Preventing Clinical Errors in Hearing Care

Introduction:

The cost of providing and receiving healthcare continues to rise each year, partly because of the risks and liability associated with delivery of care. As healthcare advances, the complexities of diagnosing and treating medical problems become more apparent. Millions and millions of dollars are spent in resolving cases of medical liability, and our profession, while somewhat limited in scope and risk compared to other healthcare practitioners, is not immune. Regulatory agencies continue to impose more and more responsibility on the licensed practitioner, and it is worthwhile to acknowledge our professional accountability and take reasonable precautions to minimize the risk of clinical errors in delivering care to our patients.

Some hearing health care practitioners question how greatly medical malpractice concerns should impact their day-to-day practice. Malpractice can be either a deliberate or a negligent act committed by a health care provider, resulting in injury or other adverse outcome to the patient. As will be presented in this article, injury may encompass a broad spectrum of incidences from actual physical injury to the unintentional mismanagement of a patient's hearing loss.

Malpractice is defined by how one's delivery of services matches the expected standard of care in the community. As an example, in the state of Florida, the standard of care is defined by statute (The 2005 Florida Statutes, Section 766.102) as "The prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers." To ensure our own livelihoods as licensed health care providers, it is imperative that we be well versed in the areas of practice that may leave us subject to a loss of license or disciplinary action as the result of an avoidable clinical mistake.

The first rule in medicine, which may be applied here as well, is to do the patient no harm. While primarily addressing the patient's best interest, this mantra also protects the clinician and our organization from potential liability issues in the event that the patient is harmed or otherwise adversely affected during the course of clinical practice. One of the best ways to minimize adverse risk to our patients and ourselves is to follow established clinical guidelines that have been carefully developed to assist us in delivering conscientious and appropriate care. Scope of practice documents are available from the American Academy of Audiology www.audiology.org and the American Speech-Language-Hearing Association (www.asha.org), and we encourage all practitioners to be familiar with and to follow established protocol. Additionally, HearUSA Practice Guidelines, developed over a long period of time, are continuously reviewed and updated, and reflect "best practices" to the extent that we have been able to define them.

This paper has been developed to help identify some of the potential areas in hearing care practice that could lead to clinical errors. Hopefully, by brining these areas into focus, the probability of these errors occurring in a hearing care practice will decrease. The areas covered in this paper include:

• Infection Control
  
• History and Documentation
  
• Cerumen Removal
  
• Hearing Testing
  
• Earmold Impressions
  
• Circuit Selection of Programming Errors
  
• Verification Errors
  
• Electrophysiology Errors - ABR
  
• Electrophysiology Errors - ENG
  
• Supervisory Considerations

Infection Control:

In the delivery of any health related service, it is the healthcare professional's responsibility to ensure the safety of all patients served. Toward this end, it is imperative that audiologists and hearing aid dispensers provide their patients with testing and treatment environments that control for the transmission of disease from clinician to patient, patient to clinician and patient to patient.

Elderly patients, especially, may present with compromised immune systems placing them at particular risk of contracting infection while visiting a health facility. Direct contact occurs not only between clinician and patient but also between patient and equipment/tools that in turn come in contact with other patients. Adherence to established infection control protocol is especially important when potential for contact with bodily fluids exists.

While it is neither the intent nor purpose of this article to provide details of the implementation of infection control protocol, it should be noted that it is each professional's responsibility to ensure that established protocols are followed in a constant effort to reduce the occurrence of clinical errors within clinical practice. There are several published sources (Bankaitis & Kemp, 2005; Bankaitis, Kemp, Krival & Bandaranayake, 2005; Kemp, 2000) to find additional information on infection control including an internet course /audiology-ceus/course/infection-control-cerumen-mgmt-infection-control-in-hearing-aid-2358 on Audiology Online (Bankaitis, 2004)

Infection Control - Common Clinical Errors:

• Not washing hands between patients
  
• Handling unclean hearing aids
  
• Failure to disinfect patient contact areas
  
• Infrequent changing of ultrasonic solution
  
• Failing to clean and disinfect tools
  
• Reusing foam earphone inserts, tympanometry tips, and real ear measurement (REM) tubing without proper disinfecting
  
