Imagine if…

You receive an email from a parent stating that they’re holding you responsible for their child’s injury sustained while at your centre and are suggesting they’ll complain to your regulatory authority if you don’t pay the child’s medical bills.  As you’re sure you and your staff are not to blame and it was simply an accident, you reply to the parent informing them of your version of events.  Some time after you hear from your regulatory authority informing you they’ve received a complaint about your centre which they’ll need to investigate.

Guild Insurance’s Liabilities policies state that as soon you, as the policy holder, experience a claim made against you or an incident which could give rise to a claim, you are required to notify Guild.  However, Guild has noticed a worrying trend where policy holders are responding to complaints on their own without first notifying Guild.  This can have a number of consequences for these people as they’re not receiving the support or guidance their insurance policy may entitle them to.  It can also mean the policy holder is not adhering to the conditions of the insurance policy.

Possible scenarios

The following scenarios are some examples of when you should notify Guild Insurance:

• A parent has requested financial compensation due to their child suffering an injury
• Your regulatory body has informed you that they’ve received a complaint about your centre and will be investigating
• You have been contacted by the Fair Work Commission regarding a disgruntled former employee alleging they’ve been treated unfairly.
• Any other circumstance where you have an uneasy feeling about an incident or situation; when in doubt, notify!

When to notify Guild

Policy holders are sometimes unsure whether a matter is serious enough to warrant notifying their insurance company.  There are some occasions where notifying an insurance company is a must, such as when responding to a regulatory body or when faced with a demand for compensation.  Also, if the incident requires you to notify your regulator, this is a matter which Guild should be made aware of.  However, there are occasions where you need to use your judgement.  If a parent has simply informed you that they’re unhappy with an aspect of your centre yet doesn’t seem overly annoyed or demanding, then this may be a matter which can be sorted by you alone.  Yet if you’re in doubt or unsure, then you should notify Guild. 

Will my premium go up if I notify Guild of a matter?

Notifying Guild of an incident is unlikely to be the cause of a premium increase the following year as Guild’s premium pricing is influenced by a number of factors.  However, as detailed below, not notifying Guild may lead to further stress and complications.  Therefore, the cost of the premium should not be a factor in deciding whether or not to notify Guild.  

Consequences of not notifying Guild

Facing an allegation or investigation of any sort can be an extremely stressful situation.  When an early learning staff member handles a matter themselves without the support of Guild, that stress is compounded as they’ll be dealing with a process they’re unfamiliar with. 

Guild has seen cases where an early learning employee’s own response has either not provided the required information, or a response has been worded in a way which is likely to inflame or escalate the situation.  This usually leads to further investigations being conducted and Guild being notified after the investigation has begun, inhibiting Guild’s support and influence.

When Guild isn’t notified as soon as is reasonably possible of a claim being made, the policy holder may be considered to not be complying with the conditions of the insurance policy.  This can lead to cover under the policy being cancelled or the claim not being paid.

It’s also important to understand that a policy holder may leave themselves with out of pocket expenses by not notifying Guild at the beginning.  This may occur if they engage their own legal counsel not approved by Guild and at a rate Guild believes to be exorbitant or if they have offered to settle a matter without Guild’s consent.

The staff at Guild Insurance have a great deal of experience and expertise in managing allegations and investigations and are well aware of what is required when responding to them.  For this reason, it’s of benefit to everyone involved to notify Guild immediately and be sure the necessary support is provided and process is followed from the start.

How to contact Guild Insurance

To notify Guild of an incident, and therefore make a claim against your insurance policy, either call Guild on 1800 810 213 or go to guildinsurance.com.au/claims.

Download PDF here

Imagine if…

You are advised by your State Veterinary Board that a client has complained about the treatment you provided, suggesting it was performed negligently.  As you’re sure your treatment was appropriate, you immediately reply to the Board informing them of your version of events.  Some time after you hear from the Board again stating that they still have questions about your treatment and will be investigating further.

Guild Insurance’s Liabilities policies state that as soon you, as the policy holder, experience a claim made against you or an incident which could give rise to a claim, you are required to notify Guild.  However, Guild has noticed a worrying trend where policy holders are responding to complaints on their own without first notifying Guild.  This can have a number of consequences for these people as they’re not receiving the support or guidance their insurance policy may entitle them to.  It can also mean the policy holder is not adhering to the conditions of the insurance policy.

Possible scenarios

The following scenarios are some examples of when you should notify Guild Insurance:

• If your Veterinary Board has notified you of a complaint from a client or other person and the Board has asked you to reply with your version of events.
• If a pet insurer has requested access to your clinical records as evidence of treatment provided and billing practices.
• If a solicitor or law firm representing a client has requested access to your clinical records.
• If a client has complained directly to you or your clinic with a formal demand for compensation or suggested they’ll make a notification to the Board.
• Any other circumstance where you have an uneasy feeling about an incident or situation; when in doubt, notify! 

When to notify Guild

Policy holders are sometimes unsure whether a matter is serious enough to warrant notifying their insurance company.  There are some occasions where notifying an insurance company is a must, such as when replying to a Veterinary Board following an allegation, when there is a request for clinical records from a solicitor or funding provider or when there is an allegation of an animal suffering harm following treatment.  However, when a client complains directly to you, this is when you need to use your judgement.  If the client has simply informed you that their animal didn’t respond as hoped to treatment yet doesn’t seem annoyed or demanding, then this may be a matter which can be sorted by you alone.  Yet if you’re in doubt or concerned about the complaint or allegation from the client, then you should notify Guild.

Will my premium go up if I notify Guild of a matter?

Notifying Guild of an incident is unlikely to be the cause of a premium increase the following year as Guild’s premium pricing is influenced by a number of factors.  However, as detailed below, not notifying Guild may lead to further stress and complications.  Therefore, the cost of the premium should not be a factor in deciding whether or not to notify Guild.   

Consequences of not notifying Guild

Facing an allegation or investigation of any sort can be an extremely stressful situation for a veterinarian.  When a veterinarian handles a matter themselves without the support of Guild, that stress is compounded as they’ll be dealing with a process they’re unfamiliar with. 

Guild has seen cases where a veterinarian’s own response has either not provided the required information, or a response has been worded in a way which is likely to inflame or escalate the situation.  This usually leads to further investigations being conducted and Guild being notified after the investigation has begun, inhibiting Guild’s support and influence.

When a veterinarian doesn’t notify Guild as soon as is reasonably possible of a claim made against them, they may be considered to not be complying with the conditions of the insurance policy.  This can lead to cover under the policy being cancelled or the claim not being paid.

It’s also important to understand that a veterinarian may leave themselves with out of pocket expenses by not notifying Guild at the beginning.  This may occur if they engage their own legal counsel not approved by Guild and at a rate Guild believes to be exorbitant or if they have offered to settle a matter without Guild’s consent.

The staff at Guild Insurance have a great deal of experience and expertise in managing allegations and investigations and are well aware of what is required when responding to them.  For this reason, it’s of benefit to everyone involved to notify Guild immediately and be sure the necessary support is provided and process is followed from the start.

How to contact Guild Insurance

To notify Guild of an incident, and therefore make a claim against your insurance policy, either call Guild on 1800 810 213 or go to guildinsurance.com.au/claims.

Download PDF here

A number of errors where medications are dispensed to the wrong customer are reported to Guild Insurance every year.   Of note, many of these occurred when a pharmacist dispensed scripts for two or more members of the same family.  For example, the pharmacist labelled the medications intended for a woman, with her husband’s name.

Similar errors have also occurred when pharmacists dispensed medications via dose administration aids.  For example, Webster packs were prepared correctly, but the pharmacist then put the wrong person’s label on the pack.

These errors can and do happen, even to experienced pharmacists who’ve never made a mistake before.  They can happen to you and they can have serious consequences for you and your customers.

