PREP 4 Patient Safety Technical Assistance Bulletin

 

Volume Five, March, 2004

 

Great resources in this issue of the Practitioner Remediation and Enhancement Partnership (PreP) 4 Patient Safety Technical Assistance Bulletin! The PreP 4 Patient Safety Technical Assistance Bulletin is a free e-mail publication for individuals and groups interested in receiving assistance, progress reports, news and information about the Practitioner Remediation and Enhancement Partnership, a partnership of licensing boards and hospitals whose goal is to jointly identify, remediate and monitor practitioners whose practice is not up to standard but whose actions do not require discipline. Thanks to all of you who forwarded this bulletin on to colleagues, and welcome to our new subscribers. If you have feedback, please e-mail mark@4patientsafety.net. If you have received this newsletter from a colleague, you can subscribe at the web site, www.4patientsafety.net, and see the archived copies of the Technical Assistance Bulletin, the newsletters, and other information.  If you don't want to continue receiving this bulletin, unsubscribing instructions are at the end.

 

THIS ISSUE:

1. RHODE ISLAND INITIATES PROGRAM WITH PHYSICIAN CASES

2. DAVID SWANKIN SPEAKS TO MISSOURI COMMISSION ON PATIENT SAFETY ABOUT THE PreP 4 PATIENT SAFETY PROGRAM'S POSITIVE IMPACT ON IMPROVING PATIENT SAFETY PROGRAMS IN HOSPITALS

3. WEB SITE ADDITIONS

4. PREP 4 PATIENT SAFETY UPCOMING EVENTS

 

1.  RHODE ISLAND BOARD OF MEDICINE INITIATES PreP 4 PATIENT SAFETY PROGRAM WITH 28 PHYSICIAN CASES

The Rhode Island Board of Medicine began its PreP 4 Patient Safety program in a big way – in its first six months, the program has reported twenty-eight cases, with more in process.  The summary of its first cases:

 

Case 1. The Physician  provided  sub-standard care to a geriatric patient, and the documentation was inadequate.   The physician was required to obtain CME of 10 additional hours of geriatrics per year for the next two years.

 

Case 2.  The physician provided care that was only minimally adequate, including poor documentation; inadequate follow up of abnormal laboratories in the outpatient setting; and lack of aggressive follow up of diagnostic test results in symptomatic patients.  The physician was required to complete a formal course on documentation and also required to take directed CME in geriatrics (total CME 40 hours per year for the next 5 years with at least 5 hours per year in geriatrics.)

 

Case 3.  This patient had been to the emergency room multiple times during a short period, yet the treating physician failed to perform an appropriate evaluation or note the change in her condition, and failed to realize that delirium and elder is associated with morbidity and mortality and demands an appropriate evaluation.  The Board directed CME of 10 additional hours of geriatrics per year for the next two years.  The Board may take additional action regarding this case.

 

Case 4.  This physician who is ultimately responsible for the care provided to this patient provided only superficial supervision in the post-operative period, as indicated by minimal documentation.  The physician failed to draw a connection between the failure to diagnose a profound anemia and the patient's subsequent stroke. The physician must take a course on documentation and the Board is will consider other action.

 

Case 5.  The physician failed to recognize the potential grave significance of recognition of sepsis, and the hematologic findings in this young diabetic patient.  The findings should have prompted consideration of a serious infection process and additional evaluation.  The physician was required to undertake directed CME on early infection in patients with chronic illness.

 

Case 6.  In this case, there were several problems.  The system in place for notifying patients of negative x-ray findings, in which the physician participated, was flawed, and resulted in a delay of the diagnosis of lung cancer.  In addition, this radiologist failed to recognize a 4-centimeter mass lesion on the original interpretation of the Cat Scan. The Board also  expressed concern with the physician’s ability to correctly interpret radiographs and overall competency.  This radiologist was required to complete a documentation course, undergo an evaluation by CPEP and comply with each and every recommendation made by CPEP, and participate in a board-approved remedial education program and undergo subsequent re-evaluation.

 

Case 7.  This physician was prescribing controlled substances in a poly-pharmacy approach which was inappropriate.  The physician must take a course in documentation and prescription writing at Case Western, and directed CME on poly-pharmacy.