• Not washing hands after handling used tools and equipment
  
• Improper storage of clean and dirty tympanometry tips

History and Documentation:

It is impossible to develop an effective plan of care for any patient without first evaluating each patient's medical and audiologic history. By asking the right questions, we are in a position to determine the most appropriate direction of care, whether that is hearing aids, an assistive listening device (ALD), cochlear implant, and/or medical/surgical intervention. That's why it's important that we explore every question in a case history, and document the answers into the appropriate areas. This saves time and inconvenience in the future, especially if the file is audited by a managed care plan or other regulatory agency.

Good record keeping helps us stay focused and develop logical plans for patient care. Although time consuming, there are many good reasons for taking the time to record the results of each visit and contact with the patient. Primarily, it's important to have patient information available when reviewing the file. Secondly, patient files are legal documents and subject to subpoena, audit, and other types of regulatory review. Our professional name and license number is attached to the patient's record, and judgments and opinions are rendered according to the extent and quality of supporting documentation. To ensure that our work is represented well, we are best served by taking precautionary measures to detail progress and events.

Here is a simple example of poor documentation: "Patient is unhappy with hearing aids and never wears them." While the unresolved complaint was documented in the patient file, no follow up option or action plan was entered.

It is critical that hearing healthcare professionals keep records of the exact hearing aid make, model, circuitry, features and experiences of the previous hearing aid user. Appropriate recommendations for improvement should incorporate past experience as well as current and future expectations. We gain much insight from knowing the details of the previous fitting when we develop our go-forward plan.
If medical clearance is so indicated by the results of the test, it is important that we make reasonable effort to obtain it. Although the patient may sign the medial clearance waiver, there is still a professional and ethical responsibility to bring a medical opinion into the picture if there is some question about the patient's condition. Often physicians will view our communication with them as conscientious and professional, creating an opportunity to strengthen that relationship while making sure that our patients have appropriate medical direction.

If we are unable to acquire medical clearance, a fully documented entry in the chart describing the circumstances will suffice, as long as this is explained to the patient and the waiver is signed. (This step, of course, assumes a comfort level with the patient's medical condition and reasonable confidence that pursuing the fitting is not adverse to the patient's outcome).

A binaural waiver is signed when patients choose a monaural fitting when a binaural fitting was recommended. While there are few cases where litigation ensued when a binaural fitting was not provided, there may be some precautionary value to using the waiver. However, this is left to the discretion of the dispensing professional.

A detailed review of the history and current experiences, along with a carefully formulated plan to meet the patient's expectations, guides us in the right direction. Note, however, that it is strongly recommended that we utilize our collegial resources - more than 2 clinic visits without significant gains toward success is cause to ask for assistance from another professional colleague. Unresolved problems lead to frustration and failure for the patient and the professional!

History & Documentation - Common Clinical Errors:

• Failure to document all patient visits
  
• Failure to initial/sign and date all patient visits
  
• Failure to include subjective and objective data at each visit
  
• Failure to document actions and follow up
  
• Failure to evaluate and document previous hearing aid experiences
  
• Insufficient amplification history and documentation of needs and expectations
  
• Neglecting to print programming and real ear sheets for future reference
  
• Missing physician scripts and signed clearance forms as indicated
  
• Failure to ensure hearing aid make, model and style match CMS invoice
  
• Documentation fails to follow patient care adequately
  
• Failure to effectively address unresolved problems

Cerumen Removal

Cerumen removal is an area of clinical practice which presents the possibility of clinical error with subsequent malpractice litigation. Approximately 150,000 ears are cleaned of cerumen each week in the United States (Grossan, 1998). Cerumen management has become a prerequisite to comprehensive patient care within hearing care practices unless prohibited by a state's licensing laws. Within a rehabilitative/hearing aid practice, excess cerumen can interfere with hearing assessment, ear mold impressions, probe-microphone hearing aid measures and hearing aid function.

Cerumen removal procedures may include removal by curette, suction, or irrigation. Only physicians or audiologists who have been trained in cerumen removal should perform cerumen management. Audiology personnel engaging in cerumen removal should have documentation of appropriate continuing education for this procedure. Even with training, one's personal limitations should be recognized so that procedures attempted do not exceed either the comfort level of the audiologist or the patient.

