what to do about procedural errors

[heathermed]

Was hoping for some advice or any words of wisdom.

Quick context:
I recently joined a midsized academic practice about 8 months ago. During the last few months, I've inherited many patients that used to be seen by my colleagues. After reviewing the charts of patients from 1 colleague in particular, I began to see many consistent errors in their previous imaging. The most common thing that I've picked up is incorrect spinal levels being injected, usually off by 1 level. Also other less common things are clear posterior contrast spreads and RFA needles being very posterior as well on lateral imaging. I am by far the most junior in the group. The person in question has almost 10 years on me and so does the director of pain.

Any advice on how to handle this situation?
thank you

---

Members don't see this ad.

 

[lonelobo]

Easy.....Perform procedures correctly on the patients.

 

[heathermed]

Easy.....Perform procedures correctly on the patients.

sounds good to me. just wanted to get an idea given this is new to me. thank you.

 

[SommeRiver]

Could also be images being saved incorrectly.

 

[Orin]

The things you've mentioned so far are primarily not errors causing significant harm. If the individual is still performing procedures, you may want to just ask about technical differences in approach or labelling levels for medial branches, as perhaps their nomenclature or approach is just...different. They may just not save their final shots after a few false losses with contrast.

They may however just be not practicing to the current standard. If they're not causing harm, you may be justified in leaving it alone. It may cost you your job if you raise concerns too vociferously or you'll get labelled as a diva.

Often though in academic settings, there are less stressful avenues to pursue through QI or M&M conferences. If those aren't in place, you could propose things like blinded reviews of case images from months prior as something that would look good in case someone like the ACGME of JCAHO came asking what y'all do for that.

 

[chibadriver]

Was hoping for some advice or any words of wisdom.

Quick context:
I recently joined a midsized academic practice about 8 months ago. During the last few months, I've inherited many patients that used to be seen by my colleagues. After reviewing the charts of patients from 1 colleague in particular, I began to see many consistent errors in their previous imaging. The most common thing that I've picked up is incorrect spinal levels being injected, usually off by 1 level. Also other less common things are clear posterior contrast spreads and RFA needles being very posterior as well on lateral imaging. I am by far the most junior in the group. The person in question has almost 10 years on me and so does the director of pain.

Any advice on how to handle this situation?
thank you

These are delicate circumstances in your position. I’ve seen similar issues with numbering/nomenclature (confusion about C2-3 innervation or L5 MB vs. L5 DR) and procedures (fluoro-guided trigger points?!?wtf). I think your results will speak for themselves, but I’m not sure your partners will change because if it. A couple passive aggressive/Karen approaches: hold an inservice on ‘updates’ in current procedure technique or make remarks like “interesting, I’ve never seen it done that way.” In all seriousness, I think I would like to be told, even challenged, if a colleague feels I’m not up to par and there’s respectful way to do it.

 

[callmeanesthesia]

May want to move this to the private forum. Won’t help if they’re also on here but would reduce visibility.

I have a similar though not quite equivalent situation - I’m in an Ortho practice and have a family med/sports med partner who somewhere along the way learned to do epidurals (I think through an SIS course). Except his transforaminals, when I’ve reviewed them, are nowhere near the neural foramen. He has excellent pics saved - AP, oblique, and lateral, all showing contrast spread that is clearly not epidural, and a needle tip that is a cm or more posterior from the foramen. Thankfully he doesn’t do RFs. I just recently bought into the group. He’s been a partner for about 5 years. Now that I’m a partner I’d have a little more security in bringing it up with him but not sure it’s worth it. I don’t think he’d take well to being told he’s doing a procedure wrong.

 

[Ducttape]

dont forget to review your own work... its unlikely, but maybe you were taught wrong.

at an academic center, do not be afraid to ask simple questions, usually prefacing by the "when i was a fellow, Dr.. (insert big name here) would call this level L5S1, and would do L4 and L5 median branch blocks"...


callme - don't take care of his patients... just see your own.

 

[Bostonspine]

May want to move this to the private forum. Won’t help if they’re also on here but would reduce visibility.

