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Professionalism & Professionalism & Professionalism & Professionalism &
Accountability When Accountability When Accountability When Accountability When
MANAGINGMANAGINGMANAGINGMANAGINGOUTCOMES:OUTCOMES:OUTCOMES:OUTCOMES:
Accountability When Accountability When Accountability When Accountability When
Things Go Wrong in Things Go Wrong in Things Go Wrong in Things Go Wrong in
PracticePracticePracticePractice
If you’ve done everything If you’ve done everything If you’ve done everything If you’ve done everything you’re supposed to do as a you’re supposed to do as a you’re supposed to do as a you’re supposed to do as a
practitioner, you have the practitioner, you have the practitioner, you have the practitioner, you have the practitioner, you have the practitioner, you have the practitioner, you have the practitioner, you have the right to be wrong. right to be wrong. right to be wrong. right to be wrong. But you But you But you But you
don’t have the right to miss don’t have the right to miss don’t have the right to miss don’t have the right to miss steps along the waysteps along the waysteps along the waysteps along the way....
Dr. Greg DunnDr. Greg DunnDr. Greg DunnDr. Greg Dunn
► Chiropractor since 1976Chiropractor since 1976Chiropractor since 1976Chiropractor since 1976
► With CCPA for 18 yearsWith CCPA for 18 yearsWith CCPA for 18 yearsWith CCPA for 18 years► With CCPA for 18 yearsWith CCPA for 18 yearsWith CCPA for 18 yearsWith CCPA for 18 years
► International lecturer on International lecturer on International lecturer on International lecturer on
Risk ManagementRisk ManagementRisk ManagementRisk Management
► [email protected]@[email protected]@ccpaonline.ca
Five Five Five Five ImportantImportantImportantImportant
LessonsLessonsLessonsLessonsRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too Great
Fresh Eyes at Every VisitFresh Eyes at Every VisitFresh Eyes at Every VisitFresh Eyes at Every Visit
Diagnoses Must Match EvidenceDiagnoses Must Match EvidenceDiagnoses Must Match EvidenceDiagnoses Must Match Evidence
Your First ObligationYour First ObligationYour First ObligationYour First Obligation
Only You Can Be the DoctorOnly You Can Be the DoctorOnly You Can Be the DoctorOnly You Can Be the Doctor
RISK CAN RISK CAN RISK CAN RISK CAN BE TOOBE TOOBE TOOBE TOOGREATGREATGREATGREATBE TOOBE TOOBE TOOBE TOOGREATGREATGREATGREAT
1.1.1.1. Patient presents with “extreme” neck painPatient presents with “extreme” neck painPatient presents with “extreme” neck painPatient presents with “extreme” neck pain
KEY FACTSKEY FACTSKEY FACTSKEY FACTS1.1.1.1. Patient presents with “extreme” neck painPatient presents with “extreme” neck painPatient presents with “extreme” neck painPatient presents with “extreme” neck pain
2.2.2.2. Desperate for relief, patient consents to Desperate for relief, patient consents to Desperate for relief, patient consents to Desperate for relief, patient consents to treatment in spite of warning from the DCtreatment in spite of warning from the DCtreatment in spite of warning from the DCtreatment in spite of warning from the DC
3.3.3.3. Treatment causes neck injuryTreatment causes neck injuryTreatment causes neck injuryTreatment causes neck injury
The best word to characterize their The best word to characterize their The best word to characterize their The best word to characterize their
communication was desperate.communication was desperate.communication was desperate.communication was desperate.”“I recall telling them the risk of fracture, I recall telling them the risk of fracture, I recall telling them the risk of fracture, I recall telling them the risk of fracture,
paralysis or stroke was about 50paralysis or stroke was about 50paralysis or stroke was about 50paralysis or stroke was about 50----50.50.50.50.”“ paralysis or stroke was about 50paralysis or stroke was about 50paralysis or stroke was about 50paralysis or stroke was about 50----50.50.50.50.”“I clearly told them the situation was risky I clearly told them the situation was risky I clearly told them the situation was risky I clearly told them the situation was risky
and they confirmed they wished to try and they confirmed they wished to try and they confirmed they wished to try and they confirmed they wished to try
something because the pain was so something because the pain was so something because the pain was so something because the pain was so
severe.severe.severe.severe.”
“
DO NOT TREAT.DO NOT TREAT.DO NOT TREAT.DO NOT TREAT.If the Risk is Too Great.If the Risk is Too Great.If the Risk is Too Great.If the Risk is Too Great.