Hearing instrument dispensers will find cerumen removal necessary at times in order to make ear impressions. However, it should be noted that clinical cerumen management is not within any scope of practice for hearing instrument dispensers and is not addressed in most state's licensing regulations for dispensers. For these reasons cerumen management procedures are not covered by the dispensers' professional liability insurance. It is paramount that hearing instrument dispensers neither jeopardize their position within their chosen profession nor place their employer at a potential liability risk. Patients requiring cerumen removal should be referred to an audiologist or a physician.

Cerumen Removal Contraindications

• Effusion in the ear canal or other active ear disease
  
• Hematoma in the ear canal
  
• Surgical modification of the canal wall
  
• Unidentifiable foreign objects
  
• Diabetic patient
  
• Pending legal proceedings
  
• Suppressed immune systems
  
• Bleeding disorders
  
• Required constraint for removal

Cerumen Removal - Common Clinical Errors:

• Ignoring Contraindications
  
• (see above) Unsigned cerumen consent form
  
• Neglecting to clean and disinfect cerumen tools
  
• Canal abrasions
  
• Improper storage of tools

Hearing Testing

Hearing aid dispensing is regulated through state licensing or registration within 47 of the 50 states. Testing must include as a minimum, except where concomitant handicaps or mental or chronological age preclude, speech audiometrics including word recognition measures, air-conduction threshold assessment, and a measure of middle ear involvement. Historically, this latter measurement is bone-conduction threshold assessment, typanometry and acoustic reflex testing.

To avoid clinical errors in our hearing care practice, even the most routine procedure must be controlled. The simple reversal of earphones cannot only alter the diagnosis but lead to erroneous recommendations of hearing aid parameters or surgical intervention. Patient confusion over testing procedures can result in false-positive or false-negative results. Double check your results and make sure that everything "adds up" and that obvious discrepancies are corrected. Likewise, when conflicting data is present, it is our responsibility to attempt to more closely diagnose the condition, not just to report it. For example, if a Type B tympanogram occurs with present reflexes, there is a problem with some aspect of the test. Similarly, if the speech scores do not support the air conduction thresholds, additional work is necessary to clear up any uncertainties. Rule out air-bone gaps that may be associated with improper insertion of insert receivers or collapsed canals.

Masking is an area that is confusing for some, but an important part of establishing the patient's diagnosis. Clinicians needing a refresher on masking skills may consult an introductory audiometric testing text, or work closely with their supervisor on this subject area. Inaccurate tests due to improper masking can lead to inappropriate recommendations, improper referrals, and inadequate hearing aid fittings. Diagnostic testing is not permitted through hearing instrument dispenser licensing. Dispensers by law must refer patients with potential medical problems for audiologic assessment when indicated.

An over or under estimation of required hearing aid gain and output levels can lead to the prescription of inappropriate hearing aid matrices or programming strategy. Determination of gain is based upon accurate threshold determination; output is based upon the measurement of tolerance levels. When performing REM in the presence of conductive involvement, it is important to enter the bone conduction scores because the target will change to compensate for the additional amount of gain required to overcome the air-bone gap.

Hearing Testing - A Note About Masking

In repeated surveys, most recently Martin, et. al., (1998), it has been found that depressingly large numbers of seasoned audiologists (and one would assume, hearing instrument dispensers as well) mask incorrectly, ostensibly due to a lack of understanding of the principles of cross hearing. Cross hearing always occurs by bone conduction and both test stimuli and masking stimuli can cross to the contralateral ear during audiometric testing. Some general concepts to hold in mind:

1. Masking is required any time the intensity of the stimulus in the test ear minus the interaural attenuation is equal to or greater than the bone conduction threshold of the non-test ear. (The best bone-conduction threshold of the non-test ear [excluding 250 Hz] is used when the test stimulus is speech.)
   
   
2. Interaural attenuation is assumed to be 40 dB HL when testing with supra-aural earphones, 60 dB HL with insert earphones and 0 dB when testing by bone conduction.
   