Cases

A pharmacist was processing scripts for a customer and her husband.  The pharmacist inadvertently labelled Carvedilol 12.5mg with ‘Mr’ instead of ‘Mrs’.  As a result, the woman’s husband began taking the medication as directed.  He experienced hypotension and dizziness, causing him to fall and suffer a fractured scapula.

A number of customers were waiting for their scripts to be dispensed.  The pharmacist called out the customer’s name and a woman stepped forward and collected the script.  The customer left the pharmacy and commenced taking the medication as directed. Sometime later, the pharmacist realised that the wrong customer had taken the dispensed medication.  The customer had claimed someone else’s script for Karvea 300mg instead of the Chlorsig eye drops she had been prescribed.  Unfortunately, by the time the customer had been located she had taken the medication and suffered severe hypotension requiring hospitalisation.

Reduce the risk of dispensing errors         

• Adhere to the PDL ‘Guide to good dispensing’ every time. Don’t be coerced into rushing or cutting corners. When errors occur, pharmacists often say “if only I’d taken the time to…”
• Display posters or reminders in the dispensary to promote compliance with dispensing procedures.
• Use barcode scanning every time.
• Make use of the safety features available in your dispensing software. Set up different alerts to remind people to perform certain tasks. Likewise, make use of advanced scanning features that automatically print a barcode on the dispensing label.
• Use alert tags or signs to help distinguish between people with the same or similar surname.
• Don’t process scripts for two or more customers at once. Many errors occur when the wrong person’s labels are affixed to a medication. Don’t rely on the customer to tell you that the label is incorrect.
• Ask the customer to identify themself before handing over the dispensed item. It is not uncommon for the wrong customer to step forward and claim a script. Nor is it uncommon for a customer to say “yes” to the wrong name!
• When handing medications to a customer, point out all warnings and directions on the label and packaging. This not only helps with counselling but serves as a final check against any dispensing error.
• Reducing distractions when a pharmacist is dispensing is everyone’s responsibility. Agree to strict rules for minimising interruptions and distractions in your pharmacy.
• Promote a culture where all staff are confident to point out risky practices when they occur.

Osteopaths, like any health professionals, must take care to clearly and effectively communicate throughout the treatment process in order to avoid misunderstandings which may threaten the osteopath patient professional relationship.

An osteopath must ensure that a patient consents to each part of the treatment process, and it is important to be highly sensitive to signs that the patient is uncomfortable or has potentially withdrawn consent.

While an osteopath may be accustomed to treating patients who are in a state of undress, an individual patient may not be comfortable or understand why they are required to be in a state of undress in the presence of their health practitioner. Osteopaths have a professional responsibility to provide each patient with appropriate covering, and respond sensitively and respectfully to each patient’s needs.

Practitioners are reminded to keep discussions with patients professional at all times. Be wary about discussing personal matters. Casual comments about a patient, even where intended to make the patient feel at ease, may be misinterpreted. Conversation should be limited to topics that are appropriate in the clinical setting.

Case Scenario:

A female patient attended for the treatment of a left knee injury sustained from running. The practitioner requested the patient remove her jeans. The purpose was to allow the practitioner to examine how the patella tracked and also to assess how the tissues surrounding the patella were moving. Towels were available but not offered. The patient felt uncomfortable and could not recall the practitioner explaining why she needed to undress. The patient complained to the Australian Health Practitioner Regulation Agency (AHPRA).

The Likely Finding:

The request to remove clothing was clinically justified. The practitioner acted inappropriately by not offering some sort of covering. The practitioner also acted inappropriately by not clearly communicating the need for the patient to remove her jeans, before making the request. In all of the circumstances, the practitioner’s performance is likely to be regarded as below the standard reasonably expected of an osteopath of a similar level of training and experience.

Common Errors

Effective communication is the key to avoiding any misunderstandings on the part of patients regarding the nature and need for all aspects of their clinical care.

This article was written by Principal, Kellie Dell’Oro and Graduate Lawyer, Marianna Kirchmann. Please contact Kellie Dell’Oro if you have any questions or would like further information.

Kellie Dell’Oro
Principal

T | +61 3 9810 6775

E | kdelloro@meridianlawyers.com.au 

Case studies from practices

• A client claimed her dog was harmed as a result of a medication error. She alleged the dog suffered ‘tick poisoning’ after the practice supplied an inadequate dose of ‘tick prevention medication’. The dose given was calculated on a lower weight range than the dog’s current weight.
• A client alleged his dog died from renal failure as a result of incorrect dosing with an anti-inflammatory agent. The wrong weight had been recorded in the animal’s record. Although the dog was a small breed, a weight of 28kg was recorded. The veterinarian then used that weight to calculate the dosage, without recognising that it was unlikely to be accurate for a dog of that size.
• Guild Insurance also receives a number of similar claims every year where the cause of the incident is difficult to identify. In some instances, the veterinarian simply made a prescribing error and recorded the wrong dose or medication. In others, doses were weaned or titrated incorrectly. That is, a dose was increased when it should have been decreased, or a medication was continued long after it should have been ceased. While many of these errors result in minimal or no harm to the animal, some have had serious consequences. Errors involving prednisolone, NSAIDs or insulin have allegedly caused renal and hepatic failure. Some animals have died.

Tips for practice improvement

• The cases above serve as a timely reminder about just how easily errors can occur. Fatigue, distraction, lack of decision support tools and poorly designed work areas are all recognised as common contributing factors. Therefore, take the time to evaluate your current prescribing and dispensing practices.
  • Are you really doing everything you can to reduce the risk of error? Is your clinical workflow conducive to safe practice?  That is, do poorly designed work areas make it difficult to access things like dosing charts, calculators or product information?
  • Is your prescribing system easy to use and supportive of safe practice?  Have you considered using software with inbuilt alerts to warn you of prescribing errors?
• Always verify an animal’s weight before prescribing or dispensing medication. Weigh the animal at the time and reconcile what’s documented in the record. That is, does the recorded weight seem reasonable for the size, breed and condition of the animal? If it’s not possible to weigh the animal at the time, clarify the recorded weight with the client and again consider what is reasonable for the breed.
• Instruct staff to be particularly careful to double check and dispense the correct size of any medication. For example, 20 mg and 50 mg tablets of some popular NSAIDs may look very similar, but dispensing the wrong ones may cause disastrous consequences.
• Consider the benefits of asking another member of the practice to double check your calculation or selection, particularly if you are working under pressure or fatigued.
• To reduce the chance of inadvertently selecting the wrong medication from the shelf, introduce measures to differentiate between medications that look or sound similar. Ideas include the use of separators and flags, along with avoiding the temptation to store stock in strict alphabetical order.
• Instruct staff to point out all directions on the label and packaging when handing medications to the client. This not only helps to educate them, but serves as a final check against any error.
• Ensure staff always take the time to explain to a client what is meant by using a medication ‘off label’. There have been cases where this has not been explained to the client and they have later complained when they have read the label and seen it is not recommended for their animal.
• Use ‘alerts’ to help distinguish between the records for different animals belonging to the same client. Errors can occur when information, such as weight or test results, are inadvertently entered in the wrong record.
• Promote a culture where all staff are confident to point out risky medication practices when they occur.
• Finally, don’t believe these scenarios couldn’t happen in your practice. While the financial impact can be costly, the impact on your reputation shouldn’t be underestimated. Increasingly, people are choosing not to return to a practice once an error has occurred, instead venting their dissatisfaction via social media and the like.

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Guild Insurance and our claims experience

Guild Insurance regularly analyses its claims data to gain an understanding of the risks faced by dentists insured with us.  This information is then used to create risk messages to assist those dentists to manage their risks.

Guild’s claims data shows that general dentists performing orthodontic treatment are at a high risk of receiving a complaint.  The likelihood of a claim against a general dentist who undertakes orthodontic work is almost twice that for a general dentist who doesn’t do orthodontic work. 

