Risk Management Review Failure to Properly Manage Care Following Cataract Surgery Results in Loss of Vision Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM INTRODUCTION As with any surgical case, care following cataract surgery requires careful attention to detail, especially when there are complicating factors, such as limited patient understanding of the procedure and compliance with instructions. This interesting case from the Southwest illustrates how a series of errors can cause a poor outcome following a relatively routine surgery. FACTS The patient was a 66-year-old Hispanic male who did not speak English. He was referred to a MedPro-insured ophthalmologist (Dr. A) by his regular optometrist (Dr. B) for evaluation of early cataracts. Other than the developing cataracts, he had no significant medical or ocular history. At the time of his examination, the patient s visual acuity was 20/60 in the right eye and 20/50 in the left eye. His intraocular pressures (IOPs) were 16 in the right eye and 18 in the left eye, both within the normal range. However, his cup-to-disc ratio was.75.8, which is borderline elevated and can be indicative of glaucoma. Given the reassuring IOPs, Dr. A was not unusually concerned about glaucoma. No other visual field testing was done. Because the cataracts were affecting the patient s daily life, Dr. A recommended surgery to remove them. Note: The records do not indicate whether an English interpreter was ever used, or whether Dr. A relied on her very limited Spanish proficiency to communicate with the patient. Surgery was performed on the left eye first, and it was unremarkable. The records reflect that fairly limited phacoemulsification was required to remove The Medical Protective Company.2013. All rights reserved.
the cataract. Dr. B saw the patient the following day, and his visual acuity was documented as 20/400, which is not necessarily concerning on the first postoperative day, especially when a hazy cornea was also noted. However, Dr. B noted an extremely increased IOP of 55 70. Dr. B faxed a note to Dr. A s practice regarding the elevated IOP, and that information was conveyed to Dr. A later that day. Dr. A felt that the patient needed to be seen at one of her three offices that day so the incision could be burped to relieve the pressure. (Optometrists cannot perform this maneuver unless they have been specially trained.) However, because of transportation difficulties, the patient was unable to come to any of the three offices for the procedure. As a result, he was started on Combigen and asked to come to one of Dr. A s offices the following day. On the second post-operative day, one of Dr. A s specially trained optometrists saw the patient. At that time, his IOP was 18, his visual acuity was 20/200, and corneal edema and haziness were noted. The patient was instructed to continue the Combigen and eye drops that had been prescribed and to return to Dr. A s office in 1 week. Instead of returning to Dr. A s office, the patient returned to Dr. B s office the following week. At that time, his visual acuity was 20/200, his IOP was 8, and his cornea was clear. This information was communicated to Dr. A s office; however, there is no indication of any response to it. Five days later, the patient s daughter called Dr. A s office to advise them that her father s vision was still poor since the cataract removal. The staff responded that they would like to see the patient that day, but again, because of transportation problems, he was not seen at Dr. A s office until the next day. At that visit, it was documented that his functional vision was very poor (only able to count fingers at two feet), but his cornea was clear. IOP at that visit was 18 and the cup-to-disc ratio had risen to.8.9. The examining ophthalmologist (not Dr. A) opined that the poor vision was due to a retinal problem or damage to the optic nerve. An immediate referral was made to a university eye clinic. Although the records from the university visit are not available, Dr. A was told that the university ophthalmologist was very critical of the care the patient had received, and that the doctor told the patient he was probably now permanently blind in one eye due to Dr. A s mismanagement of the case. The patient was seen in Dr. A s office about 10 days later. At that time, he was noted to be counting fingers at one foot, had a normal IOP, and a cup-to-disc ratio of.8.9. Other testing was suggestive of optic nerve damage. The patient was seen in subsequent visits; however, no improvement was noted, and it was accepted that the patient had lost vision in his left eye. The exact etiology of the optic nerve damage was never definitively determined. 2
