Q: As part of my practice, I sometimes perform invasive procedures such as biopsies, lipomas, sutures, etc. in the office setting. But I don’t use moderate or regional sedation. Am I still at risk of liability?
A: Any procedure performed using anesthesia, even minimal or local, carries the risk of liability, no matter how adequate the care. When doing procedures that don’t require moderate or deep sedation, or regional anesthesia, you can employ some fundamental risk management strategies to help minimize your risk.
First, it’s a good idea to review all current and relevant diagnostic studies associated with the procedure. If appropriate, ensure the patient has a driver to take him home. Confirm that the patient has completed the informed consent process and review the patient’s form.
It’s important to have a patient identification process and, immediately prior to the procedure, you, the physician, should verify with the patient and the staff the patient’s name, the surgical site and the procedure being performed. Also, physicians should obtain and document pre-, intra- and post-operative patient vital signs.
Risk management experts recommend that physicians document prior to discharge:
- Patient’s vital signs
- Patient’s tolerance of the procedure and mental status
- Discharge instructions, including what signs/symptoms the patient needs to report to the physician or that need immediate attention
- To whom the patient was discharged
Risk management experts also recommend physicians provide a phone number so the patient can contact the physician, if necessary. A scheduled follow-up appointment is recommended. The physician also may want to contact the patient the following day to determine if any problems or patient questions have developed. Physicians should periodically review medical records to ensure the above information was documented.
Indiana established standards, effective Jan. 1, 2010, for procedures performed in office-based settings that require moderate sedation/analgesia, deep sedation/analgesia, general anesthesia, or regional anesthesia. Find these standards here.
Physicians insured by ProAssurance Indemnity Company, Inc. may contact our Risk Management department for prompt answers to liability questions by calling (800) 292-1036 or via e-mail.