LESSON #1LESSON #1LESSON #1LESSON #1
Patients in pain often Patients in pain often Patients in pain often Patients in pain often make bad choices.make bad choices.make bad choices.make bad choices.
AT EVERYAT EVERYAT EVERYAT EVERY
VISITVISITVISITVISIT
FRESH EYESFRESH EYESFRESH EYESFRESH EYES
VISITVISITVISITVISIT
1.1.1.1. Patient presents with lower back painPatient presents with lower back painPatient presents with lower back painPatient presents with lower back pain
KEY FACTSKEY FACTSKEY FACTSKEY FACTS1.1.1.1. Patient presents with lower back painPatient presents with lower back painPatient presents with lower back painPatient presents with lower back pain
2.2.2.2. Then begins to complain of head & neck painThen begins to complain of head & neck painThen begins to complain of head & neck painThen begins to complain of head & neck pain
3.3.3.3. Stroke occurs very soon after upper cervical Stroke occurs very soon after upper cervical Stroke occurs very soon after upper cervical Stroke occurs very soon after upper cervical adjustment. Patient’s breathing stops.adjustment. Patient’s breathing stops.adjustment. Patient’s breathing stops.adjustment. Patient’s breathing stops.
4.4.4.4. Eventual surgery removes portion of cerebellum Eventual surgery removes portion of cerebellum Eventual surgery removes portion of cerebellum Eventual surgery removes portion of cerebellum
1.1.1.1. No reassessment at onset of head & neck No reassessment at onset of head & neck No reassessment at onset of head & neck No reassessment at onset of head & neck pain symptomspain symptomspain symptomspain symptoms
2.2.2.2. No new informed consent prior to No new informed consent prior to No new informed consent prior to No new informed consent prior to
Complicating Factors:Complicating Factors:Complicating Factors:Complicating Factors:
2.2.2.2. No new informed consent prior to No new informed consent prior to No new informed consent prior to No new informed consent prior to treatment plan changetreatment plan changetreatment plan changetreatment plan change
3.3.3.3. DC waiting to call ambulance in spite of DC waiting to call ambulance in spite of DC waiting to call ambulance in spite of DC waiting to call ambulance in spite of textbook stroke symptomstextbook stroke symptomstextbook stroke symptomstextbook stroke symptoms
4.4.4.4. Young patient at time of incidentYoung patient at time of incidentYoung patient at time of incidentYoung patient at time of incident
1.1.1.1. Treatment plan changesTreatment plan changesTreatment plan changesTreatment plan changes
2.2.2.2. Symptoms, diagnosis changesSymptoms, diagnosis changesSymptoms, diagnosis changesSymptoms, diagnosis changes
Update Informed Update Informed Update Informed Update Informed
Consent When:Consent When:Consent When:Consent When:
2.2.2.2. Symptoms, diagnosis changesSymptoms, diagnosis changesSymptoms, diagnosis changesSymptoms, diagnosis changes
3.3.3.3. Patient health status changesPatient health status changesPatient health status changesPatient health status changes
4.4.4.4. Prolonged absence from careProlonged absence from careProlonged absence from careProlonged absence from care
5.5.5.5. Informed consent is “stale”Informed consent is “stale”Informed consent is “stale”Informed consent is “stale”
FRESH EYES AT FRESH EYES AT FRESH EYES AT FRESH EYES AT
EVERY VISIT.EVERY VISIT.EVERY VISIT.EVERY VISIT.
LESSON #2LESSON #2LESSON #2LESSON #2
Patients are people.Patients are people.Patients are people.Patients are people.
Their conditions Their conditions Their conditions Their conditions change and evolve.change and evolve.change and evolve.change and evolve.
DIAGNOSESDIAGNOSESDIAGNOSESDIAGNOSESMUST MATCHMUST MATCHMUST MATCHMUST MATCH
EVIDENCEEVIDENCEEVIDENCEEVIDENCEMUST MATCHMUST MATCHMUST MATCHMUST MATCH
EVIDENCEEVIDENCEEVIDENCEEVIDENCE
NE
UR
OL
OG
ICA
LN
EU
RO
LO
GIC
AL
NE
UR
OL
OG
ICA
LN
EU
RO
LO
GIC
AL
RA
NG
E O
F M
OT
ION
RA
NG
E O
F M
OT
ION
RA
NG
E O
F M
OT
ION
RA
NG
E O
F M
OT
ION
OR
TH
O &
PA
LP
AT
ION
OR
TH
O &
PA
LP
AT
ION
OR
TH
O &
PA
LP
AT
ION
OR
TH
O &
PA
LP
AT
ION
► Lower neuro. Lower neuro. Lower neuro. Lower neuro.
