The Impact of Anesthesiologist Situational Awareness on Patient Safety and Liability Risk
CME Information
Sponsored by: The NORCAL Group of companies includes NORCAL Mutual Insurance Company, along with its subsidiary companies Medicus Insurance Company, FD Insurance Company, NORCAL Specialty Insurance Company and its affiliate Preferred Physicians Medical RRG.
NORCAL Mutual Insurance Company is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
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Original Release Date: February 15, 2018
Expiration Date: March 1, 2020
Learning Objectives
By reviewing medical professional liability claims and/or emerging topics in healthcare risk management, this enduring material series will support your ability to:
Assess your practice for risk exposures.
Apply risk management best practices that increase patient safety and reduce medical professional liability claims.
Target Audience
Anesthesiologists, CRNAs, surgeons, medical proceduralists including gastroenterologists, and other members of the surgical or procedure team
Credit Designation Statement
NORCAL Mutual Insurance Company designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure Policy
As an ACCME accredited provider, NORCAL Mutual Insurance Company requires planners, reviewers or authors who influence or control the content of a CME activity to disclose financial relationships (of any amount) they have had with commercial interests associated with this CME activity during the year preceding publication of the content.
Any identified conflicts of interest are resolved prior to the commencement of the activity.
Disclosures
Individuals involved in the planning, reviewing or execution of this activity have indicated they have no relevant financial relationships to disclose.
Editor
Mary-Lynn Ryan
Risk Management Specialist, NORCAL Mutual
Content Advisors
Sandra L. Beretta, MD
Chair, NORCAL Mutual, FD Insurance, Medicus and Preferred Physicians Medical RRG
Patricia A. Dailey, MD
Director, NORCAL Mutual, FD Insurance, Medicus and Preferred Physicians Medical RRG
Situational awareness is the "perception of the elements in the environment within a volume of space and time, the comprehension of their meaning and the projection of their status in the near future."1 Situational awareness can reduce the risk of patient injuries and thereby decrease liability risk exposure.2 Looking at anesthesia liability claims through a situational awareness framework provides a fresh patient safety and risk management perspective that focuses on physician thought processes.
Although it may seem effortless and automatic, situational awareness can degrade with fatigue, stress, interruptions and distractions.3 Cognitive biases, heuristics and various other non-rational cognitive processes can also interrupt situational awareness.4 A recent study by Schulz et al investigates the role of anesthesiologist situational awareness errors on patient injury and malpractice risk using claims reports from the American Society of Anesthesiologists' (ASA) Closed Claims Project database.5 The study presents situational awareness as a hierarchical model, wherein the anesthesiologist perceives information at a basic level (e.g., patient history, physical exam and vital signs), then integrates that information with long-term memory to comprehend (diagnose) the patient's medical condition (e.g., anterior larynx and morbid obesity), and, at the highest level, projects the patient's condition into the near future to make plans (e.g., has appropriate difficult airway equipment and a plan for general anesthesia induction in a patient with airway pathology and potential obstruction).5
In the ASA Closed Claim Project study, patient injuries resulting from situational awareness deficits were classified by perception, comprehension and projection errors.5 These classifications frame the discussion in this article using NORCAL closed claims. The case studies illustrate and analyze various negative influences on situational awareness and how they affect patient safety and liability risk. Strategies are proposed for avoiding perception, comprehension and projection errors.
Perception Errors
In the ASA Closed Claim Project study, perception errors were defined as failures to gather information via history, patient record, physical exam, diagnostic tests, imaging, monitors, other team members or the environment. The most common errors of perception identified by the study included:5
Absence of respiratory, peripheral capillary oxygen saturation and end-tidal carbon dioxide monitoring and/or absent alarms, which resulted in failures to recognize declining respiratory status
Inadequate preoperative evaluation and missing patient information, which resulted in inappropriate anesthesia plans and management
Consider how improved information gathering by the anesthesiologist in the following two cases could have resulted in a better patient outcome.
Case One
Situational Awareness Issue:
The anesthesiologist failed to realize the patient was deteriorating because she could not appropriately monitor her.
An obese patient with multiple comorbidities was admitted through the emergency department for stomach pain. Over the course of the week, the patient underwent two different operations, one under sedation and the next under general anesthesia. Following the second procedure, the patient started experiencing breathing difficulties and was transferred to the Intensive Care Unit (ICU).
