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

► gdunn@ccpaonline.cagdunn@ccpaonline.cagdunn@ccpaonline.cagdunn@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

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► 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

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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

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