exam performedexam performedexam performedexam performed
► Reflexes were Reflexes were Reflexes were Reflexes were
symmetrical symmetrical symmetrical symmetrical
► Decreased quad & Decreased quad & Decreased quad & Decreased quad &
hamstring strength hamstring strength hamstring strength hamstring strength
on Lefton Lefton Lefton Left
► Slight decrease in Slight decrease in Slight decrease in Slight decrease in
vibration sense on vibration sense on vibration sense on vibration sense on
► 45454545○ flexion flexion flexion flexion
with slight with slight with slight with slight
shift to rightshift to rightshift to rightshift to right
► Extension 20Extension 20Extension 20Extension 20○
to 25to 25to 25to 25○
► Rotation 20Rotation 20Rotation 20Rotation 20○
bilaterallybilaterallybilaterallybilaterally
► Lateral Lateral Lateral Lateral
flexion 20flexion 20flexion 20flexion 20○
►KKKKeeeemmmmppppssss tttteeeesssstttt ppppoooossssiiiittttiiiivvvveeee
pain bilaterallypain bilaterallypain bilaterallypain bilaterally
►PPPPaaaaiiiinnnn wwwwiiiitttthhhh ppppaaaallllppppaaaattttiiiioooonnnn
aaaatttt LLLL3333,,,, LLLL4444,,,, LLLL5555 oooonnnn lllleeeefffftttt
►BBBBiiiillllaaaatttteeeerrrraaaallll qqqquuuuaaaaddddrrrraaaattttuuuussss
lumborum & lumborum & lumborum & lumborum &
paraspinal muscle paraspinal muscle paraspinal muscle paraspinal muscle
tension noted tension noted tension noted tension noted
►Pelvic distortion Pelvic distortion Pelvic distortion Pelvic distortion
NE
UR
OL
OG
ICA
LN
EU
RO
LO
GIC
AL
NE
UR
OL
OG
ICA
LN
EU
RO
LO
GIC
AL
RA
NG
E O
F M
OT
ION
RA
NG
E O
F M
OT
ION
RA
NG
E O
F M
OT
ION
RA
NG
E O
F M
OT
ION
OR
TH
O &
PA
LP
AT
ION
OR
TH
O &
PA
LP
AT
ION
OR
TH
O &
PA
LP
AT
ION
OR
TH
O &
PA
LP
AT
ION
vibration sense on vibration sense on vibration sense on vibration sense on
leftleftleftleft
► Prone Knee flexion Prone Knee flexion Prone Knee flexion Prone Knee flexion
produced pain at produced pain at produced pain at produced pain at
L5L5L5L5
flexion 20flexion 20flexion 20flexion 20
left, 25252525○ to 30to 30to 30to 30○
right
► left sided left sided left sided left sided
pain was pain was pain was pain was
reported in reported in reported in reported in
all ranges all ranges all ranges all ranges
except for except for except for except for
right lateral right lateral right lateral right lateral
flexionflexionflexionflexion
►Pelvic distortion Pelvic distortion Pelvic distortion Pelvic distortion
nnnnooootttteeeedddd wwwwiiiitttthhhh lllleeeefffftttt ppppeeeellllvvvviiiicccc
fffflllleeeexxxxiiiioooonnnn aaaannnndddd////oooorrrr rrrriiiigggghhhhtttt
pelvic extension pelvic extension pelvic extension pelvic extension
resulting in a right resulting in a right resulting in a right resulting in a right
leg length leg length leg length leg length
discrepancy of discrepancy of discrepancy of discrepancy of
approx. ½ inchapprox. ½ inchapprox. ½ inchapprox. ½ inch
Pelvic Imbalance with Pelvic Imbalance with Pelvic Imbalance with Pelvic Imbalance with
resultant right leg resultant right leg resultant right leg resultant right leg
length discrepancy and length discrepancy and length discrepancy and length discrepancy and
secondary sacroiliac secondary sacroiliac secondary sacroiliac secondary sacroiliac
joint, and/or lumbar joint, and/or lumbar joint, and/or lumbar joint, and/or lumbar
facet dysfunction facet dysfunction facet dysfunction facet dysfunction
DDx
DDx
DDx
DDx
facet dysfunction facet dysfunction facet dysfunction facet dysfunction
affecting the left affecting the left affecting the left affecting the left
sacroiliac joint and sacroiliac joint and sacroiliac joint and sacroiliac joint and
left L3, L4 and L5 left L3, L4 and L5 left L3, L4 and L5 left L3, L4 and L5
segments and including segments and including segments and including segments and including
radicular signs on the radicular signs on the radicular signs on the radicular signs on the
leftleftleftleftDDx
DDx
DDx
DDx
Disc HerniationDisc HerniationDisc HerniationDisc Herniation
Diagnoses Must Follow Diagnoses Must Follow Diagnoses Must Follow Diagnoses Must Follow
from Examination.from Examination.from Examination.from Examination.
