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Method and Medium
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Original Release Date: April 15, 2017
Expiration Date: May 1, 2019
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
Primary care physicians, administrators and other physicians and staff who receive actionable test results.
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Disclosures
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The emergency medicine physician faces a high volume of patient encounters that require prompt diagnosis and management of often difficult or puzzling clinical presentations.
This article addresses several challenges emergency medicine physicians face that impact patient care and professional liability exposure. The emergency medicine physician faces a high volume of patient encounters that require prompt diagnosis and management of often difficult or puzzling clinical presentations. Reaching accurate diagnosis and initiating appropriate management demands patience; requires analysis and the willingness to consider many possibilities; and asks that physicians practice risk management techniques of clear communication, vigilant follow-up and complete documentation. The closed claim data overview, case examples, and discussion of systems issues in this article are intended to illuminate these challenges. Risk management strategies are presented throughout to help physicians reduce the likelihood of a poor patient outcome and subsequent liability.
The most frequent medical factor (i.e., the allegation) in recent NORCAL closed claims involving emergency medicine physicians has been diagnosis error, which occurred in more than half of the claims. The most frequent associated issues (i.e., secondary issues) involved problems with patient history, examination or work-up (almost one-fourth of the claims). The most frequent care rendered in these claims was "interview and evaluation." We can infer that close attention to history, examination and work-up - which involve interview and evaluation - are keys to reaching an accurate diagnosis.
Kachalia, et al (2007), examined professional liability claims against emergency physicians. The information the authors gleaned is consistent with the NORCAL data. They found that more than half the claims involved a missed or delayed diagnosis. Review of these claims (including associated medical records), identified cognitive factors in nearly all cases. The study also cited high incidence of specific issues in the diagnostic process: failure to obtain an adequate history and physical; failure to order diagnostic tests; incorrect interpretation of diagnostic tests and failure to seek appropriate consultation.1
These data points should send a signal to emergency medicine clinicians and organizations to review their clinical and systems processes. Risk management education, such as this article, can support those endeavors.
Consider the challenges that arose for NORCAL-insured physicians in the following cases.
Patients Who Leave Against Medical Advice
Patients who leave against medical advice present risks to themselves and to the providers who were rendering care to them. Patients may leave with unresolved symptoms, no clear diagnosis, lack of treatment and little direction for follow-up. The potential risk to providers is a claim alleging negligence. Underlying this liability exposure is the provider's failure to explain to the patient the risks of refusing care and to document that this discussion took place (i.e., obtaining the patient's "informed refusal").
Case One
Allegation:
The ED physician's failure to adequately work up the patient contributed to the patient's death.
A 22-year-old female was brought by ambulance to the emergency department (ED) of a community hospital shortly after 2 a.m. on a Sunday morning. The patient's roommate had found her unresponsive in their living room and called 911. The roommate told paramedics that the patient had been at a music festival all day Saturday and had reportedly taken ayahuasca, a hallucinogenic drink. When the patient returned home around 9 p.m., she and the roommate drank several glasses of wine. The paramedics administered naloxone to the patient, and she began to respond on the way to the ED. The roommate met the patient at the hospital. The patient's father and stepmother arrived shortly thereafter.
Once the patient was placed in a room, she was fully awake. During evaluation, she vomited and complained of nausea and a headache, but denied having taken any opiates. The ED physician ordered urine and blood work, but the patient refused. The physician suggested to the patient that she rest for a bit and try to drink small sips of water; she also asked her to reconsider undergoing a blood and urine test so they could make sure there were no medical issues other than the probable effects of the ayahuasca and the alcohol. An hour later, at approximately 3:15 a.m., the patient became agitated and verbally combative with the attending nurse. She stated that she couldn't "stand being here one more minute," and then insisted on going home. The physician strongly recommended that the patient remain under observation for a while; however, the patient refused, and her father agreed to take her to his house. He said that he and his wife would take responsibility for watching her and making sure she recovered. The physician agreed to discharge the patient to her parents' care; she provided them with instructions relative to a discharge diagnosis of acute vomiting and nausea secondary to consumption of alcohol and hallucinogenic drugs.
Several hours later, the patient's stepmother called the ED and reported that her daughter had fallen asleep, and they could not wake her. The receptionist consulted with the ED physician who had evaluated the patient, and who was still on duty. She told the receptionist to tell the parents to call 911 and return to the hospital immediately. When paramedics arrived, the patient was still unresponsive. She was brought back to the ED. Resuscitation attempts were unsuccessful, and the patient died.
Experts who reviewed this case were critical of several aspects of the ED physician's care. They were concerned about the lack of substantive documentation, the inadequate work-up and observation, and her judgment regarding discharge of the patient.