I have a similar though not quite equivalent situation - I’m in an Ortho practice and have a family med/sports med partner who somewhere along the way learned to do epidurals (I think through an SIS course). Except his transforaminals, when I’ve reviewed them, are nowhere near the neural foramen. He has excellent pics saved - AP, oblique, and lateral, all showing contrast spread that is clearly not epidural, and a needle tip that is a cm or more posterior from the foramen. Thankfully he doesn’t do RFs. I just recently bought into the group. He’s been a partner for about 5 years. Now that I’m a partner I’d have a little more security in bringing it up with him but not sure it’s worth it. I don’t think he’d take well to being told he’s doing a procedure wrong.

Where I work and the sport guy I did residency with call them nerve blocks and they don’t every try to get transforminal. If there is an outline of the nerve outside the foremen they are done

 

[lobelsteve]

If I got a hold of these charts I would send pics to insurance and get my 10% whistle blower fee.

 

[drusso]

Was hoping for some advice or any words of wisdom.

Quick context:
I recently joined a midsized academic practice about 8 months ago. During the last few months, I've inherited many patients that used to be seen by my colleagues. After reviewing the charts of patients from 1 colleague in particular, I began to see many consistent errors in their previous imaging. The most common thing that I've picked up is incorrect spinal levels being injected, usually off by 1 level. Also other less common things are clear posterior contrast spreads and RFA needles being very posterior as well on lateral imaging. I am by far the most junior in the group. The person in question has almost 10 years on me and so does the director of pain.

Any advice on how to handle this situation?
thank you

You need to confront them in a positive and nonthreatening manner. "Start with the heart." I'd suggest offering to meet for lunch or a beer, sit-down, build rapport & catch up a little, then just say, "Hey, I'm only bringing this up out of the goodness of my heart, but really, WTF?"

 

[callmeanesthesia]

dont forget to review your own work... its unlikely, but maybe you were taught wrong.

at an academic center, do not be afraid to ask simple questions, usually prefacing by the "when i was a fellow, Dr.. (insert big name here) would call this level L5S1, and would do L4 and L5 median branch blocks"...


callme - don't take care of his patients... just see your own.

He referred them to me after his injections didn’t work.

 

[deleted993114]

Was hoping for some advice or any words of wisdom.

Quick context:
I recently joined a midsized academic practice about 8 months ago. During the last few months, I've inherited many patients that used to be seen by my colleagues. After reviewing the charts of patients from 1 colleague in particular, I began to see many consistent errors in their previous imaging. The most common thing that I've picked up is incorrect spinal levels being injected, usually off by 1 level. Also other less common things are clear posterior contrast spreads and RFA needles being very posterior as well on lateral imaging. I am by far the most junior in the group. The person in question has almost 10 years on me and so does the director of pain.

Any advice on how to handle this situation?
thank you

You would be surprised how often that happens.

You need to keep your mouth shut and do your job. If you point these things out, it will cause a huge ruckus and you will be named a trouble maker. A subtle means of helping would be to do a talk on proper needle position for rf. It is surprising how few people will take a lateral view for this procedure. Also, do some talks on anatomy and the importance of counting from above. Maybe some of the staff will be there and privately incorporate your information. By no means should you confront them; also, DO NOT breathe a word of this to the fellows/students.

Regarding the "wrong level", I often will enter one segment below stenotic patients and those with large disc herniations and then place a catheter to the appropriate level. In doing so, it is less painful for the patient. Perhaps that is the cause of "one level off"? Also, it is surprising how many people count from the sacrum, rather than T12, when identifying segments.

MANY pain docs in academic programs have poor training. However, arrogance has prevented them from getting proper instruction. Steve Loebel here is a SIS instructor- I'm sure he could tell you horror stories about "experienced" pain docs who don't know what the hell they are doing in cadaver courses.

 

[deleted993114]

You need to confront them in a positive and nonthreatening manner. "Start with the heart." I'd suggest offering to meet for lunch or a beer, sit-down, build rapport & catch up a little, then just say, "Hey, I'm only bringing this up out of the goodness of my heart, but really, WTF?"

DO NOT CONFRONT THEM!

That will result in your dismissal and you will not get a reference for your new job. BE SUBTLE if you do anything, like the talks I suggested. If you go into private practice, NEVER RUN DOWN OTHER PAIN DOCS, PARTICULARLY YOUR PARTNERS. It will come back to haunt you.