LESSON #3LESSON #3LESSON #3LESSON #3
Differentials Differentials Differentials Differentials –––– even if youeven if youeven if youeven if you
think they are unlikely think they are unlikely think they are unlikely think they are unlikely ––––
must be noted in must be noted in must be noted in must be noted in
the patient file.the patient file.the patient file.the patient file.
YOUR FIRSTYOUR FIRSTYOUR FIRSTYOUR FIRST
OBLIGATIONOBLIGATIONOBLIGATIONOBLIGATIONOBLIGATIONOBLIGATIONOBLIGATIONOBLIGATION
1.1.1.1. Patient received a cervical adjustment & felt “incredibly Patient received a cervical adjustment & felt “incredibly Patient received a cervical adjustment & felt “incredibly Patient received a cervical adjustment & felt “incredibly
KEY FACTSKEY FACTSKEY FACTSKEY FACTS1.1.1.1. Patient received a cervical adjustment & felt “incredibly Patient received a cervical adjustment & felt “incredibly Patient received a cervical adjustment & felt “incredibly Patient received a cervical adjustment & felt “incredibly
dizzy”dizzy”dizzy”dizzy”
2.2.2.2. Dizziness continued, plus profuse sweating & vomitingDizziness continued, plus profuse sweating & vomitingDizziness continued, plus profuse sweating & vomitingDizziness continued, plus profuse sweating & vomiting
3.3.3.3. Patient could not walk in a straight linePatient could not walk in a straight linePatient could not walk in a straight linePatient could not walk in a straight line
4.4.4.4. After 20 minutes an ambulance & family member were After 20 minutes an ambulance & family member were After 20 minutes an ambulance & family member were After 20 minutes an ambulance & family member were calledcalledcalledcalled
1.1.1.1. Patient was a nurse, understood her symptoms Patient was a nurse, understood her symptoms Patient was a nurse, understood her symptoms Patient was a nurse, understood her symptoms better than the DCbetter than the DCbetter than the DCbetter than the DC
2.2.2.2. Patient was told their was no risk of strokePatient was told their was no risk of strokePatient was told their was no risk of strokePatient was told their was no risk of stroke
3.3.3.3. Patient was left alone in the clinic washroom a Patient was left alone in the clinic washroom a Patient was left alone in the clinic washroom a Patient was left alone in the clinic washroom a
Complicating Factors:Complicating Factors:Complicating Factors:Complicating Factors:
3.3.3.3. Patient was left alone in the clinic washroom a Patient was left alone in the clinic washroom a Patient was left alone in the clinic washroom a Patient was left alone in the clinic washroom a number of times number of times number of times number of times
4.4.4.4. Patient had to ask twice for an ambulance to be Patient had to ask twice for an ambulance to be Patient had to ask twice for an ambulance to be Patient had to ask twice for an ambulance to be calledcalledcalledcalled
5.5.5.5. DC lied about performing the adjustmentDC lied about performing the adjustmentDC lied about performing the adjustmentDC lied about performing the adjustment
Your Patient’s health isYour Patient’s health isYour Patient’s health isYour Patient’s health is
Your First Obligation.Your First Obligation.Your First Obligation.Your First Obligation.
LESSON #4LESSON #4LESSON #4LESSON #4
In a medical emergency, In a medical emergency, In a medical emergency, In a medical emergency,
your only concern your only concern your only concern your only concern
should be for the should be for the should be for the should be for the
patient in distress. patient in distress. patient in distress. patient in distress.
