However, the country-wide concern about medical errors is relatively recent. A 1993 article in Quality Review Bulletin, admittedly a publication not widely read among clinical health care providers, summarized the types of errors associated with diagnosis, treatment, and prevention of health problems.2 Some types of medical errors are directly applicable to diagnostic audiology, such as a mistake or delay in diagnosis, use of outmoded tests, and failure to act on the test results. Medical treatment errors, like inappropriate or delayed management, are also relevant to audiological rehabilitation.
Studies in the late 1990s provided further research evidence on the scope of medical errors, while also describing systematic approaches to reduce the problem.3 Hospitals and other health care facilities implemented medical checklists, computerized systems for dispensing medications, regular training of physicians and other health care providers, and a no-fault approach to encourage disclosure of errors. Despite these widespread efforts to reduce medical errors and heightened national attention to the problem, statistics on mortality and morbidity continue to worsen. Concerns about preventing medical errors have extended to audiology and the provision of hearing health care.
A 2014 article in The Hearing Journal discussed specific risky areas, including ear mold impressions, cerumen removal, failure to diagnose hearing loss in infants and young children, and infection control, and provided general recommendations such as obtaining a signed consent from patients prior to any audiological procedures and careful documentation and record-keeping.4 This article provides additional steps and strategies for minimizing professional liability while also protecting patient rights and enhancing patient safety.
STEP 1: ENSURE PATIENT RIGHTS, PRIVACY, SECURITY, AND SAFETY
Patients have the right to expect their audiologist will take all practical steps to protect them from unreasonable risks, closely control personal health information to maintain patient confidentiality, and fully comply with state and federal laws and regulations to assure patient privacy.5 Table 1 shows some clinic policies that contribute to the protection of patient rights, privacy, security, and safety. Since the implementation of HIPAA rules in 2005, health care providers have been expected to maintain confidentiality of patients’ protected health information (PHI) in all formats, including verbal, oral, and electronic communications (e.g., email messages), along with paper and electronic reports and records. PHI includes any data about patients that might be used to identify them. Unintentional breaches of confidentiality can happen rather easily. Nonetheless, audiologists and other health care professionals who fail to maintain PHI confidentiality run the risk of getting serious penalties, including substantial fines and even prison time.
STEP 2: STRENGTHEN THE WEAK LINK
Every person in an audiology clinic—from the audiologist in charge to the front desk receptionist and/or clerk—is expected to play an equal role in preventing medical errors. An audiologist who employs others is vicariously responsible and legally liable for all clinic personnel, including unlicensed health care providers and support staff. All clinic personnel should be regularly and systematically educated about patient rights, privacy, security, and safety. For example, all personnel should know exactly what to do if a patient gets injured in the clinic or experiences a medical emergency like a heart attack or epileptic seizure. Even the most junior staff member or student-in-training should feel empowered to bring to his or her supervisor's attention any perceived potential or actual problems involving patient rights, privacy, security, and safety.
STEP 3: FOLLOW STANDARD OF CARE
Standard of care in our context is defined as the degree of prudence and caution that a reasonable audiologist should exercise in caring for patients in a given clinical situation. In the modern health care setting, standard of care is almost always consistent with national clinical practice as defined in written statements of guidelines and recommendations, as reviewed next. These documents include those generated by audiology professional organizations and also multi-disciplinary groups of professionals. Standard of care in audiology must also be consistent with statements of scope of practice, code of ethics, state licensure laws and regulations, and federal health care regulatory entities like the Centers for Medicare & Medicaid Services (CMS).
STEP 4: KNOW AND COMPLY WITH GUIDELINES
Evidence-based, peer-reviewed clinical practice guidelines exist for almost everything audiologists do in the process of identifying, diagnosing, and managing hearing loss and related disorders (e.g., auditory processing disorders, vestibular disorders, tinnitus, and disorders of decreased sound tolerance). Sample guidelines in Table 2 online (bit.ly/Table2Hall). Compliance with clinical practice guidelines is the simplest and most straightforward step that audiologists can take to lower the risk of professional liability. These documents are readily available on the websites of professional organizations like the American Academy of Audiology and the British Society of Audiology. An audiologist who is drawn into a professional liability lawsuit has a strong legal defense if she or he can prove full compliance with relevant clinical practice guidelines. Practicing audiology as recommended in widely accepted evidence-based guidelines demonstrates adherence to standard of care.
STEP 5: COMMUNICATION AND DOCUMENTATION
Another important two-part step in minimizing professional liability is not at all complicated. First, audiologists should consistently communicate effectively with patients and their family members, beginning with compassionate and caring interactions upon the initial meeting. Before performing any procedure, the audiologist should explain the process first and answer the patient's questions. It's a good policy to reassure patients that they can ask you to discontinue a procedure at any time if they have concerns or experience physical discomfort. Provide patients with reports of services provided and respond promptly to any telephone calls or emails from patients or family members. Second, audiologists must carefully and completely document in writing everything that was done with and to the patient. Supplement written notes with printouts of all test findings and/or photographic documentation (e.g., images from video-otoscopy). Of course, all documentation must be safeguarded for patient privacy. Common legal advice about documentation is straightforward: If you did not document what you did, then you did not do it.
These steps offer a practical and effective approach to minimizing risk of professional liability, including civil and criminal malpractice claims. Unstated was the requirement to maintain current clinical credentials like state licensure and specialty certificates. Audiologists working in hospitals, large multi disciplinary practices, and academic health care systems are no doubt familiar with and regularly receive updates on these and other systemic approaches to minimizing medical errors in providing hearing care. Audiologists who own or are employed in individual practices are advised to develop and implement similar approaches to mitigate professional liability while also improving patient care.
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2. Leape LL, Lawthers AG, Brennan TA & Johnson W (1993). Preventing medical injury. Quality Review Bulletin,
3. Kohn LT, Corrigan JM & Donaldson MS eds. (2000). To err is human: Building a safer health system. Washington DC: Institute of Medicine, National Academies Press.
4. Shaw G (2014). Preventing medical errors: How to proceed with caution. The Hearing Journal (July),
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5. Hall JW (2014). Introduction to Audiology Today.
Boston: Pearson Educational.