Guild isn’t suggesting general dentists cease orthodontic work.  However general dentists who perform orthodontic work need to have a clear understanding of the risks they face so they’re in a position to reduce the likelihood of those risks becoming a reality.

Expanding your practice

It needs to be acknowledged that whilst the primary concern for dentists is the care of their patients, they’re also running a business.  And any businessperson would be wise to think about how they can improve and grow that business.  However it also needs to be acknowledged that most changes to a business’ operations present new risks which need to be managed. 

One of the key ways the risks of introducing orthodontics into the services being offered by a general dentist can be managed is to carefully consider the training which is undertaken.  As with any CPD, dentists have an obligation to ensure that the orthodontic training they take up is of the standard and quality required.  Not all training will be of the same standard and dentists need to thoroughly research their training options so they select that which is most ideal.  Selecting training simply based on cost, location and convenience is not acceptable, yet unfortunately this does happen.  Dentists need to remember that they’re responsible for any treatment they provide.  Therefore they need to take responsibility for ensuring they’re appropriately trained to provide this treatment.

Understand your level of knowledge and expertise

Whilst all areas of dentistry are in a dentist’s scope of practice, dentists should form their own personal and unique scope of practice.  This requires dentists being honest with themself in terms of their individual level of knowledge and expertise and only performing treatments which fit within this.  Dentists need to know the extent of their ability; this helps to ensure they provide appropriate and safe treatment to all patients. All dentists will have their limitations in terms of what treatments they can and should undertake.  No dentist will be the answer to all dental needs for all patients.

Knowing when to treat and when to refer

This may sound like an unusual message to give to a health professional, however knowing when to NOT treat is incredibly important. 

General dentists who undertake orthodontics have a professional responsibility to identify patients whose clinical situation and treatment need is beyond their scope and expertise.  And once this is identified, these patients must be referred to an orthodontist.  This requires dentists to have an open and honest conversation with the patient explaining why they aren’t able to provide treatment and why they need to see a specialist orthodontist. 

During this conversation dentists mustn’t allow patients to convince them to provide treatment.  It’s not uncommon to hear of cases where a dentist has recommended a referral to a specialist yet the patient hasn’t wanted to take that referral; this may be due to cost, distance to travel or simply that they want to continue treatment with who they know.  Again, dentists are responsible for any treatment they provide.  If the patient suffers a poor outcome following treatment, claiming that the patient requested you carry out the treatment, rather than a specialist, is no defence for poor treatment or clinical decision making. 

Being responsible for treatment provided also extends to situations when the patient has requested particular treatment.  It’s not uncommon for patients to do their own research and then request specific orthodontic treatment from their dentist, rather than wishing to discuss treatment options.  However in these cases the dentist must ensure the patient is thoroughly assessed, has had treatment options explained to them, has given their informed consented to treatment and only receives treatment that is in their best interests.  And of course, a patient requesting specific treatment from a specific dentist doesn’t negate the need to refer when required.

Openness about not being an orthodontist

Guild regularly sees complaints from patients where they claim they didn’t realise that the dentist performing their orthodontic treatment wasn’t an orthodontist.  It’s hoped that in the majority of these cases the dentist hasn’t intentionally misled the patient into believing they’re a specialist when they aren’t, instead the patient has simply made an assumption.  When patients don’t have clinical expertise, making an incorrect assumption is easy to do.  It’s not hard to imagine patients thinking that someone performing orthodontic treatment must be an orthodontist.

Regardless of how a patient forms this view, the dentist must make sure the patient is clear in their understanding.  This means being very upfront and honest with the patient in explaining that you’re a general dentist who is able to perform some orthodontic treatment, but that you aren’t an orthodontist.  It’s also important to make it clear to these patients that they have the option of choosing to see an orthodontist if they wish.  Not suggesting you’re an orthodontist isn’t enough; dentists should be explicit in informing the patient that they aren’t.

In summary…

If a general dentist decides to provide orthodontic treatment, it’s imperative they understand the risks involved and take conscious steps to reduce those risks.  This is likely to lead to better treatment outcomes for patients, which usually leads to satisfied patients who are less likely to complain.

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Sometimes the best treatment a dentist can provide is none at all.

This may sound like an unusual thing to suggest.  After all, a dentist’s job is all about treating patients.  However it’s vital that the treatment provided is performed appropriately and in the best interests of the patient.  To ensure this, there will be times where referring a patient to another dentist, rather than providing treatment, will be the most appropriate course of action.

Understanding your scope of practice

All dentists should develop their own personal and unique scope of practice.  This will be based on what they know they’ve been appropriately trained to do and have the necessary experience in.  It also requires them to be honest and open with themselves regarding their knowledge and expertise.

The next step for a dentist once aware of their own personal scope of practice is to recognise when the required treatment is outside that scope of practice and therefore not something they should undertake.  When the treatment is outside a scope of practice, the patient should be referred to another dentist.

Benefits of referring

Whilst it may at times be tempting to not refer a patient to another dentist as that could be seen as losing business, there are a number of benefits to consider.

By referring a patient to a specialist, you’re providing the patient with what you see to be the most appropriate treatment.  Whilst the outcome of treatment can never be guaranteed, the most appropriate treatment is more likely going to provide the patient with the most appropriate outcome.

Guild Insurance regularly sees claims where a patient has experienced a poor outcome following dental treatment and then requires corrective treatment from a specialist.  It can be argued that in some of those cases, the dentist should have considered referring prior to commencing treatment.  If these poor outcomes lead to a complaint or demand for compensation, the dentist’s clinical decision making and treatment planning may be questioned.

These poor outcomes can also have a detrimental impact on the relationship with a patient.  It’s to be expected that a patient will be disappointed if they experience a poor or unexpected outcome following treatment.  However factors other than the outcome can contribute to or exacerbate this disappointment.  When a patient requires corrective treatment from a specialist, they often question why they weren’t referred to a specialist initially.  This can lead to patients developing a sense of not trusting their dentist due to believing the dentist hasn’t acted in their best interests.  Some patients will even question if the reason for not referring was due to financial greed.  And it’s important to keep in mind that patient’s don’t just complain about clinical outcomes, many also question the behaviour and professionalism of the dentist.

It’s not uncommon for health professionals to feel uncomfortable telling a patient that they can’t perform a particular procedure.  However patients quite often appreciate this honesty and don’t expect a health professional to know and do anything and everything.  Patients will most likely appreciate being informed that there is another dentist who may be more skilled in a particular treatment and that it would be beneficial for the patient to be treated by this other dentist.

Refusing to treat

Sometimes not treating a patient is about more than just a referral and becomes a refusal to treat.  Occasionally patients will be referred to another dentist, yet they don’t want to take up that referral and would prefer to be treated by the dentist they know and trust.  However dentists need to remember that if the treatment is outside their personal scope of practice, they shouldn’t provide it.  If there’s a poor outcome following that treatment, claiming that the patient insisted on it being provided is no justification.  Dentists are always responsible for the treatment they provide and they mustn’t let a patient convince them to treat if they know they aren’t appropriately skilled or trained to do so.

In summary…

Before providing treatment, always stop to consider whether you are the most appropriate person to be performing this treatment and whether the treatment you intend to provide will be in the best interests of the patient.  And remember that referrals can contribute to patient satisfaction and lesson the likelihood of complaints.

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If you launder towels and linen in your business, there’s an unexpected fire risk you may not have thought about.

When you hear stories about things going wrong in other businesses, it’s tempting to think “that’ll never happen to us… we’re different”.

When laundry has oily or chemical residue on it from creams, massage oils and the like, it significantly increases the risk of a catastrophic fire. That’s because linen left sitting in piles, dryers or stacked in cupboards has been known to spontaneously combust, causing a fire.

