Norwegian Board determines each year a significant number of supervisory issues facing healthcare professionals and businesses in the health service based on information on individual events. Some of these will be published on this website in anonymous form. The cases are intended as such matters for the businesses and personnel to benefit from them and to inform them about our business and not as an aid to identification of individual cases and individual personnel.
The public demands for transparency in individual cases are handled through that anyone can request access to individual documents, based on publicly available mailing lists.
Exempt from public disclosure pursuant to offline a. § 13 cf. PAA. § 13, first paragraph. 1
Procedural process
The subject matter
Your statements to the case
Norwegian Board of Health reviews
About the concept of responsibility and diligent care
Emergency
Review
Norwegian Board of Health has decided to give you a warning under the Health § 56, first paragraph. We have concluded that you have violated the requirements for proper care and diligent care of the same Act § 4, and the duty to provide immediate assistance in § 7.
You can complain the decision within three – 3 – weeks of receiving this letter.
Procedural process
Norwegian Board received from the County of XXXXXX submitted two audits matters relating to your business as ophthalmologist by letter dated XXXXXX and XXXXXX.
Supervision cases concerning your treatment respectively XXXXXX, born XXXXXX (hereinafter patient 1) and XXXXXX, born XXXXXX (hereinafter patient 2).
We oriented you by letter dated XXXXXX that we would consider giving you a warning. You stated you to this by letter dated XXXXXX.
The subject matter
You are a graduate of the University of XXXXXX XXXXXX in, and received authorization as a doctor in Norway the XXXXXX, HPR no. XXXXXX. You were approved ophthalmologists in Norway the XXXXXX. At the time of the relevant events were you in private practice specialist with agreement with XXXXXX RHF (75%) and employed at XXXXXX HF (25%). You are now working in 100% position at XXXXXX.
Norwegian Board has considered the matter on the basis of the documents you’ve got submitted earlier in the proceedings. Below is a discussion of the factors that have had an impact on our rating.
Patient 1 ( XXXXXX , born XXXXXX )
The patient was at the time of consultation with you the XXXXXX a fresh woman on XXXXXX years.
Journal Notes from consultations
Of journal memo dated XXXXXX stated that the patient came to you as immediate help, because she in the morning the same day had suddenly Class for blindness in the right visual field (right-sided hemianopsia) combined with easy left-sided headaches. Furthermore, it says that the patient did not enter anything diplopia, and that she smoked. It is stated that the patient had no known diseases. She had been examined by ophthalmologist in XXXXXX because she had discomfort in left øyeblokk sometimes, without it ever was made some discoveries.
Upon examination of the visual field (Donders method), it was found homonym right-sided hemianopsia. The sight in his right eye and left eye was set to be 0.8. Upon examination of eye grounds, it was found pale eye grounds with clear lenses and “ neat ” optic nerve heads (papillae) although they were a little reddish (hyperemic). There were no signs that the optic nerve head was protruding (congestion). Furthermore, it was found “ pretty ” yellow vision spot (macula) of the retina and dense crossing phenomena. In parentheses is the noted “ smoking, hypertension .”
At the end of the journal paper says it indicated that the patient be referred to MRI of the brain and the eye socket (orbit) at XXXXXX HF, radiology department, considering the tumor in the left hemisphere (hemisphere).
The patient was then to consultation with you the XXXXXX. By preliminary examination of visual field with Donders method, did you right-sided hemianopsia, and upon examination of the peripheral visual field (perimetry) did you right-sided, incomplete hemianopsia in both eyes with deeper loss in the left eye. Journal memo states that you recommended control of the visual field about four months. It is further stated that the patient had preliminary lane ban, and that the family doctor did follow up the patient for driving license. At the end of the journal paper stated the following: “ The patient even seen not satisfied out today too (she has written appeal to the County Governor of XXXXXX XXXXXX about 1 survey) . “
Patient complaints
The patient has complained about the treatment she received from you in two letters to the County , dated XXXXXX and XXXXXX.