Because her stomach pain had not resolved, the patient was scheduled for an endoscopic retrograde cholangiopancreatography (ERCP). The anesthesiologist decided to use sedation anesthesia. During the pre-anesthesia assessment, the anesthesiologist noted the patient's blood pressure, heart rate and respiratory rates were normal. She was able to take deep breaths and could cough freely with no limitations. The anesthesiologist did not believe the patient was in any distress, and had a routine anesthesia plan. However, she failed to review the patient's hospital record and did not identify the recent breathing difficulties.
Anesthesia started at 1052 with two 60 mg boluses and then 30 mg of propofol over two minutes and 2 mg of midazolam. Supplemental oxygen was being delivered at 3 liters per minute. The patient's oxygen saturation was 99%. The endoscope was inserted at 1109 with the patient in the prone position. At 1112, the anesthesiologist noticed the patient's oxygen saturation and blood pressure dropping. At 1115, the patient went into respiratory arrest, and a code was called. The patient was intubated at 1123, but never regained consciousness.
The patient's family filed a malpractice lawsuit against all members of the surgical team. Their allegations against the anesthesiologist included:
The anesthesiologist should have been more conservative with the propofol dose because of the patient's prior breathing problems.
The combination of propofol and midazolam caused the respiratory arrest.
The procedure should have been done under general anesthesia.
The patient should not have been placed in the prone position.
The patient's declining respiratory status should have been recognized and remedied more quickly.
The anesthesiologist's perception errors in this case can be directly related to the adverse outcome. First, she failed to adequately monitor the patient. Experts opined the anesthesiologist was slow to perceive the patient's declining respiratory status because she was not monitoring end-tidal carbon dioxide (ETCO2) and could not watch the patient's chest for respirations because the room was dark and her patient view was obstructed. They noted that the anesthesiologist did not become aware that the patient's respiratory status was declining until her oxygen saturation dropped below 90. Because the patient was receiving supplemental oxygen, she was most likely in trouble before the oxygen saturation started to drop. Second, the anesthesiologist failed to obtain information about the patient's recent history of breathing difficulties. The anesthesiologist admitted during litigation that she would have chosen general anesthesia if she had noticed the patient's recent history.
ASA Statement on Respiratory Monitoring During Endoscopic Procedures
In its statement on respiratory monitoring during endoscopic procedures, the ASA recommends ETCO2 monitoring when "sedation is provided with propofol alone or in combination with opioids and/or benzodiazepines, and especially during these procedures on the upper gastrointestinal tract." In the same statement, the ASA warns that, "Careful attention to airway management must be provided during ERCP procedures performed in the prone position where ventilatory monitoring, airway maintenance, and resuscitation may be especially difficult."6 Although practice guidelines and professional society statements do not set the standard of care, they can be influential in malpractice litigation and can also improve patient safety when used appropriately. Therefore, it is important for physicians to document analysis and reasoning for choosing not to follow guideline recommendations. In this case, there was no documentation, and the anesthesiologist could not provide a reasonable explanation for failing to monitor ETCO2. She admitted that ETCO2 monitoring could have resulted in her earlier recognition of the patient's declining respiratory status.
Proactively gathering information to formulate a safe anesthesia plan improves situational awareness. Consider the following recommendations:4
Even if surgery is proceeding as planned, stay alert and expect the unexpected.
Monitor for ETCO2 according to practice standards and guidelines.
Assess the operative environment and make adjustments to make up for any perception deficits.
Review the patient's medical history and plan anesthesia around the risks associated with patient comorbidities.
Case Two
Situational Awareness Issue:
The anesthesiologist failed to obtain reliable patient health information before making an anesthesia plan.
A patient was scheduled for minor elective surgery at a surgery center. She had multiple comorbidities that increased her anesthesia risk, including obesity, heart failure and diabetes. A week prior to surgery, the patient underwent a pre-operative evaluation with her primary care physician (PCP). The PCP "cleared" the patient for surgery and noted she was ASA category 3. A day prior to surgery, the patient had an appointment with her cardiologist to check the function of her pacemaker. It was not a pre-operative evaluation.