Documentation There was no documentation that the physician had taken a history of drug and/or alcohol abuse. Although the physician recalled trying to convince the patient that it would be better to remain in the hospital, this was not documented in the record. The parents received generic discharge instructions; however, nothing in the chart indicated that the physician told them to watch for anything of particular concern (i.e., the patient becoming sleepy, exhibiting shallow breathing). There was no evidence that the physician discussed with the patient her use of hallucinogens and their effects.
Work-Up/Observation Two issues surfaced regarding the physician's work-up of the patient: 1) failure to obtain toxicology studies, and 2) absence of vitals taken and recorded at the time of discharge. An emergency medicine physician who reviewed this case thought the treating physician's order of urine and blood work implied the physician felt it was indicated and relevant to forming a diagnosis (indeed, the autopsy report revealed the presence of opiates). In addition, the physician reviewer opined that taking "exit vitals" would have closed the loop on the encounter and provided data that would have been material to the discharge instructions.
Discharge Decision Experts questioned why the patient was discharged instead of being released as leaving against medical advice (AMA). In deposition, the physician stressed that the patient's refusal was firm, and her parents provided a calming presence, about which she felt confident. Upon reflection, the physician acknowledged that the naloxone had reversed the effect of opiates in the patient's system, and that by the time the patient was at her parents' home, she was likely experiencing withdrawal and had overdosed on a medication that was available in that environment.
Incorporating the following risk management recommendations into your management of patients in the emergency department not only supports better patient outcomes, but can reduce the risk of a professional negligence claim.
Talk with the patient about the necessity of recommended tests and follow-up. Review the reasons for and benefits of studies, and the consequences of not obtaining tests or follow-up. Approach the patient with empathy and attempt to learn what might be behind a refusal.
The decision to proceed with tests or treatment, or to remain in the ED for a period of time, is ultimately the patient's. Sometimes patients make choices that do not seem to be in their best interest, and you cannot force them to do something. When you reach an impasse, treat the decision as an informed refusal of treatment. This includes discussing the risks of leaving against medical advice and options for the patient upon leaving.
Document the conversation, stating the patient's understanding of risks, and his or her ultimate decision. Documentation should be placed in the chart and, if available, on the hospital's leaving against medical advice form.
Always attempt to obtain the patient's signature on the form.
Refer the patient to supportive services, if applicable (e.g., Alcoholics Anonymous, Narcotics Anonymous).
Cognitive Bias in the Diagnostic Process
When a patient arrives at the ED with atypical symptoms, cognitive biases can get in the way of an accurate diagnosis. The following case is typical of the diagnostic challenges encountered by emergency medicine physicians in the evaluation of patients who are experiencing chest pain.
Case Two
Allegation:
The ED physician's failure to adequately evaluate the patient's pain contributed to her death.
A 48-year-old female was brought by ambulance to the ED at 11 p.m. with complaints of right chest and flank pain, as well as low back pain. The physician on duty examined her and, through a scribe, documented the presence of back and abdominal pain. The patient reported that she had experienced recent bouts of indigestion. The physician ordered a metabolic panel, urinalysis and an EKG. The EKG revealed slight abnormalities (Q-wave inversions, flat T-waves). He ruled out kidney stones; gallstones; urinary tract infection; pneumonia; and acute coronary syndrome. The patient was observed in the ED until 3:10 a.m., when she reported her symptoms had subsided. She was discharged home with a diagnosis of dyspepsia. Later that morning, after being found unresponsive at her home, she was taken to the ED by ambulance and was pronounced dead. The cause of death was an aortic aneurysm.
The ED physician did not consider aneurysm because of the patient's atypical presentation - she was relatively young, had normal vitals and had a mild level of pain. When considering his care in retrospect, the physician realized he thought the patient's presentation was too benign to raise suspicion of an aortic aneurysm - he envisioned aortic aneurysm manifesting in a more dramatic way. Instead, he pursued and ruled out other diagnoses that seemed more likely. This is a type of bias that can occur in the diagnostic process.2
Experts were critical of the ED physician's failure to investigate a potential thoracic problem (such as pulmonary embolism) once pneumonia and other conditions were ruled out. To rule out pulmonary embolism, the physician would have likely ordered a D-dimer blood test. If a dissection were present, D-dimer results would have been elevated and prompted ordering of a CT. One reviewer of this case questioned why the doctor did not order a chest x-ray. She thought that an x-ray might have led to a CT scan or ultrasound being ordered as a basis for ruling out kidney stones and gallstones. Had a CT scan been performed, it would have likely identified an aneurysm. It was also felt that the complaint of pain in more than one area was significant and warranted more extensive work-up.