 

Case 8.  The system in place for notifying patients of abnormal x-ray findings was flawed and resulted in a delay in the diagnosis of lung cancer.  The physician is the medical director of the facility and bears primary responsibility for the system in place.  As the responsible party, the physician was requested to take a documentation course.

 

Case 9.  This physician was found to be over-coding some procedures.  The physician must take a course in documentation, and a course on billing and coding.  The physician must submit a plan for billing compliance, including review of notes to ensure proper coding.

 

Case 10.  This physician performed an incomplete cardiac assessment on a patient.  This doctor was required to complete two hours of directed CME on cardiac assessment. This physician worked with patients in critical health and was not certified in Advanced Cardiac Life Support.  The physician completed the certification as his remediation program.

 

Case 11.  Physician failed to perform appropriate laboratory monitoring on patients taking  lipid lowering agents. Also, there was poor documentation in the patient medical record. Physician must take a course on hyperlipidemia and a course on medical record keeping approved by the Board.

 

Case 12.  The Physician failed to maintain compliance with federal regulations regarding documentation of flu shots.  Physician must take a course on medical record keeping approved by the Board, and it was recommended that the physician include influenza as a part of the inoculation history form.

 

Case 13.  This physician paid inadequate attention to the patient’s comfort during treatment, so the physician agreed to take a course on medical ethics and professionalism at Case Western Reserve University in Cleveland, Ohio.

 

Case 14.  In this case, the physician was found to have generally poor medical records.  While the physician initially was required to take a course in medical record-keeping, the physician was excused from this requirement when he gave up his practice of medicine due to illness.

 

Case 15. In this case, adequate treatment was delayed because the physician did not take a more aggressive approach to follow up with the patient in light of the fact that the patient had cardiovascular risk factors and is in a vulnerable population. Physician must take an AMA approved course in cardiovascular diseases.

 

Case 16.  This physician acted inappropriately by using inflammatory language towards a nurse, and the physician agreed to take the course entitled "Intensive Course in Medical Ethics and Professionalism" at Case Western Reserve University.

 

Case 17.  This doctor failed to follow-up appropriately on an x-ray with positive findings, and so agreed to  take the course entitled "Intensive Course in Medical Ethics and Professionalism" at Case Western Reserve University.

 

Case 18.  A Letter of Concern was issued by the Board because this physician represents himself as a cardiologist with only minimal training.   This physician must take the course entitled "Intensive Course in Medical Recordkeeping with Individual Preceptorships" as well as an AMA approved course on diabetes management approved by the Board.

 

Case 19.  This physician agreed to take an AMA-approved course on record keeping approved by the Board because there was no documentation in the progress notes that an examination was performed on the patient.

 

Case 20.  In this remediation case, the Board made a finding of unprofessional conduct for a lack of candor in addressing the source of bleeding and in describing the patient's post-operative status.  Respondent's surgical judgment regarding indication for surgery is inadequate, pre and post operative documentation is inadequate, and intra-operative decision making is inadequate.  The physician agreed to undergo a clinical skills evaluation at the Colorado Physician Evaluation Program (CPEP), and undergo any remedial work recommended by CPEP.  The physician further must obtain any continuing medical education recommended by the board, and must obtain a pre-surgical second opinion for all spinal surgery cases from a spinal surgeon unaffiliated with the Respondent's medical practice.

 

Case 21.  This physician failed to take responsibility for the informed consent form. Physician must take the course entitled "Intensive Course in Medical Ethics and Professionalism"  at  Case Western Reserve University.

 

Case 22.  This physician was found to be pre-dating and pre-signing prescriptions for narcotics in violation of the Rhode Island Uniform Controlled Substances Act. The physician must attend a course on appropriate pain management and prescribing.

 

Case 23.  This physician failed to provide aggressive care and treatment to a patient whose first-degree relatives were diagnosed with colon cancer. The lack of an aggressive treatment plan by the physician resulted in the patient having to undergo chemotherapy treatments and experiencing a poor prognosis for recovery. The physician must take an AMA approved course on management of patients with a family history of colon cancer.  The course must be completed within 6 months. The physician must report to the board upon completion of this course. 