I have been around the block politically and can tell you how your situation will end if you choose to confront or even mention this behind their backs. They will do fine- YOU will be fired.

Ever wonder why so many guys coming out of fellowships suck with procedures? Many times it is the blind leading the blind.

 

[drusso]

DO NOT CONFRONT THEM!

That will result in your dismissal and you will not get a reference for your new job. BE SUBTLE if you do anything, like the talks I suggested. If you go into private practice, NEVER RUN DOWN OTHER PAIN DOCS, PARTICULARLY YOUR PARTNERS. It will come back to haunt you.

I have been around the block politically and can tell you how your situation will end if you choose to confront or even mention this behind their backs. They will do fine- YOU will be fired.

Ever wonder why so many guys coming out of fellowships suck with procedures? Many times it is the blind leading the blind.

If you were doing something wrong or putting patients in harm's way, wouldn't you expect ANY decent person to tell you?

 

[Laryngospasm]

This is one of those situations you don’t get taught how to handle. Just be very careful.. lots of opportunities for bad outcomes for you.. not a lot of upside.

 

[deleted993114]

If you were doing something wrong or putting patients in harm's way, wouldn't you expect ANY decent person to tell you?

yes, of course- people can (and do) tell me a lot of things and I never get offended. One of my nurses routinely tells me to "shut my ***** mouth" (which I find very amusing- what exactly is a "***** mouth"?). I think most confident people welcome questioning and take no offense at all. My new partner has showed me a ton about ultrasound, as I really sucked at it. Come to find out a lot of that was identifying adjacent vasculature! Stupid me. I find little use for US, but it is damn good to be well versed in it. Also, my other partner has taught me to do CT guided injections, which I had not done before. Medicine is very humbling- lots to learn. You guys have taught me a lot of cool things as well.

You guys here can tell me I am full of crap and I will not take offense, as sometimes I am full of crap.

However, I can tell you most people would not look at it that way, particularly in an academic setting. Many of those providers are not highly skilled in the first place and have pretty thin skins.

I can tell you with nearly 100% certainty that he/she would be fired. Again, I think he/she needs to keep his/her (how many pronouns do I have to list now?) mouth shut and just do a "resident/fellow talk" on proper technique which many times is attended by staff. Another way would be for he/she to ask "the opinion" of the staff in question during one of his/her procedures and see the right way to do things.


Trust me on this one- confronting those guys will create mayhem and being the low man on the totem pole, he/she will be fired.

 

[deleted993114]

If I got a hold of these charts I would send pics to insurance and get my 10% whistle blower fee.

Steve- I agree with you on 99.9% of the things you say and respect your views. You have a lot of experience and good common sense. However, I differ on this one and would really suggest treading carefully for this person.

I believe you had stated that in the past you were fired for standing up for the right thing at another job- correct? Unfortunately, that is what sometimes happens. You can stand tall and sleep at night for having done the right thing, but I am sure the experience was unpleasant. However, a youngster at a practice needs to be very careful. I have certainly paid the price as well in the past for opening my big mouth (Regrettably I have no filter and really need to watch what I say, as I can be a real prick at times).

Both you and I have had "political" experience in medicine and I really believe that it is best to be low key and try a very subtle approach. I am sure that as an instructor, you probably see things that are incorrect and sometimes shocking and really have to bite your tongue.

 

[SommeRiver]

Wrong level - There are many ways to skin a cat.

I would say 95% of the time I go a level below to reduce procedural pain.

30 min ago I did an S1 TFESI on a woman with L5 radic. Of course I did NOT inject her at L5-S1 bc I'm not a sociopath.

I think I covered her problem with dex 10mg and 2cc of normal saline.

 

[drusso]

yes, of course- people can (and do) tell me a lot of things and I never get offended. One of my nurses routinely tells me to "shut my ***** mouth" (which I find very amusing- what exactly is a "***** mouth"?). I think most confident people welcome questioning and take no offense at all. My new partner has showed me a ton about ultrasound, as I really sucked at it. Come to find out a lot of that was identifying adjacent vasculature! Stupid me. I find little use for US, but it is damn good to be well versed in it. Also, my other partner has taught me to do CT guided injections, which I had not done before. Medicine is very humbling- lots to learn. You guys have taught me a lot of cool things as well.