Sparse medical record documentation also complicated the defense of the claim. The examination note was limited to, "Complaint of chest and abdominal pain." The physician failed to document any evidence of his decision making (e.g., rationale for not ordering a CT scan, not accounting for the patient's complaint of pain in multiple areas). There was no indication the physician discussed the abnormal EKG with the patient.
Consider the following risk management recommendations:3,4,5
Create an accurate record of what occurred during a patient encounter and demonstrate thought processes, rationale and medical decision making.
Establish a differential diagnosis. Develop a routine of asking yourself "what else might this be?" in diagnostic situations.
Consider various alternatives for a patient's symptoms.
Ask yourself what the worst possible diagnosis would be for a patient with the same symptoms.
Consider that a patient may have comorbidities or multiple disease processes occurring at the same time.
Consider less-common diagnoses when evaluating a patient, although you will not necessarily test for all of the other considered diagnoses.
Document your analysis.
When faced with an ambiguous diagnostic situation, think about:
Less-common diagnoses
Re-examining and re-questioning the patient
Re-reading the medical history and other chart notes
Taking other steps to gather additional information (e.g., diagnostic tests to help verify an initial impression or further investigation)
Educate patients by sharing information about their diagnosis with them.
In situations in which you are still investigating the causes for symptoms, educate patients about the diagnostic process.
Communicate as clearly and specifically as you can about what has not yet been ruled out, what to watch for, and what to do if symptoms persist or worsen.
Discharge Communication Documentation
In the following case, various errors contributed to the patient's death. However, the lack of adequate documentation of discharge communication significantly complicated the defense of the following claim, as the patient returned in full cardiac arrest shortly after discharge from the ED.
Case Three
Allegation:
If the ED physician had appropriately evaluated the patient for myocardial infarction and admitted him for further observation, the patient might have survived.
A 50-year-old male was brought by ambulance to the ED at 3 p.m. on a Saturday. The patient presented with complaints of chest pain and mild shortness of breath. The paramedics noted that the patient was experiencing twinges of pain in both arms, had a history of chronic atrial fibrillation and was taking warfarin. He did not smoke and denied using alcohol. His body mass index (BMI) of 43.5 indicated obesity.
The ED physician's exam revealed moderate-to-severe chest tenderness over the sternum, as well as mild edema in his legs. The patient had reported recently experiencing a mild cold or allergies, and that he had played golf the day before. Chest x-ray, labs (troponins, D-dimer) and an EKG were ordered. The chest x-ray showed an enlarged heart but no acute findings; the EKG showed atrial fibrillation and lab results were normal.
The physician considered the following differential diagnoses: musculoskeletal chest wall pain; pulmonary embolism; angina; a rib fracture; pneumothorax or a cardiac problem. He ultimately diagnosed the patient with musculoskeletal pain, based on the fact that the patient's pain changed with breathing; there was a more general tenderness of the chest; the pain increased and decreased when the patient changed position and his test results were normal. He concluded the recent golf game explained the pain and the recent cold explained the shortness of breath.
The physician ordered an injection of ketorolac and prescribed acetaminophen with hydrocodone for the pain. The patient was put on a monitor for two-and-a-half hours, after which time he reported that his pain had subsided. The patient was instructed to follow up with his primary care physician or return to the ED if his symptoms worsened. Six hours later, the patient returned to the ED in full cardiac arrest. Resuscitative efforts were unsuccessful.
Similar to the diagnostic process in Case Two, the physician in this case seemed to have arrived at a diagnosis at a certain point in the work-up of the patient and decided not to pursue obtaining additional information.
Expert reviewers had reservations about supporting the ED physician's decision not to order a repeat EKG (specifically a stress EKG) and troponins. It was felt that repeating these tests would have been valuable because evidence of a myocardial infarction can take some time to detect. The treating physician did not order repeat studies because he was able to reproduce tenderness when he pushed on the patient's chest.
There was also criticism about the physician's evaluation of the patient's pain: Lack of documentation made it impossible to confirm whether the doctor asked the patient if the pain stopped when he ceased pushing on the patient's chest. The chart did not indicate that the physician evaluated the timing of the pain (e.g., did it come and go, or did it last for a constant period to indicate heart pain?). The physician did not document anything about the patient complaining of twinges of pain in his arms, so it was never clear whether he reviewed the EMT's documentation. There was no evidence that the physician considered a cardiology consult, contacted the patient's primary care physician or obtained additional medical records.