The day of surgery, the anesthesiologist conducted a pre-anesthesia evaluation. The patient informed the anesthesiologist she had been cleared for surgery by her cardiologist. (No cardiology notes were available in the patient's surgical center file, and the anesthesiologist did not contact the cardiologist.) The PCP's pre-surgical consultation note was in the patient's medical record. The anesthesiologist went along with the PCP's classification of the patient as ASA category 3, even though he thought she was closer to a 4. He decided the surgery could go forward in the surgical center under sedation. Ten minutes into surgery the patient became unresponsive. The surgery was halted and resuscitative measures were undertaken, but the patient expired. The likely cause of death was determined to be respiratory arrest as a result of sleep apnea that resulted in cardiovascular collapse, cardiac arrest and hypoxic encephalopathy.
The patient's family filed a malpractice lawsuit against all members of the surgical team, but the target defendant was the anesthesiologist because he controlled the ultimate decision of whether to allow the surgery to go forward and chose the type of anesthesia.
Errors of perception include failing to gather pre-operative test results and obtaining incorrect information from the patient.5 According to defense experts, the patient could not legitimately be classified as an ASA 3; she was an ASA 4. Furthermore, the anesthesiologist's reliance on the patient's report of being cleared by her cardiologist was problematic. Although the working status of the pacemaker was an important factor in determining whether sedation anesthesia was appropriate, there were other significant comorbidities the anesthesiologist should have considered prior to going forward. Furthermore, the cardiology defense expert believed the patient should not have been allowed to undergo any type of elective surgery because of her very high risk for perioperative cardiac events. Had the anesthesiologist contacted the cardiologist directly, he most likely would have had more accurate information upon which to make anesthesia decisions.
Over-reliance on reports that endeavor to clear a patient for surgery can increase the risk of patient injury because consultants may not be aware of an anesthesiologist's expectations of a pre-operative clearance. Consider the following recommendations:
If the patient presents to a pre-surgical anesthesia examination on the day of surgery without enough information to determine if he or she can safely undergo the planned procedures, discuss any concerns with the proceduralist or surgeon to determine whether the procedure should be postponed until adequate information can be obtained.
Do not rely on a patient's report of being cleared for surgery.
Do not over-rely on a PCP's or specialist's clearance of a patient for surgery. When in doubt, contact the PCP or specialist directly.
Weigh the risks and benefits of ambulatory surgery for each patient.
Tailor anesthesia to the patient and procedure.
Utilize ASA categories and ensure you have a rationale if deviating from any recommendation based on the ASA category. Document the rationale.
As the previous and following case studies indicate, perception errors nearly always lead to comprehension and projection errors.5
Comprehension Errors
In the ASA Closed Claim Project study, comprehension errors were defined as "failure to understand the significance of information obtained from history, physical exam, diagnostic tests, imaging findings, or monitors; that is, the information was available, but it was not understood or was misunderstood, which led to an incorrect diagnosis." Comprehension can be complicated by various cognitive biases, which influence thinking, problem solving and decision making.4 Cognitive biases that commonly affect situational awareness include:
Anchoring Bias
Anchoring bias is the tendency to settle on a particular diagnosis due to certain sign-and-symptom patterns, coupled with a failure to adjust the diagnosis in response to subsequently obtained diagnostic evidence.4
Confirmation Bias
Confirmation bias causes a physician to look for confirming evidence to support an anchor diagnosis while downplaying, ignoring or not actively seeking contrary evidence.4
Attentional Bias
"Cognitive tunneling" and "inattentional blindness" describe how attention tends to focus on some information and exclude other information in stressful situations. Although this may prevent an anesthesiologist from becoming overwhelmed with information, it can also prevent the assimilation of new information, which decreases situational awareness.7
Case Three
Situational Awareness Issue:
The anesthesiologist should have diagnosed bilateral tension pneumothoraces in a more timely manner based on the information available to her.