You guys here can tell me I am full of crap and I will not take offense, as sometimes I am full of crap.

However, I can tell you most people would not look at it that way, particularly in an academic setting. Many of those providers are not highly skilled in the first place and have pretty thin skins.

I can tell you with nearly 100% certainty that he/she would be fired. Again, I think he/she needs to keep his/her (how many pronouns do I have to list now?) mouth shut and just do a "resident/fellow talk" on proper technique which many times is attended by staff. Another way would be for he/she to ask "the opinion" of the staff in question during one of his/her procedures and see the right way to do things.


Trust me on this one- confronting those guys will create mayhem and being the low man on the totem pole, he/she will be fired.

I'm not saying you're wrong. I'm just saying that when it comes to patient care and safety, you got push aside all the BS and butt-hurt and do the right things.

 

[deleted993114]

I'm not saying you're wrong. I'm just saying that when it comes to patient care and safety, you got push aside all the BS and butt-hurt and do the right things.

Yes- of course. But you do so subtly. Approaching someone and telling them they have the wrong need position will assuredly get her fired. Again, those guys in academics have pretty thin skins and would not take that news very well.

That's just the way it is.

 

[deleted993114]

Wrong level - There are many ways to skin a cat.

I would say 95% of the time I go a level below to reduce procedural pain.

30 min ago I did an S1 TFESI on a woman with L5 radic. Of course I did NOT inject her at L5-S1 bc I'm not a sociopath.

I think I covered her problem with dex 10mg and 2cc of normal saline.

Why did you not do an L5 transforaminal? Sometimes with an S1, the contrast will spread medially and superiorly and cover L5, but not usually.

I can see not entering at a stenotic level with an interlaminar injection, but you should be just fine on those radiographs entering at L5.

PS- how are the birdies doing?

 

[cowboydoc]

Wrong level - There are many ways to skin a cat.

I would say 95% of the time I go a level below to reduce procedural pain.

30 min ago I did an S1 TFESI on a woman with L5 radic. Of course I did NOT inject her at L5-S1 bc I'm not a sociopath.

I think I covered her problem with dex 10mg and 2cc of normal saline.

Didn't even require a 4 level TFESI!

In an academic practice, and even some non-academic situations, informal BSing about techniques can go a long way. Using social skills to not "call out" questionable practices, but talk about how you do things can be useful (like this forum until the discussion devolves into a pi$$ing match or politics). You can encourage improving sloppy practices by setting a higher standard without confronting the old school partner at all. If they are receptive to improving their skills/practice, you can talk here and there and show them some pics of your "interesting" cases.

If they are set in their ways, stay in your lane unless they are being fraudulent or placing patients at risk.

I'm taking over a practice of some old "pain" docs that is quite enlightening. When I joined the system, I met with them, asked how they treated facet-mediated pain (since all of their procedures were IL ESIs or SIJs). The response was, "I think epidurals cover them pretty good." Never said another word to them, just did things better (like using EBM from this century).

 

[Ducttape]

Wrong level - There are many ways to skin a cat.

I would say 95% of the time I go a level below to reduce procedural pain.

30 min ago I did an S1 TFESI on a woman with L5 radic. Of course I did NOT inject her at L5-S1 bc I'm not a sociopath.

I think I covered her problem with dex 10mg and 2cc of normal saline.

I don't think that is what OP is talking about.


what you are doing is making a medical treatment decision and the description of the procedure is correct, and not an error in description, technique or judgement or otherwise. sounds like the OP's partner is making those errors (ie "L4 Transforaminal" at the L5 transforaminal opening)

 

[paindoc007]

Why did you not do an L5 transforaminal? Sometimes with an S1, the contrast will spread medially and superiorly and cover L5, but not usually.

I can see not entering at a stenotic level with an interlaminar injection, but you should be just fine on those radiographs entering at L5.

PS- how are the birdies doing?

Agree w Hawkeye. Interlam at the level of stenosis may be “sociopathic”. A tfesi I don’t have that same issue, so I prefer injecting at the level of the problem

 

[SommeRiver]

Why did you not do an L5 transforaminal? Sometimes with an S1, the contrast will spread medially and superiorly and cover L5, but not usually.