The patient indicates in his letter of XXXXXX that she was referred to an ophthalmologist after being on XXXXXX emergency. She was told that the doctor did not come before 09.00, but that she was referred to akuttime so she would be add quickly.
The patient waited in the waiting room, and noon. 9:00 gave the receptionist message to the waiting that ophthalmologist would be delayed. You arrived at closer. 09:30. The patient heard when she was mentioned as acute patient, and it was questioned whether you could inflow her first. You came looked and shouted two other patients. Time passed, and the next time you came out into the waiting room, you cried a third patient. The patient then contacted the emergency room again and wondered if it was not like that she should be checked by an ophthalmologist. Patient states that it seems like it then was given new messages, and she came in to you about kl. 10.50.
After you had examined the patient, she was reportedly told that she had lost 50% of vision in both eyes, but that there were eyes there was something wrong with. Vision loss could be due to a tumor or something else neurological. She was told that you had sent a referral to XXXXXX HF, and that you could not specify when she would get an appointment – she had to eventually turn to the hospital to know this. Further indicating the patient that she was told to go home and wait for the request.
The patient indicates that she was very distraught over this, and she tried to get reconsideration of emergency and their GP. The patient and her husband feared that there could be a blood clot, and they insisted that the patient was going to hospital for radiography. About. kl. 16.00 she was sent in ambulance to XXXXXX and around kl. 19.00 was taken a CT which showed an ischemic stroke.
In the appeal of XXXXXX stated that the patient felt that she was greeted by a “ very cross and person ” when she was back to consultation with you the XXXXXX. The patient indicates that you scolded her and accused her of having treated you badly. The fact that she felt badly treated by previous consultation, you should have brushed aside with the patient to understand that you were in a hurry as ophthalmologist. You should also have stated that you did something reprehensible during the consultation.
You did then new patient assessment. When the patient asked about the survey results, you should have said that she had to discuss this with your GP. The patient stood up then and left the office.
Your statements to the case
You have stated you matter in a letter dated XXXXXX, XXXXXX and XXXXXX.
From the statement of XXXXXX stated that you usually start your practice at. 8:30, but that you were delayed because XXXXXX. You indicate that you first saw an urgent care patient with questions about visual disturbance / visual field defect when you arrived at the office. 09:30. Then sow you the first two patients in your work list since they had waited for about five months to get to the hour. You show that immediate aid patients in addition to conventional patients on the list and that some doctors put them up at the end of the day.
You further indicates that you did a thorough eye examination of the patient, and immediately sent reference to the radiology department at XXXXXX hospital with ophthalmologist note. You emphasize that there is no “stroke unit” in XXXXXX, and that one does not have MR / CT in the radiology department, so that one can not make the correct diagnosis.
In the statement of XXXXXX indicates that you were not rude during the last consultation with the patient. What you said was that you thought that the appeal was unfair, and that you were disappointed because you always seek to do your best. Regarding the outcome of the investigations that were done, you say that the patient was explained this. She was told that she still did not fulfill the requirements for driving, and she got a printout of the results of the field survey. The patient seemed frustrated by this, and you said that further follow-up in terms of driving licenses had to be done by your GP, or neurologist. You mean you were professional and courteous and you regret that the patient was not happy, but believes that this does not excuse the false accusations against you.
In the statement of XXXXXX type that you usually had 1-2 immediate -help-patients daily in your practice in XXXXXX. You point out that you received the referral for emergency care when you arrived the office XXXXXX, but that there was no information in the citation that indicated that it was urgent “to the minute”; there were questions about visual disturbance and visual field defect. After the examination the patient was told that everything was normal with the eyes, and that the symptoms were caused by illness / injury to the visual pathway in the head. You deeply regret that you have not personally contacted the referring duty doctor.
When it comes to the patient’s other complaint, write the patient received explained the outcome of the investigation, and she received a copy of the current perimetry (visual field control) so all your patients get. This is also recognized in the discharge summary. You affirm that you appeared calm, professional and polite, but you apologize for that she has felt badly treated.