The patient was placed under general anesthesia for a tracheostomy revision and laryngoscopy. The surgeon made multiple unsuccessful attempts to ventilate the patient through the tracheostomy tube. At each failed attempt, he removed the tracheostomy tube and slid the endotracheal tube back below the incision, which kept the patient adequately ventilated. He finally succeeded with ventilation through the tracheostomy tube; however, 30 minutes into the laryngoscopy, the patient's peak inspiratory pressures markedly increased, her oxygen saturations decreased and bilateral wheezing was heard on auscultation. The anesthesiologist replaced the tracheostomy tube with an endotracheal tube, but there was no improvement. Suspecting bronchospasm, the anesthesiologist administered bronchodilators, but oxygen saturations continued to decline and airway pressures continued to increase. The surgeon then called for a STAT chest x-ray, suspecting pneumothorax. Within moments, the patient arrested. Three minutes into CPR, the chest x-ray confirmed large bilateral pneumothoraces. Chest tubes were immediately placed, but the patient never regained consciousness and subsequently died. False passage in the patient's trachea was discovered on autopsy. It was attributed to the surgeon's multiple passages of the tracheostomy tube.
The patient's family filed a wrongful death lawsuit against all members of the surgical team. The main allegation against the anesthesiologist was failure to timely diagnose and treat the bilateral tension pneumothoraces.
Errors of comprehension contributed to the delayed diagnosis of bilateral tension pneumothoraces. Experts opined the anesthesiologist had all of the information she required to make a more timely diagnosis. For example:
Multiple attempts at tracheostomy created a risk of tracheal injury and false passage.
A well-known complication of tracheostomy placement is tension pneumothorax.
When the patient's respiratory status started to decline, the switch to an endotracheal tube did not improve it; however, distal reinsertion of the endotracheal tube during the unsuccessful attempts at placement of the tracheostomy tube had initially provided adequate ventilation.
There was no improvement with bronchodilators.
The patient's inspiratory airway pressures kept increasing.
This case is an excellent example of how cognitive biases can influence situational awareness. "Zebra retreat" is a cognitive bias causing resistance to a rare diagnosis, although the clinical signs are present.8 Being aware of cognitive biases can prevent them from causing diagnosis errors.9
In cases like this, there is not a lot of time available for careful analysis. Lack of time plays an enormous role in comprehension errors. It is crucial to have pre-contemplated the potentially worst outcomes and have a rehearsed and efficiently executed plan in mind for when it occurs.
Case Four
Situational Awareness Issue:
The anesthesiologist became convinced that the monitors were malfunctioning, when, in fact, the patient's respiratory status was declining.
An anesthesiologist planned sedation anesthesia for ERCP with fentanyl, midazolam and propofol. Because the procedure room did not have an anesthesia machine with monitors, a portable monitor was employed. Surgery started at 1720. At 1730, the anesthesiologist noticed the patient's oxygen saturation and heart rate were falling, and the ETCO2 was rising. She performed a jaw thrust and called for a replacement SPO2 cable. Once the cable was replaced, the oxygen saturation seemed to improve momentarily, but it fell again. The anesthesiologist then called for a different monitoring machine. At 1745, the patient arrested. A code was called and the patient was revived, but she suffered a significant anoxic brain injury.
The patient filed a malpractice lawsuit against all members of the healthcare team. The allegations against the anesthesiologist focused on her delayed response to the patient's worsening respiratory status.
Experts disagreed about whether general anesthesia or a different sedation anesthesia technique should have been used. However, experts agreed the anesthesiologist's response to the patient's dropping oxygen saturation, dropping heart rate and increasing ETCO2 was problematic. The anesthesiologist's response was an "error of comprehension"; in other words, she failed to understand the significance of information available to her. Instead of concluding the patient's condition was deteriorating, the anesthesiologist became convinced the monitor was malfunctioning. Her fixation on monitor malfunction as the cause of the abnormal monitor readings is an example of anchoring and confirmation bias. Had the anesthesiologist believed what she was seeing on the monitor, instead of spending time trying to fix the monitor, she could have undertaken measures to improve the patient's respiratory status. It can be difficult to accept medical error, which can feel like a violation of the Hippocratic admonition "Do no harm." It is important to keep denial from clouding decision-making.
Experience and heuristics may reduce cognitive load, but biases can skew appropriate decision-making.4 Consider the following strategies to recognize deviations from rational thought processes and clarify thinking:4,9
Understand how non-rational cognitive processes can interrupt situational awareness.
Slow down your thinking processes and use analytical reasoning to work through complex or uncertain clinical presentations.
Test assumptions.
Seek alternative explanations.
Check information integrity and address problems.
Use cognitive forcing/self-monitoring strategies, such as:
"Rule of Three" - consider at least three alternative explanations before accepting a diagnosis, and reassess the diagnosis if the first three treatments do not produce the expected response.
