The Ten Commandments Of Risk Management

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The Ten Commandments Of Risk Management

• Dr Paul Nisselle AMSenior Consultant,
  Educational Services

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Ten Risk Management Commandments

1. Keep good records
2. Document all discussions with patient
3. Dont alter records
4. Follow up referrals and test results
5. Check the history before writing a prescription
6. Dont diagnose and treat over the phone
7. Show patients you care
8. Give patients enough time
9. Manage adverse events pro-actively
10. Talk to your medical defence organisation

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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
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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.

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

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3. Dont 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.

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3. Dont alter records
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3. Dont alter records
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3. Dont alter records
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4. Follow up referrals and test results

• But I told the patient to see the specialist
  its their fault if they didnt 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.

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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, thats 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?

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5. Check the notes before writing scripts

• a) Never write a script from memory Never
  just sign a script
• Always call up the patients 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

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5. Check the notes before operating

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5. Check the notes before operating

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6. Dont prescribe/treat over the phone.

• Yes, theres 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 its safe, not just
  convenient?
• Are you sure you know to whom youre talking?

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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
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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-
  thats bad medicine.

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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

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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
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Manage adverse events pro-actively
Apology of SympathyIm sorry this happened to
you -v- Apology of Responsibility Im
sorry I/they did this to you
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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)

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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 BPResignation Statement 27 July
  2010
•  

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10. Talk To Your MDO
I only talk to them when Im hit with a writ. If
I tell them about every damn thing that happens,
theyll put up my premium WRONG!!
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Ten Commandments

1. Keep good records
2. Document all discussions with patient
3. Dont alter records
4. Follow up referrals and test results
5. Check the history before writing a prescription
6. Dont diagnose and treat over the phone
7. Show patients you care
8. Give patients enough time
9. Manage adverse events pro-actively
10. Talk to your medical defence organisation

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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

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The Ten Commandments Of Risk Management

• Dr Paul Nisselle AMSenior Consultant,
  Educational Services

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• Other education available from MPS

• Risk management workshops
• Clinical risk self assessments for general
  practice
• Presentations, seminars and workshops on
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• Web based education
• Publications