   
3. A masking signal in the non-test ear can cross as readily to the test ear as a test signal can cross to the non-test ear.

Hearing Testing - Pediatric Considerations

Test procedures will need to be modified based upon the clinician's professional judgment when working with a young child or an adult whose cognitive functioning precludes more standard test protocols. There are times that hearing instruments are fit on children before full audiometric data is available. It is for this reason that hearing instruments with the greatest flexibility are preferred for children. Frequent follow up and re-assessment will ensure that each patient receives the best possible care.

Hearing Testing - Medical Referral

Coordination of care between you and the patient's physician will ensure that the patient receives the appropriate treatment for the hearing condition, and provide a good opportunity for you to advocate for our profession while developing the professional relationship.

It is important that we refer to established practice guidelines to avoid the over or under referring of medical care. Under referring patients for physician intervention may deny patients the opportunity for the most effective and appropriate resolution to the hearing condition. Over referral of patients for medical care is costly and inconvenient. Professionals should follow practice guidelines that have been researched and developed with the goal of appropriate medical referrals based on the patient's subjective and objective evaluation.

Earlier mention was made of false air-bone gaps secondary to ear canal collapse or shallow insertion of insert receivers. It is imperative that referral for medical consultation be made whenever indicated from observance of any medical conditions or from test results that may indicate medical pathology. It is also important that any unnecessary medical referrals be avoided. The presence of artificial air-bone gaps due to test error is a primary source of over referral. Physicians and audiologists can call clinical judgment and competence into question if patient care is misdirected through erroneous test results and recommendations.

Hearing Testing - Common Clinical Errors:

• Improper placement of headphones (reversal) or bone oscillator.
  
• Poor or unclear test instructions to patient
  
• Inappropriate masking
  
• False positive air bone gaps related to insert receiver positioning
  
• Speech recognition testing at levels too low to reach maximum performance
  
• Failure to perform annual calibration on test equipment
  
• Failure to perform daily/weekly listening checks

Earmold Impressions

With proper clinical training and experience, the taking of ear impressions can be performed safely and is an integral part of everyday practice. It is important to note that in our experience the vast majority of incident reports and adverse events are related to this procedure. Through a conscientious approach to inspecting the ear canal and confirming otoblock placement, we can avoid causing discomfort to the patient.

While taking ear impressions becomes routine very quickly, it is important to remember that this is an invasive procedure that can lead to complications, and quite probably the riskiest procedure that we perform. Certainly, the potential for damage to outer, middle and even inner ear structures exists and this potential increases when taking deep canal impressions. Complications include, but are not limited to, canal abrasions, trauma lesions to the tympanic membrane and middle ear ossicles; accidental removal of a pressure equalization tube; perilymph fistula with resultant fluctuating, progressive, or long-standing sensorineural hearing loss; or concussive inner ear trauma accompanied by temporary or permanent threshold shifts.

Earmold Impressons - Ear Light Bracing

Whenever an ear light or otoscope is placed within the ear canal, appropriate bracing should be employed to avoid potential injury of the canal wall or the tympanic membrane. Placing the heel of the hand or the extended little finger against the mastoid process or the pre-auricular facial region will prevent the ear light probe from unexpectedly going to deep within the canal if the patient's head moves suddenly toward the clinician. This is especially important when working with young children, patients who may be frightened by the impression process, or patients with complicating disorders that preclude normal neuromuscular control, which may lead to unexpected movement.

Earmold Impressions - Common Clinical Errors

• Blow by
  
• Canal abrasions
  
• Impression embedded
  
• Hematoma

Circuit Selection and Programming Errors

With the introduction of programmable and digital hearing aids, dispensing professionals and patients alike were introduced to a new world of flexibility and possibilities. With these benefits came the added complexity of multiple memories and continuously evolving features and algorithms. Undeniably, programmable hearing aids are a tremendous advantage over conventional products for a number of very good reasons.

That's not to say, however, that the implementation of programmable amplification will automatically result in an improved patient outcome. It is incumbent upon us, as licensed practitioners, to employ the skills and techniques that will result in the patient realizing the many benefits.