Fire may result from:

• Leaving soiled linen in a pile or laundry bin overnight, particularly if it’s been treated with bleach, stain remover or other oxidising chemicals.
• Not washing linen thoroughly before placing it in the dryer.
• Not allowing linen to cool down after drying, particularly when the dryer is stopped before it’s cool down cycle has finished.
• Over-heating linen by drying it for too long.

Tips for reducing the risk of fire

• Don’t leave soiled linen in piles or laundry bins overnight before washing.
• Remove lint from the dryer after every use.
• Don’t ever place linen in the dryer unless it has been thoroughly washed in hot water, as cold water doesn’t adequately remove any oily residue. Some items may also need pre-soaking.
• Remove linen as soon as the dryer stops and allow it to cool before stacking or putting it away. Similarly, don’t stop the dryer mid-cycle without immediately removing the linen and spreading it out to cool. Warm linen left in a confined space really can spontaneously combust, causing a fire!
• When purchasing a new dryer consider getting one with automatic fire suppression.
• Don’t be tempted to operate any equipment beyond its rated capacity. Don’t push the dryer to its limits or use it for purposes other than what it was designed for.
• Ensure all dryers are regularly inspected and maintained, including calibration of timers or temperature controls.
• Consider the benefits of outsourcing the washing and drying of your linen.

Claims reported to Guild Insurance highlight an alarming trend.  Sloppy medication handling can compromise the security of not just your pharmacy, but all pharmacies. Practices such as storing methadone in cupboards rather than the drug safe or being coerced into dispensing multiple repeats may seem convenient, but it sends a disturbing message to the public.  It suggests that community pharmacy is an easy target for criminal activity. 

It may surprise you to know that hundreds of burglaries or armed hold-ups occur every year.  Some pharmacies have been attacked multiple times leaving staff traumatised and the business closed for repairs.  Criminals know who’s vulnerable.  Busy pharmacies ordering large supplies of pseudoephedrine, opiates, alprazolam and the like, are attractive to thieves.    So too are pharmacists who bend the rules of dispensing by not challenging prescribed quantities or suspicious scripts.  Deliveries are easily monitored by thieves and tracking technology can help pinpoint the exact location of particular stock and security measures.    

And to make matters worse, some pharmacies have been unable to accurately quantify their drug losses after a theft because their drug register wasn’t up to date.   

Good dispensing practice protects the profession.

• Experienced pharmacists must be role models for professional practice – you can’t expect others to follow the rules if you’re cutting corners.
• There’s no excuse for not knowing what’s expected of you as a registered pharmacist. The Pharmacy Board of Australia has little tolerance for pharmacists who don’t adhere to accepted standards. Allocate time in your diary to research your obligations. Don’t keep putting it off – it’s not worth the risk of costly penalties and damage to your reputation.
• The risk of inadequate drug safe storage can no longer be ignored.  Safes should meet accepted standards and be positioned to maintain security and support good dispensing workflow.
• Don’t be blinded by commercial opportunities - carefully consider how new ways of working may impact safe dispensing and security.

Download PDF here

Guild Insurance regularly receives claims relating to errors with Dose Administration Aids (DAA).  Errors often involve pharmacists filling and dispensing DAAs for the correct patient but based on an obsolete medication profile.  Such incidents provide a timely reminder to pharmacists that the accuracy of any DAA, filled on site or remotely, is primarily dependent on the accuracy of the customer’s medication profile.

Another common error occurs when a pharmacist prepares two or more DAAs at the same time and inadvertently transposes the labels resulting in significant harm to one or both customers.

These errors can and do happen, even to experienced pharmacists who’ve never made a mistake before.  They can happen to you and they can have serious consequences for you and your customers.

Cases

An elderly lady experienced a prolonged period of hospitalisation for renal failure as a result of a dispensing error.  Although she was prescribed Methotrexate weekly, the pharmacist inadvertently packed a daily dose into her ‘webster pack’.  Her claim for compensation was successful as the pharmacist had failed to demonstrate due care in the dispensing process.  While he usually followed the computerised ‘webster care’ program, he chose not to on this occasion stating he was “too busy”.

An elderly man was admitted to intensive care with hyperkalaemia because of a dispensing error.  The pharmacist had mixed up the labels for two ‘webster packs’.  As a result, this man received another person’s medications, including a potassium supplement.  Unfortunately, the patient had a history of renal failure and required many months of haemodialysis as a result.

Reduce the risk of dispensing errors

• Adhere to the PDL ‘Guide to good dispensing’ every time. Don’t be coerced into rushing or cutting corners. When errors occur, pharmacists often say “if only I’d taken the time to…”
• Display posters or reminders in the dispensary to promote compliance with dispensing procedures.
• The importance of checking that the customer’s medication profile is current cannot be overstated. While it can be time consuming to do, the consequences can be catastrophic if you don’t.
• Make sure there are robust procedures in place for ensuring new medication profiles are filed correctly. Emphasise the importance of this to all staff, not just pharmacists. Make people aware of the potential consequences of dispensing from an obsolete profile.
• Don’t prepare DAAs for two or more customers at once. Many errors occur when the wrong person’s labels are affixed to a medication. Don’t rely on the customer or their carer to tell you that the label is incorrect.
• Adhere to the PGA’s Quality Care Pharmacy Program – Dose Administration Aids source checklist.www.guild.org.au/qcpp
• Use alert tags to help distinguish between people with similar names.
• Make use of the safety features available in your dispensing software. Set up different alerts to remind people to perform certain tasks.
• Reducing distractions when a pharmacist is dispensing is everyone’s responsibility. Agree to strict rules for minimising interruptions and distractions in your pharmacy.
• Promote a culture where all staff are confident to point out risky practices when they occur.

Download PDF here

Guild Insurance sees numerous claims every year relating to artificial breeding material (ABM). As a veterinarian, if you’re involved in the collection, transfer, storage or transit of ABM, you may be exposed to the risk of damaging or losing the material. This article outlines the steps veterinarians can take to manage the risks associated with ABM.

Storage

Many of the ABM related claims received by Guild Insurance relate to risks associated with storing ABM.  Sometimes cases can arise when ABM is stored incorrectly, mistakenly left in a transit tank or compromised because of loss or seepage of liquid nitrogen from the storage tank.  The loss or damage of such ABM can leave the client demanding significant financial compensation from you.

Risks in storage: case example

A veterinarian had agreed with a third party to store two lots of equine semen (lot A and lot B). The third party sent the ABM to the veterinarian in a semen transport tank. When the veterinarian received the tank, they took lot A and stored it in their clinic. However, the veterinarian accidentally left lot B in the transport tank which was left open. When the third party engaged the veterinarian to artificially inseminate their horse with lot B semen, the veterinarian checked their clinic tank only to realise that the lot B semen was not there. It was later found in the transport tank, by which stage the semen had thawed and was rendered useless.  Whilst this was an error in storing semen, it highlights the need for strict processes around checking and confirming receipt of ABM.

Process for proper storage

To avoid damaging the ABM, it’s important to adhere to the following process:

• Store semen and embryos in special cryogenic liquid nitrogen containers. Each liquid nitrogen tank should be easily identifiable.
• The liquid nitrogen container(s) should be stored in a space with adequate ventilation and exhaust fans. Ideally, this space or room would have an alarm system which detects significant spillage or leakage of liquid nitrogen.
• Have a maintenance plan which includes regular inspection of the tanks. The maintenance plan should include a written log for each tank detailing contents, liquid nitrogen levels, fill dates, inspection dates, condition and scheduled upkeep. Keep this log either attached to, or beside the liquid nitrogen container. Make sure that the tank contents match the list of contents recorded on the log.
• Keep a sufficient volume of liquid nitrogen containers available at all times to fill the storage tanks.
• Take all reasonable precautions for the safety of the tanks at all times and ensure they are free from contamination.

