Takeaway: Despite thorough subject-matter knowledge, physicians can miss the diagnosis of a familiar condition because of issues with clinical judgment. Clinical judgment may be influenced by distraction, interruption, or team communication issues. A new study of malpractice allegations against ophthalmologists suggests that when practices build teamwork skills, they strengthen patient safety and mitigate practice risks.
The Case: A patient came into the office complaining of blurry vision in one eye. Vision in that eye was assessed as 20/80, and the patient was diagnosed with a cataract. Several weeks later, the patient returned with ongoing blurriness in the same eye. The patient’s visual acuity was assessed as 20/400. The ophthalmologist did not perform another examination but did provide a routine referral to a cataract specialist.
A few weeks later, the specialist examined the eye and diagnosed a total retinal detachment. The patient now has only light perception in the affected eye. Experts were critical of the ophthalmologist’s failure to dilate and assess the eye, especially with the precipitous drop in visual acuity relative to the previous visit.
Analysis: This case example comes from a recent study analyzing The Doctors Company’s medical professional liability closed claims against ophthalmologists. The study included 490 closed claims from the loss years 2010 through 2024.
Among patients in the claims studied, 20% had experienced, like this patient, a high-severity injury, as defined by the National Association of Insurance Commissioners (NAIC) Severity of Injury Scale.
These clinical judgment issues are representative: The failure to appreciate and reconcile signs and symptoms featured prominently among the studied ophthalmology claims that resulted in a paid indemnity.
Tips for Malpractice Risk Reduction: Seek Team Training to Mitigate Risks from Interruptions and Distractions
Ophthalmology practices are collaborative environments, combining contributions from physicians, advanced practice clinicians, nurses, medical assistants, clerical staff members, and others. A new analysis from The Doctors Company confirms that many people on the care team, even nonclinical staff members, can contribute to—or play a role in preventing—adverse events. Therefore, organizations that build a culture of safety through a team training program, such as TeamSTEPPS®, can improve patient outcomes and mitigate practice liability. TeamSTEPPS is an evidence-based set of teamwork tools designed to improve patient outcomes through enhancing communications and teamwork skills within healthcare teams.
Because medical practice is collaborative, diagnostic challenges may not always be accounted for by gaps in the physician’s knowledge or a patient’s unusual presentation. And in fact, ophthalmology malpractice allegations related to common conditions like retinal detachment are more frequent than one would suppose. Workplace factors like distraction and interruption can play a significant role in missed and delayed diagnosis.
Interruptions sometimes preserve patient safety, such as when a clinician speaks up to prevent a medication error. However, perpetual interruption and distraction increase cognitive load, which can tax diagnostic thinking to the point where interruption and distraction become a patient safety issue. Interruptions can also cut vital information out of a handoff conversation or create other safety hazards.
The TeamSTEPPS program can help. Participation can bolster a care team’s communication clarity during high-risk moments and help practitioners identify patterns of interruption and distraction that present barriers to clear communication and impact patient safety.
Overall, practices that invest energy in adapting their workflows and communication habits to prioritize maintenance of clinicians’ cognitive bandwidth will reap dividends in reduced liability risks.
This discussion of practice risks in ophthalmology is based on Lessons From Ophthalmology Malpractice Claims: Managing Patients’ Expectations With Informed Consent and Shared Decision Making, published by The Doctors Company.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider, considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
1. CRICO-Candello Clinical Taxonomy Manual, V4.0, 2021. Copyrighted by and used with permission of Candello, a division of The Risk Management Foundation of the Harvard Medical Institutions Incorporated, all rights reserved. As a member of the Candello community, The Doctors Company participates in its national medical malpractice data collaborative.