Common errors, such as forgetting to save the program, or programming to first fit regardless of patient need or lifestyle, or neglecting to counsel according to the particular programming strategy applied can result in under-performance of the hearing aids. Many times the manufacturer will set a repaired aid to full-on factory settings, to check the device for quality control purposes then ship it back. Unknowingly, a dispensing professional may hand the aid back to the patient, who experiences a very unpleasant period of time until the aid is re-programmed at a future appointment. Any of these scenarios work against the added benefits that we are working to achieve.

Other areas of potential pitfalls are failure to take into consideration previous amplification experiences, and the identification of primary needs and expectations. Both of these areas have a significant influence on the type of circuit that we select, as well as the ways in which we apply the new technology.

The best way to make the most of the technological advancements of the day is through adherence to a disciplined process of evaluating pre and post hearing aid fittings, careful observation and analysis of both subjective and objective data, and an appropriate investment in patient education and counseling.

Circuit Selection and Programming Errors - Common Clinical Errors

• Not saving program into aid
  
• Handing back factory repairs that are not programmed appropriately
  
• Too much compression/Inappropriate compression strategy
  
• Not ordering appropriate options
  
• Not activating or programming additional memories
  
• Not incorporating past history into programming logic
  
• Over-reliance on first fit
  
• Not entering bone conduction scores on manufacturer order form when an air bone gap is present.

Verification Errors

Patients purchase multi-memory products with the expectation that a specific functionality is present. When the memory button is pushed and a secondary program is activated, the user is looking for a hearing aid response that matches the expectations and counseling provided at the delivery. When this does not occur, it could be that the program is defective, the program was not saved into the hearing aid memory, or possibly the program isn't functioning as it is intended. In any event, it is our professional obligation to demonstrate that the hearing aids are functioning well. This also provides an opportunity to give additional training or instruction, as indicated. This would be particularly true with directional microphones - we need to make sure that they work like we think they do, and that the patient has mastered operation of the programs.

Our goal is to provide adequate audibility, maximize speech intelligibility and maintain a zone of comfort within the patient's dynamic range. Output curves give us good information about the patient's ability to hear soft, medium and loud inputs. In order to make soft sounds audible (consonant sounds of speech), we need more gain for soft sounds. We can confirm this by measuring that the 45-50 dB input signal results in an output that is above the patients threshold (5-8 dB).

Loud sounds require less gain, and should remain within the patient's measured dynamic range. The 85-90 dB input signal, therefore, should remain below the loudness discomfort level by at least 5 dB. Many digital products will result in loud inputs being significantly below the Loudness Discomfort Level (LDL) curve. Keep in mind that we need to preserve a dynamic range of at least 30dB in order to preserve the elements of speech, so we won't want the curves compressed too much. Aligning the curves within 10 dB or slightly more will allow us to preserve speech intelligibility, without compromising the louder speech sounds.

It is clear that digital signal processing and features such as channel coupling and channel summation, along with speech enhancement and noise reduction algorithms, that adjustments to typical probe microphone measurements should be made. This includes changing the type of probe tube signal that is used and the length of time that the signal is presented.

Verification - Common Clinical Errors:

• Failure to verify settings
  
• Failure to verify multiple programs
  
• Failure to interpret output appropriately
  
• Failure to include bone conduction in real ear targets when a conductive component exists
  
• Not using modulated speech noise as stimulus for digital products

Electrophysiology Errors - Auditory Brainstem Response (ABR)

It often takes intervention on the part of the clinician to explore different means of stimulus refining in order to obtain the most reliable and valid responses. Such techniques include calming the patient, using a slow click rate (
Be aware that significant hearing impairment in the high-frequency range can negatively affect the morphology and absolute latencies of the ABR results, so it is necessary to identify the amount of impairment and apply correction factors as indicated. For example, a click @ 90 dB will result in an actual sensation level of 40 dB when a 50 dB threshold is obtained at 4 kHz. Consequently, a decrease in stimulus intensity will result in an increase in absolute latencies. It is recommended that correction factors be applied when the hearing threshold at 4 kHz is> 50 dB by subtracting .1 ms per each 10 dB of loss above 50 dB from all absolute latencies.