ONLY YOUONLY YOUONLY YOUONLY YOUCAN BE THECAN BE THECAN BE THECAN BE THEDOCTORDOCTORDOCTORDOCTORCAN BE THECAN BE THECAN BE THECAN BE THEDOCTORDOCTORDOCTORDOCTOR
1.1.1.1. Patient expresses desire for intimate relationship with DCPatient expresses desire for intimate relationship with DCPatient expresses desire for intimate relationship with DCPatient expresses desire for intimate relationship with DC
KEY FACTSKEY FACTSKEY FACTSKEY FACTS1.1.1.1. Patient expresses desire for intimate relationship with DCPatient expresses desire for intimate relationship with DCPatient expresses desire for intimate relationship with DCPatient expresses desire for intimate relationship with DC
2.2.2.2. DC reciprocates and discontinues care, but continues to DC reciprocates and discontinues care, but continues to DC reciprocates and discontinues care, but continues to DC reciprocates and discontinues care, but continues to treat patient’s childrentreat patient’s childrentreat patient’s childrentreat patient’s children
3.3.3.3. PPPPaaaattttiiiieeeennnntttt’’’’ssss ssssppppoooouuuusssseeee ddddiiiissssccccoooovvvveeeerrrrssss rrrreeeellllaaaattttiiiioooonnnnsssshhhhiiiipppp dddduuuurrrriiiinnnngggg tttthhhheeee ccccoooouuuurrrrsssseeee of ongoing divorce proceedingsof ongoing divorce proceedingsof ongoing divorce proceedingsof ongoing divorce proceedings
4.4.4.4. Patient’s spouse files a college complaint against the DCPatient’s spouse files a college complaint against the DCPatient’s spouse files a college complaint against the DCPatient’s spouse files a college complaint against the DC
► DC engaged in an DC engaged in an DC engaged in an DC engaged in an “affair” with spouse “affair” with spouse “affair” with spouse “affair” with spouse during careduring careduring careduring care
Vastly Different AccountsVastly Different AccountsVastly Different AccountsVastly Different AccountsComplainantComplainantComplainantComplainant ChiropractorChiropractorChiropractorChiropractor
► Relationship initiated Relationship initiated Relationship initiated Relationship initiated after patient discharge after patient discharge after patient discharge after patient discharge
during careduring careduring careduring care
► Simple case of sexual Simple case of sexual Simple case of sexual Simple case of sexual misconductmisconductmisconductmisconduct
► CCCCoooollllllllaaaatttteeeerrrraaaallll ddddaaaammmmaaaaggggeeee ffffrrrroooommmm “cantankerous” divorce“cantankerous” divorce“cantankerous” divorce“cantankerous” divorce
► DC billed improperly DC billed improperly DC billed improperly DC billed improperly during the course of the during the course of the during the course of the during the course of the affairaffairaffairaffair
► All patients were All patients were All patients were All patients were ddddiiiisssscccchhhhaaaarrrrggggeeeedddd oooonnnn aaaaddddvvvviiiicccceeee ooooffff RegulatorRegulatorRegulatorRegulator
ONLY YOU CAN BE ONLY YOU CAN BE ONLY YOU CAN BE ONLY YOU CAN BE
THE DOCTOR.THE DOCTOR.THE DOCTOR.THE DOCTOR.Main integrity.Main integrity.Main integrity.Main integrity.
LESSON #5LESSON #5LESSON #5LESSON #5
Main integrity.Main integrity.Main integrity.Main integrity.
Resist behaviour that Resist behaviour that Resist behaviour that Resist behaviour that
can impugn your can impugn your can impugn your can impugn your
reputation. reputation. reputation. reputation.
Five Five Five Five ImportantImportantImportantImportant
LessonsLessonsLessonsLessonsRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too GreatRisk Can Be Too Great
Fresh Eyes at Every VisitFresh Eyes at Every VisitFresh Eyes at Every VisitFresh Eyes at Every Visit
Diagnoses Must Match EvidenceDiagnoses Must Match EvidenceDiagnoses Must Match EvidenceDiagnoses Must Match Evidence
Your First ObligationYour First ObligationYour First ObligationYour First Obligation
Only You Can Be the DoctorOnly You Can Be the DoctorOnly You Can Be the DoctorOnly You Can Be the Doctor
WayWayWayWay
TheTheTheTheCCPACCPACCPACCPA
EEEEXCELLENCEXCELLENCEXCELLENCEXCELLENCE
IIIINTEGRITYNTEGRITYNTEGRITYNTEGRITY
SSSSTRENGTHTRENGTHTRENGTHTRENGTH
WayWayWayWay FFFFAIRNESSAIRNESSAIRNESSAIRNESS
ChiropractorsChiropractorsChiropractorsChiropractors
ChiropractorsChiropractorsChiropractorsChiropractorsProtectingProtectingProtectingProtectingChiropractorsChiropractorsChiropractorsChiropractors
CCPA
Member