Risk Management’s “Greatest Hits”

The Risk Management Department at TMLT provides a variety of products and services to help physicians determine and minimize potential risk exposures that may contribute to medical liability claims. Greater understanding and awareness of these risk exposures — often involving interpersonal communication, documentation, or administrative factors — can help identify “problem areas” in a practice; avoid litigation or a medical board action; offer guidance in difficult situations; and increase patient safety. 

The Risk Management team frequently observes certain liability exposures and patient scenarios that physicians have historically struggled to address. These risk management "oldies but goodies" keep coming up for good reason — they are challenging across care settings and specialties. 

Here are a few of TMLT’s "Risk Management Greatest Hits." 

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Medication errors associated with anticoagulants

As a high-risk class of drugs, anticoagulants have been implicated in serious adverse events for many years. Specifically, medication errors in the management of warfarin continue to occur with some frequency. 

While there are newer oral anticoagulants that do not require lab monitoring or careful consideration about dietary vitamin K intake, they are not appropriate for all conditions. These newer medications are also very expensive, and not all patients will qualify for assistance. 

Therefore, warfarin is still widely prescribed. Because routine lab monitoring is required for warfarin, non-compliance, tracking, and communication are areas where things can and do sometimes go wrong leading to adverse outcomes.   

Managing the risks associated with anticoagulation therapy falls in the hands of physicians across all specialties. Some risk management considerations to help reduce the chances of adverse effects include the following.

• When delegating any portion of the anticoagulation monitoring process to a staff member, ensure competencies are up to date and documented in employment files. 

• Develop and implement evidence-based clinical protocols that address the frequency of monitoring labs, dose adjustments, patient education, patient compliance or non-compliance, identification of critical values, and when physician notification is required. 

• Include a few key safety components in patient discussions and written information shared with patients and their families. Providing these details about the risks is not meant to scare patients. But it is important for patients to be fully informed so they can partner with their physician or health care professional and be an active participant in their medical care.

Key pieces of information to share with patients include the following.

• Fully explain the reason the medication is being prescribed.
• Include the risks and benefits of the medication.
• Clearly delineate the prescribed dosing and need for compliance. Does the patient know what to do if they miss a dose? 
• Educate patients on possible drug interactions (including prescription drugs and over the counter medications or supplements). Instruct patients to notify you before starting or stopping medications.
• Describe dietary factors that can interfere with warfarin. Provide handouts or links to credible resources. 
• Instruct patients on warning signs that require contacting you and when to go to the emergency department. What should they do if they cut themselves? If they develop a bloody nose? 
• Provide written instructions when prescribing anticoagulation along the continuum of care. It is a lot of information to absorb and may be challenging for patients to retain information from an oral discussion. 

Even when all of these actions and discussions have taken place, patients may still experience adverse events. Creating and following safe practice protocols and documenting all patient discussions and education efforts are helpful steps to increase the defensibility of claims involving this high-risk class of medication. 

Electronic Health Records

Electronic health record (EHR) systems were initially developed and designed to assist medical organizations with billing and coding. As these platforms evolved, improvements were made to automated processes and usability. However, there is still room for improvement. 

One issue in EHR documentation that is still a concern is “cloning,” or cutting and pasting data from one patient visit to another. Cloning is a common practice among EHR users that can result in documentation errors. If cloning data from one patient encounter to the next, it is important to take the additional steps of confirming that the information is still correct and/or editing the data to bring it up to date. There are patient safety concerns that could trickle down through the continuum of care if the data is inaccurate. Accurate billing may also become a concern if actions not actually performed are documented as being performed and bills are incorrectly generated.

There are also EHR features where the system prepopulates data with a click of a button. As with cloning, prepopulated data must also be reviewed and verified by the user for accuracy before signing and locking the notes.
  

Following up on tests

At TMLT, we often see failure to follow up on test results as an allegation listed in our claims. Unfortunately, a delay in following up on test results and referrals or failure to follow up can result in devastating patient outcomes. However, patient non-compliance, heavy workloads, multiple physicians and health care professionals managing a patient’s care, and a lack of systems or tools to facilitate timely follow up are all factors that can make tracking challenging. Because of these issues, tracking processes are often absent, inconsistently used, or incomplete. 

When a physician or other health care professional orders a test or refers a patient to a specialist or another health care professional for treatment, it is the ordering physician or health care professional’s responsibility to follow up. 

For practices still using paper medical records, the tracking system may be on paper or in the form of an electronic spreadsheet. In the tracking document, include areas for capturing the order date, patient’s name, date of birth, the name of the test, the date results are received, the date of physician review, and the date and method that results are communicated to the patient. This list should be regularly reviewed and completed with close attention given to outstanding test results. 

Now that most practices use EHRs, built in tracking systems are helping to manage this process. It is important to fully understand and become accustomed to the tracking features and other available functions of the EHR. Does the system allow the test result to get filed into the patient’s record without physician review? If so, put a safety measure in place to avoid this step from occurring. 

Some EHR systems will also share test results with patients in the patient portal, including abnormal results or results requiring additional testing or follow up with the physician. Find out if there is a way in your EHR tracking system to tell whether the patient received and reviewed the result posted in the portal. This is especially important when the result is abnormal and requires further action. 