I can see not entering at a stenotic level with an interlaminar injection, but you should be just fine on those radiographs entering at L5.

PS- how are the birdies doing?

I usually cover L5 and occasionally L4 with my S1. I drive it into the 1 o'clock position of the foramen (left S1), and if I point my needle at the contralateral shoulder and use 3-4 cc I go up reliably.

I have retaken my home from those birds. My flag is planted.

 

[SommeRiver]

Agree w Hawkeye. Interlam at the level of stenosis may be “sociopathic”. A tfesi I don’t have that same issue, so I prefer injecting at the level of the problem

I think you misplaced interlaminar with TFESI right?

I don't do many ILESI in the lumbar spine. I do occasionally, but usually I am TF in the low back. The ILESI isn't as reliable as the TF for getting injectate into the anterior epidural space.

 

[Agast]

I think the issue Heathermed is addressing is that the image does not match the operative report that is in the chart. If you want to do an L5/S1 approach to an L4/5 problem but dictate it as an L4/5 transforaminal ESI when it is clearly not, that is very concerning. That, combined with other procedural mishaps, indicates either a lack of understanding or a lack of caring. Since it's an academic group, turf the problem to whomever is in charge of your clinical practice. I wouldn't sit on it because that could be considered acting as an accomplice on suppressing information.

 

[heathermed]

I don't think that is what OP is talking about.


what you are doing is making a medical treatment decision and the description of the procedure is correct, and not an error in description, technique or judgement or otherwise. sounds like the OP's partner is making those errors (ie "L4 Transforaminal" at the L5 transforaminal opening)

I think the issue Heathermed is addressing is that the image does not match the operative report that is in the chart. If you want to do an L5/S1 approach to an L4/5 problem but dictate it as an L4/5 transforaminal ESI when it is clearly not, that is very concerning. That, combined with other procedural mishaps, indicates either a lack of understanding or a lack of caring. Since it's an academic group, turf the problem to whomever is in charge of your clinical practice. I wouldn't sit on it because that could be considered acting as an accomplice on suppressing information.

The statements above are correct. For example, C7T1 epidural in the note, but very clearly T1T2 in the images; L45 facet in the note, very clearly at L34.

Thank you everyone for your thoughts

 

[callmeanesthesia]

The statements above are correct. For example, C7T1 epidural in the note, but very clearly T1T2 in the images; L45 facet in the note, very clearly at L34.

Thank you everyone for your thoughts

Sounds like it’s a little more systematic than that but I do move down to T1-2 for a CESI if they have central stenosis at C7-T1 or I try there and am getting venous uptake. I document that in my procedure note, but it’s conceivable one could forget and just enter the regular C7-T1 template.

 

[Orin]

If there's frank harm, injury, etc, you've got an ethical obligation to ask about it. In academics though, that'll raise flags if you aren't cautious about how you do it.

It's not clear there is insurance fraud.

I would sneak things in during banter with other partners or make it look like you're the one doing something wrong/want to verify your needle positions.

It's definitely best addressed than not, but realize that the messenger often gets shot in academics. I've never seen egos more fragile than those of an academic clinician's except perhaps an academic administrator.

 

[lobelsteve]

If templates are wrong it is just sloppy. If they did not do the procedure billed for it is fraud. Like a 27g 1.25” needle tpi billed as 64483.

 

[paindoc007]

I think you misplaced interlaminar with TFESI right?

I don't do many ILESI in the lumbar spine. I do occasionally, but usually I am TF in the low back. The ILESI isn't as reliable as the TF for getting injectate into the anterior epidural space.

Someone with an L5 radic, I’m doing an L5 tfesi, or l5-s1 paramedian interlam. You said it’s be a sociopath to inject at l5 for l5 radic which is what I’m not agreeing with. I havent seen crazy intra-op pain flares during transforaminals, so I typically go right at the site. Interlams on the other hand, I’ll go a level below tight stenosis.

 

[lobelsteve]

Someone with an L5 radic, I’m doing an L5 tfesi, or l5-s1 paramedian interlam. You said it’s be a sociopath to inject at l5 for l5 radic which is what I’m not agreeing with. I havent seen crazy intra-op pain flares during transforaminals, so I typically go right at the site. Interlams on the other hand, I’ll go a level below tight stenosis.