A lawsuit was brought against Dr. A and her professional corporation, which, with her consent, was settled in the midrange. Defense costs were also in the midrange. DISCUSSION The first factor that made this case higher risk than usual is poor communication. Research shows that health literacy among the general population is not ideal, and language barriers greatly increase the potential for misunderstanding. Clear communication between Dr. A and the patient was imperative, preferably by means of a professional interpreter. Dr. A s limited Spanish proficiency was not sufficient. 1 As noted, the cataracts were affecting the patient s daily activities; however, there was no urgency associated with their removal. Given his potential glaucoma (as indicated by the borderline elevated cup-to-disc ratio), a detailed discussion should have taken place in which Dr. A and the patient weighed the benefits of immediately proceeding with surgery versus treating the glaucoma first. This discussion would be an essential part of the informed consent process, which should be very thorough given the elevated risk factor. Again, this discussion would need to take place using appropriate interpretive services. Another integral part of the informed consent process is communicating to the patient when (and, if appropriate, where) follow-up appointments will occur after discharge. Asking the patient if they anticipate any difficulty keeping these appointments can be useful. Also, the patient should be advised to contact the practice immediately if they are unable to keep a follow-up appointment. If this occurs, the practice might determine that it is in everyone s best interest to get the patient in to the office by whatever means necessary, even if it means sending a cab (at the practice s expense) to pick up the patient. As we know, the patient returned to Dr. B (rather than Dr. A, as directed) the week following surgery. Although his IOP was at 8 and his cornea was clear, his visual acuity was still 20/200. This information was communicated to Dr. A s office; however, there was no response to it. It is uncertain whether the information was effectively communicated within Dr. A s practice. Further, when Dr. B recognized that the patient s IOP was 55 70 (an alarming elevation), he should have called Dr. A s practice and spoken directly to her. Instead, by the time he faxed his findings to Dr. A and they were communicated to her, much of the first post-operative day was lost. Had a conversation occurred earlier in the day, it is possible that arrangements could have been made to get the patient into Dr. A s office that same day. 1 Under applicable state or federal civil rights legislation, when a non-english-speaking patient is seen in a medical practice and an interpreter is requested, the practice usually must provide one at the practice s expense. 3
The final issue with this case is the criticism of Dr. A s care by the ophthalmologist who subsequently treated the patient at the university practice. Unfortunately, this form of after-the-fact criticism occurs more often than it should. Although the patient should never be deliberately deceived, if a subsequent physician observes care that he or she considers inappropriate, the first step is not to communicate this opinion to the patient. The subsequent physician should contact the prior physician and discuss the case with him or her. If a mistake has been made, it is best for the physician who made the mistake to discuss it with the patient. If the physicians differ in their opinions of how a case should be handled, they should attempt to reconcile their opinions. If they cannot, the patient should be drawn into the discussion. Post hoc criticism (such as occurred here) rarely benefits either physician. SUMMARY SUGGESTIONS The following suggestions may be helpful to physicians attempting to provide high-quality care during the immediate post-surgical period: Clear and comprehensive communication between doctor and patient is critical at all times, including the post-operative period. When the provision of treatment is not indicated on an urgent basis, take time to discuss treatment options with the patient. This discussion is the heart of effective informed consent to treatment. Adequate communication between all contemporaneously treating providers is essential. The time sensitivity of information will dictate the immediacy of such communication. The mode of communication (specifically, the timeframe in which the information will be received) should be considered. Communication within a practice is also critically important, both from the standpoint of certainty (i.e., information not becoming misplaced ) and timeliness (i.e., when the information is time sensitive). The patient s personal circumstances should always be considered. In some cases, special measures might be necessary to provide the best care possible. Criticism of another provider s care before talking to the other provider is rarely, if ever, appropriate. Although the patient deserves the truth at all times, any miscommunication or other misunderstandings between the providers should be resolved prior to the discussion of a suboptimal outcome with the patient. 4
CONCLUSION As the provision of medical care becomes increasingly sophisticated (and therefore complex), it is important to continually attempt to identify and minimize the potential for error in the delivery process. Careful attention to nonclinical, as well as clinical, processes increases the likelihood of a good outcome and improved patient satisfaction. The information provided in the above document should not be construed as medical or legal advice. Since the facts applicable to your situation may vary, or the regulations applicable in your jurisdiction may be different, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal statutes, contract interpretation or legal question. 5