordering the test or consult, etc. Secondly, if the results aren’t important enough to review and consider, CMS figures it wasn’t medically necessary. That can lead to CMS issues.(I had a physician client some time ago who had 60 counts of episodes relating to lack of medical necessity documentation. Just to share that this is a real risk. (This physician’s office EMR didn’t have a drop- down place to enter the free-form information.)
I invite you to comment or add other risk issues and or Loss control or prevention options.