by Wayne Wenske, Senior Marketing Specialist; and
Stacey Agnew, MBA, Risk Management Specialist
Presentation and physician action
A 74-year-old woman with a history of diabetes came to see Ophthalmologist A for evaluation of her right-eye cataract. After examination, cataract surgery was recommended and scheduled.
On November 23, Ophthalmologist A took the patient to surgery and performed right-eye cataract surgery. Surgery was completed by posterior capsular rupture and an anterior chamber lens was placed. During the procedure, lens fragments dislocated into the vitreous, with vitreous and anterior chamber hemorrhage. Operative notes describe the lens fragments being retrieved using a lens spoon. Five sutures were used to close the wound.
At the patient’s postoperative exam on November 24, the patient’s visual acuity was documented as 20/100 eccentric view. The patient had a hyphema in the lower third of the anterior chamber with a clot near the wound and “posterior chamber intraocular lens” was described as being in “good position.” The patient was prescribed antibiotics and anti-inflammatory eye drops and a follow-up visit was scheduled in 10 days.
On November 30, the patient returned to Ophthalmologist A because her right eye was throbbing, scratchy, watery, and leaking “bloody matter.” Upon examination, no view of the retina was possible due to vitreous hemorrhage. Topical steroids and antibiotics were continued, and new prescriptions for diclofenac and cyclopentolate were given to the patient.
On December 4, the patient returned and reported continued throbbing and leaking of bloody matter from the right eye. Visual acuity was recorded as a light perception only. There were no significant changes in the described physical exam of the eye with no view of the retina due to vitreous hemorrhage.
On December 7, the patient returned to the clinic with continued complaints of throbbing, red eye with matter. Ophthalmologist A administered a triamcinolone injection.
On December 11, the patient returned with worsening leaking, decreased vision, and acute pain. The patient’s vision was documented as having no light perception. Wound dehiscence was noted at the 11 o’clock position, with iris prolapse and signs of endophthalmitis. The anterior chamber intraocular lens was described as “in good position.” Again, no view of the retina was possible due to vitreous hemorrhage.
Ophthalmologist A diagnosed endophthalmitis and referred the patient to Retina Specialist A for a same-day visit. Retina Specialist A confirmed blindness in the right eye and recommended enucleation. A second opinion agreed with Retina Specialist A.
On December 15, the patient underwent enucleation surgery of the right eye. Pathologic study of the specimen included bacterial endophthalmitis growing two organisms, total retinal detachment, subretinal hemorrhage, and vitreous hemorrhage.
The patient filed a lawsuit against Ophthalmologist A with numerous allegations, including:
- failure to appropriately manage and/or respond to a surgical complication;
- using an outmoded and dangerous technique during surgery (lens spoon);
- failure to conduct proper follow-up examinations; and
- failure to properly recognize, diagnose, and treat infectious endophthalmitis.
Ophthalmology consultants for the defense were critical of Ophthalmologist A’s performance of the cataract surgery. One questioned the practice of using a lens spoon to retrieve lens fragments, due to this technique bringing increased risk of vitreous traction and retinal injury.
The same consultant stated that Ophthalmologist A’s surgical approach led to the need for five sutures to close the wound, more than the usual number, increasing the risk of infection. This consultant also questioned why Ophthalmologist A would treat the patient with a triamcinolone injection.
Other defense consultants wondered why Ophthalmologist A did not suspect endophthalmitis earlier, as redness, pain, and discharge are classic indicators of the condition. Numerous documentation errors were also noted, including four consecutive exams where the intraocular lens implant was described as being in the posterior chamber.
One consultant questioned why Ophthalmologist A did not react promptly to the serious surgical complication that occurred.
Consultants for the plaintiff expressed similar opinions. One consultant felt that had Ophthalmologist A stopped surgery after the bisected cataract dislocated posteriorly into the vitreous and immediately referred the patient to a qualified retina-vitreous specialist, a better outcome may have been achieved. Instead, referrals were delayed, which diminished chances for the patient to recover vision and keep her right eye.
This case was settled on behalf of Ophthalmologist A.
Risk management considerations
Defending a claim or a medical board complaint can be challenging when a physician’s documentation of a patient’s chief complaint, progress, or condition is contradictory or inaccurate. When using preformatted text or templates in an electronic health record (EHR) system, entries should be reviewed and edited as necessary to ensure the record accurately reflects the status of the patient and clinical care delivered.
Cloned, copied, or "carried over" text from one visit to the next may be timesaving, but caution must be used to ensure that records are accurate. In this case, an error regarding lens placement was copied into multiple progress notes, presenting a challenge to the defense of this claim.
Inaccurate patient records reflecting irrelevant issues, incorrect history, or old exams could compromise patient care and the defense of a medical liability suit. The Texas Medical Board has recently added a requirement that, "All non-biographical populated fields, contained in a patient's electronic medical record, must contain accurate data and information pertaining to the patient based on actual findings, assessments, evaluations, diagnostics or assessments as documented by the physician." 1
While tracking of tests and referrals was not an issue in this case, establishing and adhering to tracking protocols is recommended.
1. Texas Administrative Code. Chapter 165. Medical Records. Rule 165.1 (10). Available at https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1. Accessed March 27, 2023.
Wayne Wenske can be reached at firstname.lastname@example.org.
Stacey Agnew can be reached at email@example.com.