Patient 2 ( XXXXXX , born XXXXXX )
The patient is a woman with long-standing hypertension and poorly regulated diabetes mellitus type 2, chronic kidney disease with excretion of protein in the urine and two previous stroke.
Consultation with you that XXXXXX
The patient was his first consultation with you the XXXXXX. Journal memo stated that the patient had insulin-dependent diabetes type 2. The sight was set to 0.9 in the right eye and 0.2 on the left eye. The pressure was measured to be 17 mmHg on both eyes. The thickness of the cornea (pakymetri) was measured at 512. Upon examination of the eyes, it was clear media, neat optic nerve heads (papillae) and crossover phenomena. The yellow spot (macula) of the right eye was “ OK “, while the macula on the left side had laser brands. There was no sign of karnydanning (proliferations) or other forms of retinal disease caused by diabetes (diabetic retinopathy). Furthermore, it says that it was taken, and that the patient should be checked in XXXXXX. The diagnosis was stated to be E10.3 Diabetes mellitus type 1 with ophthalmic complications.
Consultation with you that XXXXXX
The XXXXXX was patient to its second consultation with you. Journal memo stated that the patient had insulin-dependent diabetes mellitus type 2 since XXXXXX age with previous heart attacks, two strokes and arthritis. The sight was stated to be “ +, 9 ed ” on the right eye and 0.15 in the left eye. The pressure was measured at 18 mm Hg in both eyes. About examination of both eyes says: “ Pale. Peaceful. Clear lenses “. Furthermore, it was “ pretty ” yellow spot (macula) of the right eye and laser marks left macula and the temple of the macula. It was not found karnydanning (proliferation), but I’ve found some mikroutposninger (microaneurysms) on the small arteries (arterioles) and tight crossover phenomena. Furthermore, it says that the patient had mild retinal disease due to diabetes. The diagnosis was stated to be E10.3 Diabetes mellitus type 1 with ophthalmic complications.
Consultation with you that XXXXXX
By Journal note states that XXXXXX. The note says that the patient had insulin-dependent diabetes and elevated blood pressure, and that she at last examination of eyesight (with glasses) at your substitute the XXXXXX, had had sight of 0.4 in the right eye and 0.2 on the left eye. It is further stated that the patient had had a stroke in XXXXXX and XXXXXX and that she had received preventive laser treatment for diabetes retinopathy. It is also indicated that the patient’s vision by examination (with glasses) with you in November 2011 was 0.9 in the right eye and 0.2 on the left eye.
In the current study was the vision (with glasses) considered to be 1.0 in the right eye and 0.2 on the left eye. The examination of the peripheral visual field showed deep and large loss in the temporal lower field on the right eye and deep loss towards the nose on your left. The pressure was measured to be 18 mmHg in both eyes.
Upon further examination of the eye found you pale, clear lens, pretty papilla and mild to moderate diabetic retinopathy in the right eye combined with dry macula. On the left eye there were similar conditions, with the exception of laser marks in the macula and temporal side of the macula. Furthermore, it says: “ Enlarge the OCT “. Finally states argued that considering that the patient does not meet the requirements for driving, and the patient should be checked in six months with regard to diabetic retinopathy. As diagnosis is indicated E11.3 Diabetes mellitus type 2 with ophthalmic complications.
Your statements
You have stated you matter in a letter dated XXXXXX and XXXXXX.
In the statement of XXXXXX specify that the patient was examined by you and an ophthalmologist substitute in the period after XXXXXX. Furthermore, you indicate that it was not made findings that were notifiable to the authorities before you examined the patient the XXXXXX. You write that the patient was referred to you the first time in XXXXXX considering the care of the diabetic retinopathy. You specify that such supervision does not involve assessment of vision. Furthermore, you claim that it was the special circumstances after XXXXXX, that made you also conducted field survey the XXXXXX.