Transporting genetic material

Sometimes an owner can transport ABM to a veterinarian for storage or, if the veterinarian is already holding the ABM, the owner can request that the ABM be sent onto another location. However, numerous risks can arise during the transport of ABM, namely during the packing, the transit or the receipt of ABM.

Risks in transit: case example

A cow owner engaged an embryo transfer specialist to extract a number of embryos from his cow and send them to a veterinary clinic. The embryo transfer specialist extracted the embryos and loaded them into a dry shipper, which was topped up with liquid nitrogen, and then sent the embryos via express post to a veterinary centre. However, when the veterinary centre received the shipper, it found that the temperature of the shipper was 17 degrees and that the embryos were no longer viable.  Subsequently, the cow owner made a claim for compensation against the embryo transfer specialist.

Transit procedure

To reduce the risk of loss or damage of ABM during the transit process, consider the following actions:

• Use a reliable courier with a proven track record in successful transit of ABM.
• Take out insurance with the postal/courier service.
• Attach a shipping/transport document to the liquid nitrogen container which clearly outlines the contents of the container, including the species of ABM, the date on which it was collected, and who it was collected by. There should also be a description of which straws are in which goblet/canister.
• If, at any time, you intend to transport the liquid nitrogen tank in your own vehicle, ensure that you secure the tank properly in your vehicle and allow enough ventilation.

Handling straws

• Any movement of genetic material from one tank to another should be done as quickly as possible and the straws should be above the frost line of either tank for as short a period as possible.
• Straws are very sensitive and should only be handled by their end tips. It’s best to avoid direct physical contact with the straws as handling them can increase the risk of abnormal spot warming which can damage the ABM.
• Follow the right protocols for thawing ABM and ensure that, once straws are removed from liquid nitrogen, thawing occurs at a constant rate. Fluctuating temperatures during the thawing process can damage the ABM.
• Wear protective eye equipment when opening the tank to protect against any splashing of the liquid nitrogen or explosion of straws/ampoules.
• Wear cryogenic liquid handling gloves when opening the liquid nitrogen tank and when transferring straws to protect your hands.

Records are crucial

Claims made against veterinarians in relation to ABM can be difficult to defend due to poor record keeping. When agreeing to collect, transfer, store or use ABM in an artificial insemination program, it’s crucial to not only document your agreement with the owner for undertaking this service, but to also record the storage and use of ABM in your possession.

Risks in poor record keeping: case example

A veterinarian had been storing frozen dog semen on behalf of Client A who brought their bitch into the clinic to be inseminated. However, following insemination, the semen was not entered into the record as having been used. Subsequently, Client B brought frozen semen straws from their bitch into the clinic for storage. The clinic put these frozen semen straws into the empty slot where the Client A’s straws had been.

Later, the clinic went to retrieve more straws belonging to Client A. The labelling on the straws was difficult to read, especially in the liquid nitrogen tank. However, based upon the location of the straws, and according to the practice records (which were incorrect), it was assumed they had the correct semen for Client A and so it was thawed and used. Regrettably, it was subsequently discovered that these were not the straws belonging to client A, instead they belonged to client B.

This case highlights the need to label straws clearly and legibly and to record the use and storage of straws at each stage of the insemination process.

Tips for record keeping

Good record keeping is a crucial part of all ABM processes and can be vital in assisting in the defence of a claim. Records in relation to ABM storage and transit should include:

• The client’s name and address
• The amount of ABM and its details (i.e. sire name/number and batch number)
• The date of receipt of the ABM; and
• The location in the liquid nitrogen tank that holds the client’s ABM

Tips for the agreement between the veterinarian and ABM owner

Finally, when entering into an agreement with the ABM owner to engage in the storage or transit of ABM, it’s important to develop standard terms and conditions so that each party knows exactly what they have (and have not) agreed. This could include:

• Client’s name
• Breed and age of donor
• Donor identification (e.g. registered number, tattoo, tag, hide or horn brands)
• Dates of collection
• Numbers and doses collected and stored by you
• All straws to be identified by animal’s reference identification, date of collection and centre of collection
• Dispatch details – numbers, date, destination, all straws to be identified by animal’s reference identification, date of collection and centre of collection

Veterinarians play a very important role in artificial breeding. Following the above advice will assist you in managing the risks associated with the collection, transfer, storage, transit and use of ABM. It’s also crucial that you educate other staff in your practice on the correct process for dealing with ABM and, if you are going to effectively lead risk management in your practice, set the right example by following the right process.

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Equine pre-purchase examinations (PPE) are commonly conducted by veterinarians because they are essential for people looking to purchase a horse. However, they feature heavily in the veterinary claims managed by Guild Insurance. 

Claim examples

1. An owner alleged his newly purchased horse was not fit for the purpose of dressage even though the PPE results indicated otherwise. The veterinarian who conducted the examination claimed it wasn’t actually a PPE, but simply a general health examination.

2. Following the purchase of a horse, the owner alleged health issues became evident which were not detected during the PPE or documented in the report. The owner claimed the veterinarian who conducted the examination stated the horse ‘passed with flying colours’.

3. A horse was purchased based on information in the PPE report, which was initially requested by someone other than the purchaser. The new owner alleged various health conditions were not detected during the PPE. The veterinarian claimed this was because not all stages of the examination were completed as was requested. The new owner didn’t make the request, therefore was unaware of the stages that were performed.

Here are some tips for avoiding complaints following a PPE:

• Guild Insurance recognises EVA as the pre-eminent authority in Australia on equine veterinary practice and best practice in equine PPE. Guild Insurance therefore recommends veterinarians conducting equine PPEs join the EVA and utilise the multiple educational resources they have on offer, including:
  • A Guide to Examination of Horses (commonly referred to as the ‘Blue Book’)
  • PPE Reporting and Examination Forms
  • PPE training workshops
• Guild Insurance understands that all qualified and registered veterinarians are permitted to conduct PPEs. However, that doesn’t mean all should. Anyone carrying out these examinations needs to have the necessary skills and knowledge in equine practice. While additional specific training isn’t required, it is available and should be considered.
• Be aware of perceived or actual conflicts of interest. An example of this is when a veterinarian has previously treated a horse that is to be examined and therefore has prior detailed knowledge of the horse’s condition. Sometimes these situations can’t be avoided. In these cases the examination may still go ahead, provided the conflict has been declared to the person who has requested it and they provide consent prior to proceeding.
• Manage the client’s expectations. Discuss the examination process before it’s undertaken, so the client understands what a PPE is, what will happen during the examination and what information they’ll be given in the report. They need to understand that the report will assist them to make a decision about their prospective purchase and that it isn’t the role of the veterinarian to advise them on whether or not to proceed with the purchase.
• Ensure clients understand the different stages of an examination. Clients can choose to not undertake all stages; however they need to be aware of the possible implications if stages are omitted. A veterinarian should use their clinical knowledge to assist the client to consent to a PPE which best suits their needs. If parts of the examination cannot be completed, this should be documented and communicated to the client.
• Anyone can request a PPE. However, the EVA recommends that a PPE is only performed at the request of a prospective purchaser or agent. Prospective purchasers may sometimes not rely on an examination report requested by the vendor. When an examination is requested by the prospective purchaser, they are more likely to understand the process as well as the examination stages to which they’ve agreed.
• When conducting the examination, ensure your surroundings are suitable to give you the most accurate results. You should have adequate surfaces, space and lighting to allow you to carry out all tests required. If these factors compromise the examination, this may in turn compromise the results. Also, dirt can affect how x-rays are interpreted, so ensure horses are clean.
• A detailed and accurate report is essential for defending a complaint of wrongdoing. The EVA’s report form provides a guide to what should be documented. Document the examinations that were and weren’t performed, with an explanation of why something was omitted. Do not provide verbal findings separate to the report as this information can be misinterpreted or forgotten.
• Be mindful of the words used in the report as there is the potential for misinterpretation. The words ‘pass’ or ‘fail’ should not be used. The EVA recommends against the use of the word ‘soundness’ and advises caution if using ‘suitable for…’.Always remember that even if your clients have a thorough understanding of horses, they won’t have a veterinarian’s level of knowledge, which may increase the likelihood of misunderstandings.

