Episode 102: Hazardous Office Protocols

Speaker 1: You are listening to Your Practice Made Perfect. Support, protection, and advice for practicing medical professionals. Brought to you by SVMIC.

J. Baugh: Hello, everyone. Welcome to this episode of Your Practice Made Perfect. My name is J. Baugh and I will be your host for today's podcast. I'm one of the claims attorneys here at SVMIC. We're going to be talking about a closed claim today. Joining me in this discussion will be another claims attorney here at SVMIC, Katy Smith. Katy, welcome.

Katy: Thanks, J.

J. Baugh: We're going to discuss a case where poor office systems and protocols were to blame. Practices need for organized and effective office systems to be in place. An important example is tracking. Tracking what has been done and what's next to be done.

Katy: Yes, J. We've seen in a number of cases that office procedures can be crucial helpers to physicians and their practices in tracking important patient care. Failing to have them in place, or failing to consistently use them, can lead to delays in diagnosis or treatment, and can affect patient care. Rarely are errors in patient care the result of any one isolated action or inaction. It may also have nothing to do with the provider's lack of knowledge or their diagnostic ability. Rather, errors can be the result of poorly designed, ineffective, or nonexistent office protocols.

J. Baugh: That's right, Katy. Through the years we've seen many instances where had there been an office system in place, there wouldn't have been a plaintiff or defendant, because an incident would not have occurred. Today's case focuses on Mr. Sharp, a 75-year-old male who underwent a kidney biopsy for hematuria and suspected kidney cancer. There was no office system in place to track the specimen. The normal procedure was for the specimen to be reviewed for adequacy, separated into two vials, and given to an employee for further processing and transport to the pathology lab. Somehow the specimens went missing. It was later learned that the vials were placed in a biohazard bag, the pathology lab courier arrived, and the specimens were put in the transport bag along with numerous other specimens. The courier recalled putting the bag on the counter on arrival to the pathology lab. The bag was unpacked at the pathology lab, but the specimen in question was never logged and processed.

Katy: J, here's where the mystery deepens. The physician office staff was not able to retrace their steps to determine if the specimen was logged-in, was given to the courier for transport to the pathology lab, or was received by the pathology lab, because there was no documentation of any of these steps. No one knew what happened here. Upon internal investigation within the office, the original specimen container, which held the specimen before the frozen section was prepared, was the only evidence of the specimen at all. Unfortunately, the specimen could never be found. This left the patient with no other alternative but to have a second and unnecessary biopsy, despite having a very complicated recovery from the initial biopsy due to his other health challenges.

J. Baugh: So the question that we want to look at now is, "How does the physician's office ensure a report has been received and reviewed by the provider?" While all office systems are important for minimizing risk of error, clearly a simple tracking protocol would have outlined, first, who the specimen was given to, second, what the person does with the specimen, third, when the specimen is sent to the pathology lab, fourth, how the specimen is sent, and last, where the specimen was sent, which is most important if multiple labs are used for different types of specimens. Well established systems by both the physician's office and the pathology lab may have prevented this scenario.

Katy: In addition to creating a tracking protocol, it's also recommended that physician's offices create office protocols for basically every phase of your interaction with your patients. Beginning with their appointment scheduling, and continuing through such phases as test results, referrals, and perhaps also even telephone procedures. When thinking whether to implement an office system, it's important to, first of all, determine at what phase you need to create one. Once it's been implemented, you need to determine how to best train and educate your staff about the office protocol. Then you need to make sure that your office staff is using the office protocol. And finally, you need to periodically review the office protocol to make sure it's still appropriate and effective for the way your office and your patients are functioning.

J. Baugh: Yeah. I think that last step is really important, because I can see a situation in which a physician's office has all of these tracking protocols in place, and they assume, "Well, we've done that job. So now we can just leave it there, it'll be fine, we don't have to look at it anymore." But things change over time, so you need to periodically review all of those protocols to make sure that you don't have circumstances that have changed that would then cause you to need to review your protocols.

Katy: That's right. Sometimes there are protocols that are kind of created in a vacuum. In other words, not in a real-world scenario. J, you've probably had this experience. Sometimes I will speak with a physician or a practice after they've had a bad outcome, maybe a test result that has been lost, for example. And it gives the practice the opportunity to go back, review that system, see if there are some failings, or some vulnerabilities we'll say, within the system, and see if they can better tweak it to better respond to the situation.

J. Baugh: That's right. And if the practices would do that on some periodic basis ahead of time, rather than it being a reaction to some bad outcome, then perhaps some of those bad outcomes could be avoided.

Katy: And really, that's the whole point of establishing an office system, is to try to prevent anything from falling through the cracks with respect to patient care.

J. Baugh: So, the rule of thumb should not be that no news is good news. That you shouldn't assume that just because you haven't heard anything, that means that everything went according to plan. There has to be some followup that's done if you get no news at all. I would not rely on the rule of thumb that says that no news is good news. It's also important to advise your patients to call if you haven't heard from us, because it serves a couple of purposes. One is it allows the patient to become part of the decision-making process. It allows a patient to have some ownership in the care that's provided to the patient. And it also allows the patient to serve as a safety net in the event of a system failure. The mode of operation should be proactive rather than being only reactive after an error has occurred.

Katy: That's right.

J. Baugh: As we begin to wrap up this episode, I'd like to mention that we have a lot of resources on our website that could help with tracking protocols and the different issues that we've talked about today. Our website is SVMIC.com. We will also include links to our show notes for this particular episode. So, if you need some help in these areas, we hope that that's helpful in being able to come up with various tracking protocols for your office.

Katy, I want to thank you for being here today to help us with this closed claim about some very important steps that physicians can take to try to avoid these kinds of scenarios happening in their office.

Katy: Thanks, J.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host J. Baugh. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast.

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time. All names in a case have been changed to protect privacy.