In the statement of XXXXXX type that it is not normal in Norway to do perimetry (visual field control) by diabetes control. You also indicate that the patient after the controls with you in XXXXXX and XXXXXX was investigated, examined and treated by several doctors and ophthalmologists without her being deprived of license. XXXXXX. As XXXXXX, you found it reasonable to do perimetry in addition to the regular surveys. The results of the surveys indicated that the patient did not fulfill the requirements to hold a driver’s license, and this was reported to the police and GPs. You are now reading the CMO supervisor about guidelines for the counties in the treatment of a driving license issues, and you will strongly regret that the discharge summary of XXXXXX was not sent to the County of XXXXXX. You mean you acted properly, but this experience has made you even more aware of the symptoms in diabetics with regard to driving.
Norwegian Board of Health reviews
Norwegian Board of Health has assessed following:
- if you gave patient 1 proper diagnosis and treatment at the first consultation, ref. the Health § 4
- if you by not inflow patient 1 with once broke immediate aid duty in Health § 7
- if you gave patient 1 caring help at the second consultation, ref. the Health § 4
- if you gave patient 2 proper treatment, ref. the Health § 4
Below we list the relevant provisions.
The Health § 4, first paragraph:
health professionals must perform their work in accordance with the requirements of professional responsibility and diligent care that can be expected based on their qualifications, the nature of work and the situation in general.
The Health § 7:
Health personnel shall immediately notify the health care they abilities when it must be assumed that aid is urgently needed. With the limitations imposed by the patient and user Rights Act § 4-9, necessary health care is provided even if the patient is unable to consent, and even if the patient objects to such care.
If doubts about health care is of vital importance, health personnel carry out the necessary investigations.
The obligation does not apply to the extent that other qualified health provider assumes responsibility for providing health care.
If the concept of responsibility and diligent care
In the specific assessment of whether the way you act in the matter was proper, take the State Board of Health based on the general description of what should could be expected from professional practice. In determining what constitutes good practice, emphasis will be placed on current professional guidelines and / or guidelines.
What is justifiable is determined by an assessment of each case, and not on how the healthcare ideal should have behaved. By proper proportionality assessment we look to action alternatives in the current situation. Further emphasis will be placed on how great a risk of damaging a deviation will be associated with. The contents of the acceptability requirements tightened if there is great risk of serious injury if done incorrectly. Not any deviation from good practices considered as unjustifiable. There must be a relatively clear deviation from good practice before the action is indefensible.
Caring assistance is about the way patients are met at, and that she or he appears respect and empathy. Specifically, this gives manifested in the way healthcare is acting opposite and communicate with the patient. Caring health care requires that health professionals providing health care must be confident way. Patients are in a dependent relationship with healthcare providers provide health care, and must therefore have confidence in health services and health personnel. In a treatment situation are those professionals that sets the conditions and the patient is entitled to security in the treatment situation. Such confidence is partly dependent on the healthcare professional actor, with the ability to show care and respect in the face of the patient.
A doctor must therefore be conscious of their appearance and demeanor. It is also expected that the doctor is clearly in its communication with the patient so that situations not be misunderstood. Inadequate communication with patients can inflict the patients stress in that situation might be misunderstood, the diagnosis may be incomplete, and the treatment and follow-up of the patient may be indefensible.
Your diagnosis and treatment of patient 1
Good practices for assessment of patients with acute homonym hemianopsia
Homonym hemianopsia involves the loss of the right (or left) halves of sight in both eyes. Such Class for synsfelttap can be transient or persistent.
The most common cause of persistent homonym hemianopsia in adults, vascular conditions, such as for example stroke, and then follow the conditions as brain tumors, trauma, surgery and other diseases central nervous system.
An important difference between the homonym hemianopsia caused by cerebral infarction, and homonym hemianopsia caused by a brain tumor, is the time it takes for symptoms to occur. By homonym hemianopsia due to ischemic stroke, vision loss come acute, while the homonym hemianopsia due to brain tumor, vision loss occur gradually over time.