• Adhere to the confidentiality requirements regarding the report. The contents of the report belong to the person who has commissioned the examination, which in most cases is the potential purchaser. If the vendor or any other person wishes to access the information in the report, the purchaser needs to give permission.

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Veterinarians would be well aware of their requirements to obtain informed consent from their clients before any procedure takes place.  However, Guild Insurance’s vast experience in managing claims made against veterinarians has highlighted that many don’t meet all their informed consent requirements.

What is informed consent?

Informed consent is when a client makes a decision about treatment once they have been informed about treatment options as well as the benefits and risks involved.  This definition highlights the difference between consent and informed consent.  If a client hasn’t been made aware of the benefits and risks, their consent isn’t informed.

Informed consent isn’t required just for treatment.  In many cases, informed consent will also be required before undertaking any assessment or investigations.

Informed consent and insurance claims

Informed consent can feature in insurance claims against veterinarians in a couple of ways.

It’s not uncommon when a client is unhappy following treatment for them to allege they weren’t made aware of the risks when they consented to treatment.  Quite often they will allege the treatment was negligent and has resulted in harm or suffering.  They then add that had they been informed of the possible risks, they wouldn’t have consented.

In other cases, clients may not make any allegation about consent, their complaint might solely focus on the clinical outcome.  Yet when their claim is being managed it’s found that they didn’t give their informed consent prior to treatment being provided. 

Authority to consent

Veterinarians have a responsibility to take reasonable steps to be sure the person giving their informed consent has the authority to do so.  This will require them to establish the relationship between the animal and the person presenting, such as them being the owner or authorised agent of the owner of the animal.

The informed consent conversation

Informed consent requires a conversation between the treating veterinarian and the client.  This conversation needs to occur prior to assessment and treatment.  In emergency cases where the treatment is lifesaving, this conversation may need to be altered.

The conversation must:

• detail the recommended assessment and treatment as well as alternate treatment options
• include the expected benefits of that treatment
• provide information about the risks of the treatment
• allow time for the client to ask questions
• be held in language which can be understood by the client which means veterinarians should avoid technical clinical language.
• be tailored to that individual animal and their unique clinical needs

Recording informed consent

It’s imperative that veterinarians make a note in the clinical record regarding the client providing their informed consent.  This needs to be more than ‘IC given’.  The record needs to show what treatment options and risks were discussed as well as any questions asked by the client.  The record should also show what the client consented to as well as what they didn’t consent to where relevant.  In cases where a client’s chosen treatment path isn’t what the veterinarian has advised is most ideal, this needs to be reflected in the record.

The informed consent form

One area which leads to some confusion about informed consent is how to use an informed consent form.  Having a client sign a form is seen as a quick and simplified way of the client providing their informed consent and keeping a record of that.  However, they are unfortunately too often used inappropriately. 

Signed forms aren’t a requirement.  While recording consent is required, this doesn’t need to be done using a form.  Notes in the clinical record of a conversation are sufficient.  However, signed forms do provide additional evidence of what was discussed and agreed to.

Forms can’t be used to replace the informed consent conversation.  A client cannot read a form and gain the same level of understanding as they would from a conversation with the veterinarian.  Nor can they ask questions of the form. 

A form should only be signed after the conversation with the veterinarian has been had and the client understands what it is they’re consenting to.  Clients are occasionally asked to sign consent forms at reception before their animal has been seen by the veterinarian.  As there has been no assessment or discussion about treatment at this stage, this can’t be considered informed consent as the client hasn’t been informed.

Informed consent is not a one-off event

Veterinarians regularly question how often their clients need to give informed consent.  There is no set time frame for when informed consent conversations or signed forms need to be repeated.  The requirement is that when an animal is receiving any assessment or treatment, this needs to have been discussed with the client and consented to.  Therefore, informed consent should be an ongoing process.  When there is any change in the treatment being provided, or if the animal has returned following a period of absence, informed consent needs to be revisited.  A general ‘consent to all treatment’ for the life of the treating relationship is not appropriate.

Informed financial consent

As well as consenting to assessment and treatment, clients should also give their informed financial consent.  This means they need to be provided with information about the expected cost of treatment before this treatment commences.

When treatment doesn’t progress as planned

Treatment won’t always progress as planned; it’s not uncommon to be part way through a procedure and realise that what was planned and therefore consented to now needs to change.  Where a veterinarian knows this is a possibility, they should discuss the various treatment paths with the client and have the client agree to more than one treatment option should the situation change mid procedure. 

In summary…

There is no one right way to undertake an informed consent conversation and process.  Veterinarians must adapt what’s discussed for the animal they’re treating and its unique circumstances, as well as the circumstances of the client.  However, what must occur in all cases is that the client is informed of and understands the proposed treatment, alternate treatment options and the risks involved.  Only with this information can they give their informed consent.  The veterinarian must also be sure to make a record of this informed consent discussion in the clinical record.

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Medical record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for veterinarians to spend time thinking and talking about.  However, it is incredibly important, and Guild’s claims management experience suggests veterinarians would benefit from learning more about good record keeping.

Records and insurance claims

Records can impact insurance claims in two ways:

1. Poor records can contribute to a poor or unexpected outcome following treatment, leading to the client complaining and possibly seeking some form of compensation.
2. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence.

All veterinarians would want to avoid poor clinical outcomes as the wellbeing of the animals they treat is paramount.  However, they would also want to avoid complaints, which can lead to insurance claims, as these can be very challenging and confronting experiences.  Therefore, understanding how to improve the standard of records really should be a focus.

Why keep detailed records?

1. Continuity of care

It’s not uncommon to hear veterinarians believe they can remember the details of their consultations.  However, at Guild we see examples where veterinarians haven’t remembered key aspects of prior consultations and treatment, and this has led to a poor outcome for the animal.  It’s therefore imperative to have this information recorded to ensure certainty as to how and why you’ve treated an animal in the past.

It’s also important to be sure you refer to the information within the record.  Animals can suffer harm when key information is overlooked or forgotten about and they’re therefore not treated accordingly.

2. Regulatory requirement

All State and Territory Veterinary Boards within Australia have some sort of guideline or policy about a veterinarian’s obligations and requirements regarding record keeping.   

It is the responsibility of every veterinarian to make themselves aware of and comply with the various codes, guidelines and policies relevant to them.  Not knowing is not an excuse for not complying.

3. Defence of a complaint

If there is an allegation of wrong doing made against a veterinarian, their records are going to be incredibly important.  Those records provide evidence of what took place and why.  Without this, the veterinarian will be relying on their memory as a defence.  Information recorded at the time of the consultation is going to hold greater weight as a reliable defence than a veterinarian’s memory months after an event.  As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’. 

What to record?

A question many veterinarians ask when it comes to record keeping is ‘how much detail do I need to record?’.  Veterinarians should refer to their relevant Veterinary Board’s information to better understand the detail required in a record. 

Exactly what to include can vary according to the specifics of the animal’s condition and treatment.  However, generally records should include, but aren’t limited to:

• client identification
• treatment date
• animal(s) identification
• history
• examination details
• diagnosis
• treatment options offered and given, prescribed, or supplied
• informed consent
• response to treatment
• other records / reports such as imaging reports, laboratory reports or specialist / referral reports
• information provided to the client including post treatment instructions

In some cases, it’s worth noting what didn’t occur as well as what did.  For example, if a client has refused to consent to what would be considered the most ideal or obvious treatment option, the record should reflect that it was discussed and declined.  If it is simply left out of the record, it would appear that it wasn’t discussed as an option.