"Rule out Worst Case" - consider statistically rare, but significant, diagnoses.
Use external decision support tools - checklists, written algorithms, clinical decision aids and guidelines.
Rehearse worst outcomes and planned response so that decision-making is efficient in the critically short time available.
Linger on clinical information that deviates from what was expected or seems usual. Consider what it means and why it happened. Readjust plans as appropriate.
Ask a colleague for input.
Projection Errors
In the ASA Closed Claim Project study, projection errors were defined as failure to predict potential outcomes based on a chosen plan and poor contingency/back-up planning.5 Examples of common projection errors include:5
Failure to plan for difficult airway management
Failure to account for patient comorbidities or surgery setting when planning anesthesia
Failure to plan for fire prevention in high-risk cases
Consider how the outcomes could have improved if the anesthesiologists had strategies in mind to address potential adverse outcomes of their anesthesia plans.
Case Five
Situational Awareness Issue:
The anesthesiologist failed to plan for potential respiratory arrest in a high-risk patient.
A 40-year-old morbidly obese woman with hypertension, asthma and obstructive sleep apnea was referred to an orthopedic surgeon because of shoulder pain. Prior to surgery, the patient received midazolam 4 mg, fentanyl 250 mcg and an interscalene block. General anesthesia was then induced with propofol. Rocuronium was used for muscle relaxation. The surgery was uncomplicated and no respiratory issues were noted. Following surgery, the muscle relaxation was reversed and the patient was transferred from the surgical table to a gurney. The anesthesiologist extubated the patient after he verified she was awake and breathing adequately through the ET tube. A supplemental oxygen mask was placed following extubation, and the anesthesiologist observed spontaneous breathing, with normal oxygen saturation and ETCO2. The patient was then detached from the monitors so she could be moved to the post-anesthesia care unit (PACU). Four minutes later, the anesthesiologist noticed the patient was not steaming her mask from breathing. He started bag ventilation. No pulse or heartbeat could be found. A code was called, but the patient could not be resuscitated.
The patient's family filed a wrongful death lawsuit against the anesthesiologist, surgeon and hospital, contending the patient was prematurely extubated and her hypoxia/anoxia was not recognized in a timely manner.
According to experts, the patient presented a classic risk profile for post-anesthesia respiratory arrest and hypoxia - she was morbidly obese; had a history of obstructive sleep apnea (OSA), a thick neck and an otherwise difficult airway; had received an interscalene block and was heavily sedated. Experts also believed the anesthesiologist should have anticipated that the patient's obesity and hypertension would significantly decrease the effectiveness of CPR and bag ventilation.
The anesthesiologist's first projection error involved his anesthesia plan. Nothing in the anesthesiologist's documentation indicated he adjusted the course of the patient's anesthesia or otherwise took her increased risk of respiratory arrest into consideration when planning the anesthesia. Assuming the patient's respiratory capacity was already compromised because of her obesity, asthma and OSA, experts questioned the administration of 4 mg of midazolam (a benzodiazepine), 250 mcg of fentanyl (an opioid) and the interscalene block, which would have partially paralyzed the diaphragm. The combination of neuromuscular-blocking drugs, anesthetics and opioids most likely significantly reduced the patient's respiratory drive, muscle strength and airway patency. Furthermore, considering the administration of multiple depressive agents, experts believed continual pulse oximetry was warranted postoperatively, and that failure to do so was a breach of the standard of care. Anticipating a worse-case scenario could have prevented the outcome.
The immediate extubation following surgery was also a projection error. Respiratory problems may not occur immediately after extubation.10 Experts believed that because of her risk factors and the medications, the patient should have been intubated for a longer period of time. They pointed out that the anesthesiologist could have weaned the patient off the ventilator in the PACU, when it could be assured that she was awake and able to breathe independently.
Perception error (having inadequate critical information) set the stage for the projection error.
Similar to aviation where the most risky times are takeoff and landing, the riskiest times during anesthesia are intubation and extubation. Consider the following recommendations for patients at elevated risk for postoperative respiratory compromise:10,11,12
Balance the benefits of perioperative medications with the risks of postoperative respiratory compromise.
Interscalene block commonly results in ipsilateral diaphragmatic paralysis (a phrenic nerve block).
Long-acting benzodiazepines and opioids have central respiratory and sedating effects. When opioid use is unavoidable, ultrashort-acting opioids may be preferable.