National technical guideline for treatment and rehabilitation for stroke (IS-1688) , indicating that patients with symptoms of acute stroke, immediately be admitted hospital with stroke unit for diagnostics, emergency care and rehabilitation. Furthermore, it is stated that patients with symptoms of acute stroke, immediately should be examined with CT or MRI.
Consultation no. 1
Despite the fact that the patient had acute encountered visual field defect, it appears that you suspected a brain tumor, and referred the patient to MR with this in mind. The fact that the patient homonym hemianopsia occurred acutely, however spoke against this patient’s visual field defect was caused by a brain tumor. Given that stroke is also a far more common cause of homonym hemianopsia, it should have been obvious to you that the stroke was a more likely diagnosis than gliomas, and the urgency of getting examined patient. The patient smoked, made it more likely that the patient’s visual field defect could be caused by a stroke.
You have indicated that there are no MRI or CT in the radiology department at XXXXXX. This suggests that it was urgent the more to get the patient to a hospital where the patient could get quick diagnosis and treatment for acute ischemic stroke.
We consider it as serious that you sent the patient home after the discovery of acute occurred homonym hemianopsia, without ensuring patient rapid diagnosis and treatment. The fact that you are not referring the patient to the immediate aid assessment and treatment in hospitals, increased risk that the patient could obtain permanent synsfelttap.
You have maintained that the patient was assessed adequately, assume that was no information in the citation or signs of the patient that would suggest that it was urgent “to the minute”, such as bleeding, pain, deconditioning, etc.. State Board of Health will again point out that emergency occurred homonym hemianopsia usually caused by disease, and that it urgent to get explored such a condition. We consider it seriously that you still do not seem to take this inward you.
Norwegian Board of Health finds that your diagnosis and treatment of patient 1 was academically indefensible, and a breach of the Health Personnel § 4.
Emergency
The provision of Health § 7 instant support triggers a duty to provide assistance for caregivers, and requires that health professionals act quickly where this is urgently needed. Assessments must be given to whether there is a risk to life or risk of serious deterioration of the health condition.
You sow ordinarily referred patients before this patient, but there is no proof that it was urgent to see these patients. You exposed to inflow patient despite the fact that she was referred to urgent care and it was reported from XXXXXX emergency that she had vision outcomes. As there are long distances to hospitals and the lack of CT / MR in XXXXXX, should the patient become add to you faster. The fact that you do not quickly sow patient who was referred as urgent care, and sow ordinarily referred patients before her, violations of the Health § 7.
Consultation no. 2
When it comes to your behavior towards the patient at the second consultation it
XXXXXX indicates the patient in her complaint that she felt like a very sour and cross-person and that you accused her of having treated you badly through its appeal for you to the County. In your medical record, you have indicated that the patient seemed satisfied by this consultation, and you have also noted that the patient had written a complaint to the County on your first examination of her. In your statement of XXXXXX specify that you felt unfairly treated by the patient, but that you were not rude.
In part you have recorded that the patient had complained about your treatment of her, and you have specified in your statements that you felt treated unfairly. Norwegian Board of Health therefore assumed that you were indignant over the patient’s complaint when you re so patient, and this may have influenced how you behaved towards her.
Norwegian Board of Health pointed out that the doctor is very important to behave professionally in such a situation, and the physician must treat the patient in a caring way even if the patient has sent a complaint on one. The patient is in a more vulnerable position than the doctor, which is the professional party in the relationship. Professional Conduct will also prevent the appearance of doctor weaken further.
Based on information in the case, adding Norwegian Board assumed that during the second consultation with the patient acted in such a way that the patient did not diligent care and that a breach of the Health Personnel § 4.
Your follow-up and treatment of patient 2
Good practice for diagnosis and treatment of eye disease in diabetes
Øyemanifestasjoner of diabetes mellitus is common, and diabetes is partly associated with retinal disease ( diabetic retinopathy), fluid retention and swelling in the “yellow spot” of the retina (macula edema), premature “cataracts” (cataract) and increased incidence of “glaucoma” (glaucoma). Diabetes is still a leading cause of vision loss and blindness in the industrialized world.