When veterinarians are unsure if they have included enough detail, they should ask themselves whether or not another veterinarian could read the record and understand the full picture of what took place and why, without the treating veterinarian filling in any gaps.  If the full story isn’t there, there isn’t enough detail.

Professional and objective

Records need to always be professional and objective.  Criticisms of the client can be included, however this must be professional and only when relevant to the treatment being provided.  This may occur in situations where the client isn’t complying with instructions and this is detrimental to the health of their animal.  However, it’s important to remember that records can be accessed and read by a number of people, including the client and your regulator, so always be mindful of the language used.  The language used should match the professional language a veterinarian would use when speaking to the client during a consultation.

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Case

A client demanded compensation for additional treatment costs, alleging surgery had been performed negligently.  The client’s dog had undergone a laparotomy for removal of a foreign body from its gut, but was slow to recover.   The dog remained listless and had a poor appetite for a number of weeks.  Although the client brought the dog back for an initial follow up visit, they failed to attend subsequent appointments.  The dog was then treated for a systemic infection by a second veterinarian, who located the swab.    The dog ultimately recovered, but the client was left with considerable costs.

Tips for practice improvement

• Don’t believe this scenario couldn’t happen in your practice. Guild Insurance continues to receive a number of similar claims every year. While the financial impact can be costly, the impact on your reputation shouldn’t be underestimated.Increasingly, people are choosing not to return to a practice once an error has occurred, instead venting their dissatisfaction via social media and the like.
• Explore options for reducing the likelihood of retained swabs during surgery. Engage your staff in identifying ways in which this risk could be avoided. Is there a way you could count surgical materials ‘going in’ during a procedure and reconcile the number ‘coming out’?   While it can be tempting to declare that surgical swab counts are simply too onerous for a busy practice, some veterinarians do manage to achieve it.  Arguably, success lies in educating practice staff in the importance of completing what may be perceived as a boring, time consuming task.  Work with your staff to explore ways in which the process could be streamlined to work in your practice.
• Set rules in place, such as surgical swabs (7.5 x 7.5 or 10 x 10 cm) should never be placed into an abdomen unless held in forceps or securely grasped. Don’t ever leave them in place.
• Use abdominal sponges if it is necessary to mop up larger amounts of blood, or pack off part of an abdomen, such as opening up the intestine or stomach. They should be moistened with saline, and are reusable, so economic to use.
• Abdominal sponges should still be counted in and counted out if used deep in an abdomen. Even though they are so much larger than surgical swabs, once soaked in blood they can be surprisingly difficult to see.
• Where possible use swabs with radiopaque markings to aid in the prompt identification and removal of any retained material.
• Ensure your practice has processes in place for following up clients who fail to attend post-operative appointments.

Finally, the following article published in the Veterinary Record also emphasizes the potential harm caused by retained surgical swabs and importance of making swab counts standard procedure in surgical practice.  WHITEHEAD, M (2012) Importance of surgical swab counts. Veterinary Record 2012; 170:24 629-630.

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Case

A cat suffered significant burns to its hip when left on a heat mat to recover after surgery.  The cat’s fur was still wet, which exacerbated the risk of a burn occurring.   The wound subsequently became infected and required many weeks of treatment.  The client successfully claimed compensation for the additional treatment costs. 

This incident was entirely preventable and serves as a timely reminder of the importance of closely monitoring animals post operatively.  In this instance, the cat was unable to change position in response to the heat.  Not surprisingly, the incident caused much embarrassment to everyone in the practice.

Tips for practice improvement

• Think carefully about when to use heat mats.    Remember ‘heat mats’ can include wheat packs, hot water bottles and electric mats.  Explore other ways to keep animals warm and prevent hypothermia.  Wet animals in particular, are at risk of burns as wet surfaces transfer heat more readily. 

Hypothermia is thought to be the major cause of peri-anaesthetic mortality, so its prevention is critically important.  Putting a heat source such as an electric pad or blanket underneath an animal in an otherwise cool environment is neither a safe nor an effective means of preventing or treating hypothermia.  It is much safer and more effective to warm the environment.

The safest form of external heat source is either a hot air blower with associated blanket, which can go under or over the animal (a number of brands are readily available; one example is Bair Hugger); or a circulating warm water blanket.  Both can be used during surgery or dentistry, as well as during recovery.

• As a sedated animal is unable to change position in response to the heat, veterinary staff must monitor the animal regularly.  That is, the animal must be reviewed every few minutes, as the situation can change quickly.  This involves inspecting and feeling the surface of the animal for any signs of increased heat.
• Remember to document in the post-operative notes each time you have checked and re-positioned the animal.
• All heat mats and hot air blowers should only be used according to the manufacturer’s instructions.  They should also be inspected regularly for any damage or worn surfaces.  Develop a schedule for regularly checking all equipment and recording each time this is done.
• Think carefully about the quality of any heating equipment you purchase.  While cheaper equipment or products may be tempting, they could prove more costly in the long run.  Only purchase from reputable suppliers and ensure each product is accompanied by clear operating instructions from the manufacturer.
• Educate all staff about the safe use of heating equipment.

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Have you ever considered a situation where you’re providing therapy to a child and the parent or guardian intends to leave the child alone with you?  This may be because they wish to collect another child from school or sport, or they may wish to pick up something from the supermarket.  Regardless of why it occurs, this is unfortunately not a completely unfamiliar situation for speech pathologists to experience. 

At first thought this may not seem like a particularly concerning situation.  However, to understand the potential risks if this were to occur, it’s worth considering the following circumstances.

What if…

• The session finishes before the parent has returned and you’re ready to start your next session?
• You were in the family’s home as opposed to a clinic and the parent wants to leave to go to the shops briefly?  And consider that there may be other children in the house.
• The child becomes upset with their parent not being there?
• The child has a medical emergency?
• The child is a new client who you aren’t overly familiar with?

Do you think this situation is acceptable?

Speech Pathology Australia’s Ethics Board have advised speech pathologists that a situation where a parent leaves during therapy sessions should only occur under exceptional circumstances, it should not become the norm or commonplace.  However, this doesn’t mean speech pathologists have to allow this to occur even when there may be exceptional circumstances; they are permitted to decline to provide therapy under this situation if they don’t feel it’s appropriate or they aren’t comfortable.

It’s recommended that speech pathologists consider the possible scenarios mentioned earlier, as well as other possible similar scenarios, and decide on a standard for what they would and wouldn’t feel is professionally appropriate.  And this may be different for different practitioners based on the nature of their work and clients, as well as personal comfort levels.

A speech pathologist may feel ok when a child is left in their care without a parent when at the clinic, but not when at the client’s house.  A speech pathologist may also only accept parents leaving once the child is over a certain age.  Or they may just want to consider each situation individually based on each child.  What’s most important is that the scenarios have been considered before they arise.

Setting expectations

It’s important to set expectations with families at the beginning of the therapeutic relationship.  This should be in relation to parents being present during therapy but also other elements of the therapeutic relationship.  Imagine that a therapy a session with a child is about to start and the parent quickly tells the speech pathologist, as they’re walking out the door, that they’re heading out briefly.  If this scenario has never been discussed, this could be quite a challenging moment and the speech pathologist may not know how to respond until the parent has left.

Policies assist greatly with setting expectations.  The process of developing policies provides the speech pathologist with reason to reflect on and consider what they think is professionally acceptable and required and how they want their clinic to operate.  Policies developed for a clinic provide a standard which everyone is to work within, creating consistency between colleagues.  These policies should be discussed with clients and their families at the start of the therapeutic relationship during the process of setting expectations.  The policies will make it easier for the speech pathologist to have an open and honest conversation, making it clear how they’ll work together to achieve the best therapeutic outcomes.