Plan for safe extubation.
Extubate patients when they are awake, unless it is medically or surgically contraindicated.
Before extubation, verify the full reversal of neuromuscular blocks.
During extubation and recovery, consider whether the patient can tolerate being placed in a supine position.
Use and support the development of protocols based on clinical guidelines for safe extubation.
Ensure all members of the surgical team understand the need for heightened concentration during intubation and extubation. Distractions should be minimized during these times.
Ensure the entire operative team is aware of the patient's risk profile and is familiar with protocols that need to be followed.
Adequately monitor patients following extubation and maintain direct observation of patients without distraction until they have been safely handed off.
Case Six
Situational Awareness Issue:
The anesthesiologist failed to consider and plan for potential resuscitation difficulties in a high-risk patient.
A 500-pound patient with diabetes, hypertension and OSA was scheduled for laparoscopic gastric banding on a weekday. Because of scheduling problems, however, at the last minute the case was moved to a Saturday, when only one anesthesiologist was on site, with no anesthesiology technicians.
General anesthesia was induced, but due to the patient's size and various other problems, after multiple attempts, the anesthesiologist could not adequately ventilate the patient. Ultimately, the anesthesiologist and surgeon decided to cancel the surgery. The anesthesiologist removed the endotracheal tube, turned off all the gases and administered flumazenil to reverse the midazolam and wake the patient. The patient began to wake up and resumed breathing on his own; however, he quickly became very agitated and started kicking and flailing. He pulled off his monitors and became disconnected from the oxygen. After struggling for a few minutes, during which time the entire surgical team was engaged in attempting to restrain the patient because of his size, the patient slowly became less agitated. When the team was able to reconnect the oxygen and monitors, they discovered he had no pulse. Chest compressions were started, but the patient never regained consciousness.
The family filed a wrongful death lawsuit against all of surgical team members. The case against the anesthesiologist, who was ultimately responsible for determining whether surgery could go forward, focused on his failure to reschedule the procedure to a time when there would be adequate staff to handle resuscitation of a high-risk, morbidly obese patient.
Various anesthesiologist projection errors compromised patient safety. Considering the high risk of complications, the anesthesiologist failed to accurately predict the need for an additional anesthesiologist or anesthesia technician. He would later admit that many of the problems he encountered could have been alleviated through the assistance of another anesthesiologist or an anesthesiology technician. The anesthesiologist also failed to plan for a potentially complicated resuscitation. Experts also believed the anesthesiologist should have taken into account the surgical team's probable inability to physically restrain or appropriately position the patient when approving the surgery.
Consider the following recommendations:4,13
Take patient comorbidities and surgery setting into account when planning anesthesia.
Assess the possible patient safety consequences and analyze the risks and benefits of going forward. Adjust the plan until the patient benefits outweigh the safety risks.
Communicate potential outcomes and contingencies to other members of the surgical team.
Have a patient-specific resuscitation plan in mind and ensure the surgical team is onboard with the plan.
Be prepared to readjust plans as new information becomes available.
Use "Prospective Hindsight" - imagine an adverse outcome to treatment because of an incorrect decision and answer the question, "What did I miss?"
Situational awareness during surgery requires an anesthesiologist to gather information (perception), understand it (comprehension) and plan for the consequences of decisions (projection) in a constantly changing environment. Errors of perception usually lead to errors of comprehension and projection. Consequently, it's important for anesthesiologists to ensure that the information they receive is appropriately robust. Passivity in information gathering is a common thread in liability claims. Comprehending the information and giving it meaning can be complicated by various non-rational cognitive processes that can result in incorrect and delayed diagnoses, despite the availability of accurate and complete information. Therefore, ongoing self-assessment and insight into personal tendencies and non-rational influences on decision-making can be critical to good situational awareness.4 Finally, the case studies analyzed in this article indicate how important it is to plan for unexpected outcomes to decision-making, particularly when patients have multiple comorbidities.
| Special thanks to Brian J. Thomas, JD, Vice President, Risk Management, Preferred Physicians Medical, for reviewing this article.
The NORCAL documents referenced in this article, along with many other Risk Management Resource documents and past editions of the Claims Rx, are available in the Risk Solutions area of MyACCOUNT, or by policyholder request at 855.882.3412.
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