 

Cases 24 and 25.  Each physician who treated the patient, who had a known history of COPD, was kept on an inappropriately high level of oxygen by the physicians, and the medical management of the patient did not meet the standard of care.  The physicians are required to attend a CME course, approve by the Board, on emergent pulmonary care.

 

Case 26.  The physician failed to respond to the mother's expressed concern, which would have resulted in an earlier diagnosis of the patient properly for Type I diabetes mellitus.  The physician agreed to take a course on patient communication.

 

Case 27.  The physician 's documentation was inadequate; the physician's communication was inadequate. The physician must take a course on documentation and communication, and CME in assessment/recognition of traumatic eye injuries.

 

Case 28.  This physician was a medical director at a health plan, who was found to be overly involved in making decisions regarding discharging patients from hospitals, and, in another case, made a patient’s access to the proper treatment unnecessarily difficult.  This Physician must take the course in Ethics and Professionalism at Case Western Reserve University within 6 months.  He must also take 40 hours per year of directed CME for 5 years of which no less than 5 hours per year be in professionalism/ethics.

 

2.  DAVID SWANKIN SPEAKS TO MISSOURI COMMISSION ON PATIENT SAFETY ABOUT THE PreP 4 PATIENT SAFETY PROGRAM'S POSITIVE IMPACT ON IMPROVING PATIENT SAFETY PROGRAMS IN HOSPITALS

David Swankin, President of the Citizen Advocacy Center, spoke to the Missouri Commission on Patient Safety about the PreP 4 Patient Safety program on February 18, 2004.  Dave spoke on the background and precepts of PreP 4 Patient Safety, and discussed the relationship between the problems identified in the PreP process and systems safety issues in hospitals.

 

Dave presented a report summarizing the findings of our review of the first (almost) 100 PreP 4 Patient Safety cases.  In at least eleven (11) of the nearly 100 cases processed through the four operational PreP 4 Patient Safety programs, the investigation of individual practitioner deficiencies (physicians or nurses) led not only to timely remedial interventions with those individuals, but also to the discovery and correction of system flaws.  On the web site (at http://www.4patientsafety.net in the middle of the home page), there is a written report which briefly summarizes those 11 cases.  They underscore the relationship between PreP 4 Patient Safety programs and system safety improvements.  They show that a mechanism for finding and remediating physicians and nurses who have shortcomings in knowledge and/or clinical skills can be at the same time a tool for identifying and remediating system safety problems.  The first four cases summarized in the written report involve physicians; the last seven cases involve nurses.

 

CAC proposed that the Missouri Commission on Patient Safety include the following 3 recommendations in their final report , due later in 2004:

 

* Recommend that all Missouri hospitals develop PreP 4 Patient Safety programs in partnership with the Missouri Board of Registration for the Healing Arts

 

* Recommend that the Missouri Board of Nursing Participate in the PreP 4 Patient Safety program

 

* Recommend that the Missouri Hospital Association encourage member hospitals to participate in PreP 4 Patient Safety programs in collaboration with the boards of medicine and nursing

 

3.  WEB SITE UPDATES

Take a look at our web site for great information – linked from the home page (http://www.4patientsafety.net) are the paper on PreP 4 Patient Safety and Systems Issues, a survey by the NC Board on PreP 4 Patient Safety participants, and the PreP 4 Patient Safety Assessment and Remediation Resource Manual, to name just a few!  Visit http://www.4patientsafety.net.

 

4.  UPCOMING EVENTS: PreP 4 Patient Safety at Meetings in Fall 2004

This fall, you may be hearing a lot more about PreP 4 Patient Safety, especially if you will be attending any meetings in September or October.  PreP 4 Patient Safety is scheduled to be presented and discussed in September at the annual meeting of the Council on Licensure, Enforcement and Regulation (CLEAR) (web site: http://www.clearhq.org), in October at the American Society of Hospital Risk Managers (ASHRM) (web site: http://www.ashrm.org), and of course, at the CAC Annual Meeting – mark your calendars now -- October 28-30, 2004 at the Hotel Royal Plaza in Orlando, FL.

 

THANKS for reading our bulletin. If you have questions or comments about its content, e-mail mark@4patientsafety.net. Until our next issue, be well.