When it comes to EHR tracking systems, they are not all created equal. If you have not done so, reach out to your EHR vendor to learn more about the tracking system. 

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Ending the patient-physician relationship

Terminating a patient relationship is often difficult and uncomfortable, but it may sometimes be necessary. Patients who are rude, aggressive, or disruptive; fail to keep appointments; refuse to adhere to practice policies; or do not follow the treatment plan often leave physicians with few options but to terminate the relationship.

A few basic tenets for ending a patient-physician relationship include the following. 

• When terminating a relationship with a patient, you should do so with appropriate notice — such as with a letter or in-person conversation that stipulates an “end date” to the relationship. This end date will depend on several factors such as physician specialty, patient access issues, and the availability of other physicians. Give the patient a reasonable amount of time to find a new physician and remain available to care for the patient until the specified time elapses. Avoid terminating without notice, as that could be seen by your medical board as patient abandonment.
• Whether to end the relationship in person or in writing is at the physician’s discretion. But if you are certain that you do not want to see the patient again, it is recommended to do so in writing. In most cases, we recommend sending termination letters via both certified letter (return receipt requested) and First-Class Mail. Some physicians choose to hand the patient a letter after an in-person discussion. Whatever method you choose, document the termination — with specific details such as timeline, medical records transfer instructions, patient response, etc. — in the patient's medical record. If using a letter, retain a copy in the patient’s chart.
• In Texas, you are not legally required to give a reason for ending the relationship. If you choose to provide a reason, keep it fact-based, reasonable, objective, and brief. Avoid accusations or an accusatory tone if possible. Bottom line — keep it professional. If you practice outside of Texas, please consult your state medical board for guidance on whether you are required to provide a reason for termination.
• If the patient is in a health crisis, in the post-op period, or late in pregnancy, the physician should care for the patient until the patient is stabilized, or until another physician is found to assume the patient’s care. That said, there are exceptions for dangerous or violent patient behavior, or if the practice can manage a quick, safe transfer of care to another provider.
• Check your provider/payor contracts (Medicare, Medicaid, private health insurance companies) to confirm that you are allowed to end relationships using your standard process. You may be contractually obligated to keep patients in the practice or to follow specific steps to notify the provider of the termination. 
• Inform your front office staff and schedulers that you have terminated this patient relationship. Add an alert or a status change to the patient’s record so that office staff will no longer schedule the patient. This may be set up in your practice’s scheduling software or EHR. 

Additional resources on patient termination, including sample letter templates, articles, and more, are found on the TMLT website.

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Parental consent to treat and access a child’s medical records‍

Many practices struggle with consent issues for children with divorced parents. This can be challenging for the practice — especially if practices are hearing completely different accounts from the two parents. 

Physicians and administrators often assume that only the parent who has primary custody of the child can consent to their treatment — which may not be the case. In Texas, if parents are named as “joint conservators” with shared custody, both parents generally will have full rights to consent to the treatment of their child. Even if one parent is named the “sole managing conservator”— or the custodial parent— often, the other parent can still consent to most medical or dental treatment of the child. 

The other parent may be named as the “possessory conservator.” If the child is with them, during a visit or extended stay, this parent then has the right to consent to most medical treatment, with exceptions for invasive treatments, such as surgery, and psychological or psychiatric treatments. The sole managing conservator has the right to consent to these treatments, but the possessory conservator may not. 

In emergency situations involving immediate danger to the child, both managing and possessory conservators may consent to invasive treatment. (1)

There may also be individual limitations on either parent that could have been put into place by the courts, so these limitations must be determined and honored.

That may feel like a tall order. But the bottom line is that there will likely be court documents in place that outline who may consent to what treatments — or not — for their child. Practices must become comfortable with asking for this paperwork, especially if one parent tells them that the other parent does not have the right to consent to treatment for their child. 

When in doubt, ask for the documents. Once the individual rights of the parents have been determined, retain a copy of any pertinent court documents in the child’s records.

Access to a child’s medical records by divorced parents can be another contentious issue. In most situations, both parents have the right to access their child’s records. (1,2) But, again, there could be limitations put in place by the court. It is never wrong to ask about court documents if an argument arises between parents regarding the right to access the child’s medical records or if one parent’s access becomes limited or restricted. 

Texas laws that address consent for treatment and access to records for minors with divorced parents are in the Family Code, chapter 153.073, of the Texas Constitution and Statutes. (3)  

For more information about these topics or any risk management question, product, or service, please contact TMLT’s Risk Management Department online or by phone at 1-800-580-8658.

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Sources 

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1. Texas Medical Association, Office of the General Counsel. Consent for Treatment of Minors. November 2019. TMA log-in required.  Available at https://www.texmed.org/Template.aspx?id=2094.
   Accessed July 15, 2024.
2. TMLT Webinar: Medical Care for Minors. 2024. Available at https://hub.tmlt.org/webinars/medical-care-for-minors.
   Accessed July 15, 2024.
3. Texas Constitution and Statutes. Family Code. Chapter 153, Section 073. Rights of parent at all times. Available at https://statutes.capitol.texas.gov/Docs/FA/htm/FA.153.htm.
   Accessed July 15, 2024.