There is a clear correlation between poor glycemic control and risk of developing diabetic retinopathy in patients with diabetes. CMO national professional guidelines for prevention, diagnosis and treatment of diabetes (IS-1694) , entered earlier that long-term blood glucose (HbA1c) should be under 7%. This target was revised in October 2012 to HbA1c below or equal to 6.5%. It is also specified that patients with type 2 diabetes from the time of diagnosis should be checked annually; possibly less frequently with stable blood glucose control and the absence of retinopathy. Regular eye examina- is important for time to treat retinopathy.
A general eye examination will be so extensive that disease and conditions that may threaten the patient’s vision and other health being diagnosed. Such studies usually include the following:
- inspection of the eyelids, cilia (cilia) and lacrimal system
- biomicroscopy of conjunctiva, sclera, iris and lens
- direct and indirect ophthalmoscopy
- reflecting position, rent, mobility, pupils action, convergence
- vision with best correction
- Near Vision / lesesyn if necessary
- pressure in the eye (intraocular pressure)
- field (Donders method), or screening with perimetry
Eye examination for diabetic retinopathy should always be performed on both eyes and dilated pupils. Ophthalmologist performs its survey by ophthalmoscopy (direct and indirect) and with biomicroscopy (slit lamp and contact glass). Visusundersøkelse with best refraction and pressure measurement is a matter of course. Intravenous fluorescein angiography is usually indicated for anticipated treatment possible macular edema, and may be indicated by some other retinopatiformer such as threatening macular edema, preproliferative retinopathy and proliferative retinopathy. OCT (optical coherence tomography) is today taken routinely to follow the development of macular edema and OCT can complement and often replace fluorescein angiography.
It is important to note that stroke, and laser treatment for diabetic retinopathy, can cause visual field defects.
evaluation
It appears from the record that by consultations with the patient the XXXXXX and XXXXXX, indicated that the patient had insulin-dependent diabetes mellitus type 2 while the diagnosis is specified as type 1 diabetes mellitus with ophthalmic complications. Upon consultation XXXXXX, you specified that the patient had a diagnosis of type 2 diabetes mellitus with ophthalmic complications. We will initially emphasize that diabetes mellitus type 1 and 2 are two different diseases with different causes and treatments.
The fact that the patient had undergone two previous stroke and had undergone laser treatment, did the patient was exposed to could get visual field defect. The fact that you were familiar with these risk factors, did you should have examined the patient’s field of view closer.
In your statements you stated that it does not belong to the eye examination of diabetic patients to examine patient’s field of vision. In Norwegian Ophthalmological Society (NOF) its Quality Manual, states explicitly that it should be done examination of vision in patients with diabetes, but the investigating field belong to a regular eye exam.
The fact that you have not conducted examination of the visual field by some of your two consultations with the patient in XXXXXX and XXXXXX, despite the fact that you in XXXXXX was aware that the patient had ophthalmic complications related to his diabetes and was formerly laser treated in the retina and that, in XXXXXX was aware that she in addition also had had two strokes in the past, considered academically indefensible.
In both your statements to the case set the examination of visual field are not part of the examination of patients with eye complications due to diabetes. After the State Board of Health assessment suggests a lack of insight and recognition of the importance of field studies in diabetic patients with ophthalmic complications that have previously undergone stroke and laser treatment of the retina. This case shows the importance of such inquiries to be made.
About notification on driving licenses by Health § 34
Norwegian Board of Health will also attach some comments to the notification requirement for a driving license for Health § 34. In accordance with the regulation on the provision (regulations on physician notification that the holder of a pilot’s license or driver’s license does not satisfy health requirements) , the doctor finds that a patient does not meet the health requirements to hold a driver’s license, encourage the patient to hand their driver’s license if the condition is expected to last for less than six months. If your doctor is in doubt, or deems that the condition will last beyond six months, the doctor shall in writing notify the patient and to public authorities.