Setting expectations and agreeing on actions and behaviours means the parents know what is expected of them and it also empowers the speech pathologist and gives them the authority needed to handle challenging situations.

Implications for the family

When explaining to families what you expect from them in terms of being present during therapy sessions, be sure they understand how this will affect them and their child, not just you.

It’s beneficial for parents to be aware of their child’s diagnosis as well as progress over the course of their therapy.  Parents may also be expected to do some work with their child outside of therapy sessions.  Therefore, there is possibly going to be implications for the child and their progress if a parent isn’t present.

Discussion before they leave

If a parent does leave the therapy session, the speech pathologist should have a process in place for discussing necessary information before they leave.  This information should include:

• Where the parent is going (this may useful if for some unforeseen reason the parent doesn’t return)
• When they expect to return; the parent should agree to return by a nominated and agreed to time
• Contact names and phone numbers during this time (there may be people other than just that parent to consider, such as a neighbour)
• What will occur if they parent hasn’t returned by the agreed time, such as the child being left unsupervised in the reception area.

Record keeping

Speech pathologists would be aware of their professional obligation to maintain detailed and up to date clinical records.  However, records should contain more than clinical outcomes, they should tell the story of the therapy provided and progress made.  It is advisable that speech pathologists make a note in the record which, if any, parent was present during the session and what was discussed with the parent regarding the therapy.  This will assist with the ongoing continuity of care as the speech pathologist will have on record what the parents have been told and what information still needs to be provided to them.

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Running a dental practice isn’t just about the clinical care of patients.  Without a doubt, the treatment of your patients is of utmost importance.  However there are other areas you need to focus on to be sure you’re running a successful business and doing right by your staff and patients.  One of these areas is the maintenance of your equipment as you can’t run your business without it!

Guild Insurance is noticing a claims trend in the area of faulty or damaged dental chairs, and this is quite often due to the chairs not being maintained as they should.  These claims are often very costly due to the sometimes extensive damage to more than just the chair.

Example of what can go wrong:

The pipes inside a dental chair burst and flooded the practice.  This happened overnight; by the time it was found in the morning there was significant damage to the floors and furniture.  Insurance covered the cost for the additional damage to the practice.  However, insurance can’t fully compensate for the period of time the practice couldn’t operate due to the damage.  In that time some patients went elsewhere for treatment and others expressed frustration with what they saw as a poorly maintained practice.

Key points regarding dental chair maintenance:

• You can’t operate your business without your dental chairs. If they break down and aren’t functioning normally, this is going to impact your ability to treat your patients.
• If the chair isn’t operating as it should, this has the potential to be a safety issue for your patients who sit in it.
• Follow manufacturers’ guidelines regarding chair maintenance.
• Consider what may happen if your patients need to go to another practice to receive treatment due to your chair or business being out of operation; will they come back to you later?
• Don’t assume that insurance will cover any breakdowns and therefore maintenance isn’t needed; this won’t always be the case. Accidental damage to equipment or faulty equipment may be covered in an insurance claim, however wear and tear due to poor maintenance won’t be.

Poor maintenance of your chairs or other pieces of equipment can affect more than just that piece of equipment, it can affect your professional reputation and the running of your practice.  Don’t underestimate the importance of your chairs and other equipment; be sure you maintain them as needed.

It’s widely recognised that all fitness activities carry an element of risk that needs to be managed.  One area of risk within a fitness centre is not just the activity the member is taking part in, but how they’re taking part.  Many people go to a fitness centre to workout independently, without guidance from a personal trainer or instructor.  Whilst exercising independently has many benefits, centres should be aware of the potentially heightened risk this creates.

Tips for making the environment safer for members exercising independently

New member induction

When new members join your fitness centre they will usually be quite keen to jump straight into exercising.  However, for everyone’s safety it’s best that there’s an induction process.  Take the time to show them around the centre and discuss the services offered.  Be sure they’re clear about centre safety information such as instructions for using equipment and where to put equipment after use.

Developing an exercise program for new members with the assistance of a professional should be offered to ensure they’re exercising safely.  During this period a pre-exercise screening assessment (discussed below) should be undertaken.

Pre-exercise screening

An Australian adult pre-exercise screening tool has been developed by Fitness Australia, Exercise & Sports Science Australia and Sports Medicine Australia.  The purpose of this tool is to help identify people who may suffer from medical conditions which puts them at an increased risk when exercising.  The knowledge gained from this tool assists centres and trainers to ensure exercises prescribed are appropriate for that individual.  This information may also guide a fitness centre to recommend a new member seeks medical advice prior to beginning exercise. 

Safely manage equipment

When purchasing equipment, it’s important to think about where that equipment will be stored.  Members need adequate space around equipment to allow them to adjust settings and weights to suit them.  If people are too close to other people or equipment whilst doing this, they’re at risk of causing an injury to themselves or another person.

It’s vital that all equipment is well maintained.  This requires scheduled regular inspections of equipment to be sure it’s in correct working order.  Some members will notify staff if something isn’t working as it should.  However you can’t rely on this as some people won’t bother to inform you.  It is therefore up to staff to be vigilant when checking equipment and to have a register for recording the inspections carried out.  Equipment should also be regularly serviced according to manufacturer instructions to avoid breakdowns.  Again, these services should be monitored and recorded.

Supervision

Many gym members are quite happy working independently and do not want to engage a personal trainer.  However this can lead to issues for the person exercising.  They may be using an incorrect technique which could lead to an injury or simply a lack of benefit.  They also may not fully understand how to set up and use some pieces of equipment.

Having suitably qualified staff available within the fitness centre to assist members where necessary provides a great benefit to members working independently.  It would also mean the centre will know their members are exercising safely.  Having staff at reception that can assist when asked doesn’t fully meet this need.  It’s advisable to have assigned staff members walking around the fitness centre so they are visible and approachable for those exercising.

Communicate safety messages

Staff within a fitness centre need to be mindful of the fact that what’s obvious or common sense to them will not be so obvious to their members.  The members will quite often not have the same level of skill or training in health and fitness that staff will have and will therefore need information about exercising safely regularly communicated to them.

Equipment should display information advising how to use it correctly and safely.  Some equipment comes with this information from the manufacturer.  However you may wish to consider providing additional safety information if required.

If there is a period of time where additional hazards are present, such as during renovations or cleaning, information about these hazards needs to be communicated to members.  Members should be made aware if there are areas of the centre they aren’t to use or equipment that is out of use.

Introduction of new services

The health and fitness industry is incredibly dynamic and constantly evolving.  Many of the activities being offered in fitness centres today where unheard of 5 to 10 years ago.   Advances create new opportunities and challenges for members yet should always be implemented with care.

If you are installing a new piece of equipment or offering a new class, you need to stop and think about how it will be done safely.  How will existing members know how to use the equipment, what do you need to explain to them and how will you do this?  Do you have room for the new piece of equipment?  Are there risks to your members if it is unintentionally misused?  Do you have the right staff with the necessary skills to offer the new service? 

Answering these safety questions will assist a fitness centre to implement new initiatives in a way which is safe and appropriate.

Special deals

Many fitness centres offer special deals to attract new or lapsed members.  Deals might include free trial memberships for a few days or a bring-a-friend day.  All businesses understandably want to do what they can to increase their customer base however this needs to be done safely.

If a person is coming in to a fitness centre using a free trial deal, what sort of induction do they receive regarding the centre, its equipment and services offered?  If they only have a few days in which to exercise for free, how much time is available to undertake a pre-exercise screening assessment?  Fitness centres need to be sure that when offering special deals and benefits they are not creating risks for the people involved.

Members shouldn’t be discouraged from exercising independently as this is what suits many fitness centre members.  However, fitness centres must remain vigilant about what they can do to make this experience safer for their members.

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