Ok to do unless large foraminal disk. Tfesi becomes discography.

 

[SommeRiver]

Someone with an L5 radic, I’m doing an L5 tfesi, or l5-s1 paramedian interlam. You said it’s be a sociopath to inject at l5 for l5 radic which is what I’m not agreeing with. I havent seen crazy intra-op pain flares during transforaminals, so I typically go right at the site. Interlams on the other hand, I’ll go a level below tight stenosis.

Your previous post reads confusing man.

I'm obviously using hyperbole when I say sociopath. If it is severe foraminal stenosis I won't inject that foramen.

 

[Agast]

You can do the injection however you want, just don’t report and bill for something completely different. OP, if you’re concerned about your personal responsibility, you can consult with your malpractice carrier and they will give you an opinion on whether you have any kind of liability.

 

[deleted993114]

The statements above are correct. For example, C7T1 epidural in the note, but very clearly T1T2 in the images; L45 facet in the note, very clearly at L34.

Thank you everyone for your thoughts

Maybe they used catheters? I use them 100% of the time in the neck and always in the back when doing an interlam for stenosis. I do an interlam for stenosis, as you want the drug dorsal in that situation, unlike foraminal stenosis or a herniated disc. So if someone looked at my needle placement for some things, they would think I am way off. Sometimes the rad tech does not save the "final" image, which shows the contrast where it needs to be. Perhaps this is the situation here and she does not know that.

I can guarantee you that no regulatory agency is ever going to "discover" those errors, so that is not a consideration. It is more of a political one.

A confrontation will result in the gal getting fired. She can address the situation subtly through education, which is the best route to go. Creating a political fight in the department will not turn out well for anyone, particularly her.

Doing S1s for an L5? Well...……… if the contrast gets there, you are okay. I am just confused as to why you just would not place the needle at L5, but to each his own.

PS- No movement on the birdie situation? Perhaps you could build something else away from the house for them to provide a nice home.

 

[Crybaby]

Regarding wrong documentation, I know the techs I work with "label" the levels injected. They get it wrong half of the time. I dictate appropriately however, often my pic levels don't match what is on the picture. I ask them often to please not label my procedures since I tire of repeatedly telling them its wrong.
Just saying, that may be worth another look to see if that sort documentation is off...

 

[SommeRiver]

I have improperly saved pics all the time. In fact, I had a huge issue with no one saving my "saved pics" at one point.

I also on occasion plan on a procedure at one level, and then abort to another. My assistants do not always document that appropriately, but my note does.

 

[DrSpine]

Improperly saved pics has happened to me. I absolutely hate it and get pissed when I've specifically said "save this" - and I look back and I'm like "nice...that totally isn't what I did and if someone else saw this, it would look awful and/or fraud." The problem is, no matter how much you reprimand some people, somethings are left out of your hand and someone may still botch it. Case in point was a recent 2 level Cervical Facet J. Guy didn't properly save the images of the needle on/in the joint. Instead, it looked like trigger points because I was still far away from the facet.

 

[painfree23]

Improperly saved pics has happened to me. I absolutely hate it and get pissed when I've specifically said "save this" - and I look back and I'm like "nice...that totally isn't what I did and if someone else saw this, it would look awful and/or fraud." The problem is, no matter how much you reprimand some people, somethings are left out of your hand and someone may still botch it. Case in point was a recent 2 level Cervical Facet J. Guy didn't properly save the images of the needle on/in the joint. Instead, it looked like trigger points because I was still far away from the facet.

whos asking for these pics?

 

[SommeRiver]

Improperly saved pics - I have a pt who I ablated early 2019 with prob 90% improvement. For some reason she couldn't get back in with me April 2020, so she went to another local guy.

Saved pics from my ablation are all effed up...

He told her I never ablated her and that I'm a fraudulent doctor and a liar (I guess he got her records).

She said, "That procedure worked very well for me, so...Can you repeat it?"

He ablates her with 0% improvement.

She shows back up to me and tells me all about this BS.

So yes, saved pics matter (SPM, I'm starting a movement).