The use of insert earphones has reduced the negative effects of collapsed canals seen with headphones. However, other "technical errors" may be an issue. Ensure that the ear is free of cerumen, as an absent or significantly delayed response could be due to a clogged port on the insert. Also confirm proper placement of inserts deep into the ear canal. If the insert is dangling from the outer ear canal, the stimulus intensity has been significantly reduced and results may be invalid.

Electrophysiology Errors - Electronystagmography (ENG)

When performing ENG testing, a great deal of time and attention should be paid to describing the specific symptom that warranted the evaluation. History taking should include at minimum, time of onset, duration of symptom, types of related symptoms (feeling of fullness, hearing loss, tinnitus, etc.), neck/body/hip injuries, and prescription and non prescription medications/alcohol/tobacco taken regularly (although, a 48-hour cessation must be followed for most medications).Any other details gathered during the interview should be noted and explored.

The presence of middle ear fluid will alter the conduction of heat/cold during caloric stimulation and will result in fair test reliability. Tympanometry is always indicated prior to ENG testing to identify active middle ear disorder. The electrode montage may also affect the recording of results during the ENG. "Inverted responses" could be interpreted as a CNS disorder and the electrode montage should be the first area to review when the caloric nystagmus responses beat unexpectedly in the opposite direction.

Benign Paroxysmal Positional Vertigo (BPPV) is a unique pathology and includes very specific reactions in approximately 90% of the people affected. The Dix Hallpike Maneuvers are intended to elicit these precise symptoms: delay in onset of approximately 3-5 seconds, intense nystagmus (usually geotropic) with a sensation of spinning/falling, an eventual reduction in intensity of nystagmus and sensations, and a similar reaction when sitting up, to a lesser degree and probably beating to the opposite direction. A repeat of this maneuver is necessary to assure a fatigue from the initial maneuver's response. Each repeat will elicit a more subtle reaction when compared to the initial maneuver.

Appropriate tasking can be the determining factor in diagnosing pathology or not. Because the CNS is so strong, it can suppress the aberrant nystagmus reactions elicited by a specific ENG maneuver. It is important to know the level at which the patient can perform concentration tasks without being under or over challenged. Also, the presence of hearing loss or a language barrier will affect the communication effectiveness and may elicit unreliable responses.

Because the tympanic membrane must be directly stimulated to have the maximum effect of the water or air stimuli, it is important to review the TM after each caloric test. Otoscopic observation should reveal a redness/irritation on the TM; thus, verifying appropriate stimulation. Ear canals with cerumen debris, osteomas, excessive hair, and tortuous canals will present a challenge to the procedure. Absent or weak responses must be verified with repeated measurements and observation of appropriate TM stimulation.

The most common "technical error" is the assumption that any eye response obtained on the ENG recorder is a nystagmus response worthy of quantifying and interpreting. True horizontal nystagmus has a slow-phase (diagonal characteristic) and a repeatable consistent sequence. Eye blinks and twitches should not be interpreted as a significant finding.

Once a spontaneous nystagmus (a consistent sequence of direction fixed nystagmus beats recorded during the "center eyes-closed" ocular motor task; is apparent throughout all eyes-closed tasks) has been identified, it's effect on the inhibition or excitation of the caloric responses must be considered. It could mean the difference of a true absent response or a misdiagnosis of a present response.

Electrophysiology - Common Errors:

ABR

• Poor Transmission of Stimuli
  
• Poor Morphology
  
• Appropriate Ear Identification
  
• Unknown Peripheral Hearing Status
  
• Incomplete Medical History
  
• Failing to Confirm Normal ME Function
  
• Incorrect Electrode Montage

ENG

• Unknown Peripheral Hearing Status
  
• Incomplete Medical History
  
• Failing to Confirm Normal ME Function
  
• Incorrect Electrode Montage
  
• Identifying Benign Paroxysmal Positional Vertigo (BPPV)
  
• Using Appropriate Tasking Exercises
  
• Using Appropriate Air-Caloric Stimulation
  
• Identifying True Nystagmus versus Erroneous Eye-Movement
  
• Identifying the Effect of Spontaneous Nystagmus on Caloric Responses

Supervisory Considerations

Practitioners who are working under a state provisional license or under supervision are working under a pre-approved plan and under the auspices of a clinical supervisor. While these practitioners may be authorized to perform all duties of a fully licensed hearing health care professional, they must remain cognizant of the fact that any liability that may arise is shared by their supervisor whether that individual is physically present or not. Both supervisor and supervisee need to be familiar with the roles and responsibilities of their designated positions.

From time to time, employees may have a university student working under their supervision. It is the supervisor's responsibility to ensure that proper liability insurance has been attained in accordance with the University's guidelines and that proper supervision takes place. Although student supervision requirements in place by universities and state licensing agencies typically require only 25% supervision for therapy/rehabilitation sessions and 50% for diagnostics, it is a HearUSA policy that students receive 100% supervision for any invasive procedure including cerumen management and ear impression fabrication. Guidelines for supervision has been developed by AAA www.audiology.org and ASHA www.asha.org and additional information on this topic can be accessed via their web sites.

Supervisory Considerations - Common Clinical Errors

• Inadequate supervision and oversight
  
• Unfamiliar with state-specific requirements for supervision or sponsorship

When Clinical Errors Occur

As discussed in this tutorial, potential errors and mishaps are possible during administration of a variety of hearing care services. Most of these are avoidable by the conscientious clinician and quickly corrected when they occur. It is the ethical responsibility of all clinicians to provide the most efficacious services to their patients within a clean and safe environment. Certainly the areas most fraught with the potential for patient injury are cerumen removal procedures and ear impression fabrication. In the unfortunate circumstance where a complication should arise that may necessitate medical intervention, the following procedures should be followed:

• Fully document the circumstances and details of the event.
  
  
• If the condition persists the patient should return to the professional for advise and follow up. If indicated at the initial time of the incident, or subsequently upon follow up, the clinician should call the patient's physician, explain the situation and ask if the physician would like to see the patient, or if there is an ear, nose and throat physician that he or she would prefer be contacted. The phone call and subsequent appointment date and time should be documented. An exception to this would be if there were a medical emergency and in that case the patient should be seen as soon as possible by a physician.
  
  
• The details of the incident are not included in the patient file. The documentation should be filed separately under an incident file.
  
  
• The clinician should follow-up with the patient and/or physician following the medical consultation. The clinician's supervisor should be kept apprised of all developments.
  
  
• Take care to communicate and follow the patient through the incident. By conveying a sense of care and concern, we are best able to control the outcome and minimize further adversity.

About Cindy Beyer, Au.D.

Dr. Beyer has a master's degree from West Virginia University and an Au.D. from PCO School of Audiology. She has over 20 years of experience working as a clinical audiologist, supervisor and manager. She is currently the Senior Vice President of Professional Services at HearUSA.

About HearUSA

HearUSA provides hearing care to patients through contacts with health insurance and managed care organizations and to retail private pay patients. The company-owned clinics are located in California, Florida, New York, New Jersey, Massachusetts, Ohio, Michigan, Missouri and the province of Ontario, Canada. In addition, the company has a network of approximately 1,400 affiliated audiologists in 49 states. For further information visit www.hearusa.com.

Works Cited

The 2005 Florida Statues Chapter 766 Section 102. (2005). Retrieved on January 5, 2006 from www.flsenate.gov/statutes/index.cfm

Bankaitis, A.U. (2004) Infection Control in the Hearing Aid Clinic. Audiology Online. Retrieved on January 5, 2006 from /audiology-ceus/course/infection-control-cerumen-mgmt-infection-control-in-hearing-aid-2358

Bankaitis, A.U., Kemp, R.J., Krival, K., and Bandaranayake, D. (2005). Infection Control for Speech-Language Pathology. Boulder, CO: Auban.

Bankaitis, A.U. & Kemp, R.J. (2005). Infection Control in the Audiology Clinic (2nd Edition). St. Louis, MO: Auban.

Kemp, R. J. (2000). Infection Control in Audiology. Audiology Online. Retrieved on January 5, 2006 from www.audiologyonline.com/articles/arc_disp.asp?article_id=214