The reviewers thought the patient should have been admitted for further observation, given that he was in some degree of pain when he was discharged and he had certain risk factors: obesity, chronic atrial fibrillation, mild lower extremity edema and taking anticoagulants.
The discharge instructions were also problematic, as they failed to correspond to the patient's complaints in any meaningful way. Experts questioned whether the ED physician had reviewed the printed instructions before the nurse reviewed them with the patient.
Consider the following recommendations:
Provide patients with written discharge instructions that include:
Summary of care provided
Working diagnosis
Pending test results
Follow-up instructions (i.e., patient is to follow up with a named resource on a specific date), including any specific follow-up needed and any pending test results
Instructions to the patient about what symptoms to look for and what to do should his or her condition worsen
Include a statement that instructions were reviewed with the patient or responsible party.
Consider having the ED staff make follow-up phone calls to determine the status of the patient's condition and whether the patient obtained appropriate follow-up care.
A Word about Follow-Up
If a patient fails to follow up after an ED visit and it results in injury, the ED physician who provided treatment may become the target of a lawsuit.
Physicians often ask about the patient's responsibility for follow-up. The patient does bear responsibility for following up on physician instructions; however, the physician is ultimately responsible for "closure." The physician has the knowledge and understanding to appreciate the importance of follow-up and communicate that to the patient; the patient's job is to carry out follow-up. The physician helps the patient accomplish this by stressing the reasons for tests so the patient has a vested interest in obtaining those studies. At the time of discharge, the physician helps the patient by educating him or her on what signs and symptoms to look for, what might or is likely to happen, when to return to seek additional treatment, and how to take medications and care for an injury. Documenting instructions and patient education is evidence the physician fulfilled his or her duty.
System Issues
Among the system issues that create risk exposure in emergency medicine are consultations with on-call specialists, hand-offs and test results received after discharge.
Obtaining Consultation
Emergency medicine physicians seek consultations for hospital admission, specific procedures, technical advice, and to arrange follow-up care after discharge. Potential pitfalls in these encounters include failing to contact an on-call physician when necessary; attempting to contact a consultant who is not available or is not responding; and finding that the consultant does not have adequate information to assist in a meaningful way.
The following risk management recommendations are offered to improve contact with consultants:
Use a standardized communication process so the consultant can differentiate this from other types of communication.
Communicate directly (i.e., by phone or in person) when possible.
Provide all relevant history and clinical information; make sure to include any clinically suspicious findings.
Convey your current impression/working diagnosis; do not edit information based on your preconceived idea about the diagnosis.
Provide the reason for diagnostic tests ordered, and communicate the results of those tests.
State what you need/expect from the consultant.
Note each time you contact an on-call physician and when you called; the time of the call back; the name of the physician; the advice the physician gave (including advice about admitting or discharging the patient and recommended follow-up plans); and the action plan.
When a problem arises with on-call physicians - these are usually coverage issues - emergency physicians need to work through the medical staff channels so that issues can be reviewed and resolved.
Hand-Offs
The patient hand-off between healthcare providers is a point of care where communication breakdowns occur. Reasons for this include the emergency room environment, which is rife with interruptions, ongoing patient concerns, and routine chaos, all of which can usurp the few moments of directed attention required for safe and effective hand-offs. In addition, if a hospital lacks standardized hand-off protocols, communication between physicians coming off and on shift can be difficult and disorganized. These obstacles set the stage for potential errors to occur. It is prudent for organizations to create consistent and standardized hand-off protocols and procedures; however, these should not be developed in a vacuum. Obtaining initial and ongoing input from those who will be using the hand-off process can ensure better compliance and success.
An ideal hand-off in the ED is complete - yet concise - and fits the particular patient situation. For example, in the case of a stable patient whose ED visit is nearing conclusion and whose likelihood of requiring further intervention is low, an adequate hand-off might be limited to a short phrase with a working diagnosis and a disposition. Conversely, an abbreviated hand-off might not suffice for a patient whose course is more complicated. The physician going off duty needs to advise the person coming on duty of any pending test results or any unresolved situations, and complete all documentation. A form or checklist can help facilitate communication of this information. The physician coming on duty should review previous documentation and perform his or her own assessment in order to form an opinion.
Examples of Hand-Off Models
SBAR6
S: Situation (a concise statement of the problem)
B: Background (pertinent and brief information related to the situation)
A: Assessment (analysis and considerations of options - what you found/think)
R: Recommendation (action requested/recommended - what you want)
I PASS THE BATON7
I: Introduction (Introduce yourself and identify your role in the patient's treatment.)
B: Background (Comorbidities, previous episodes, current medications, family history)
A: Actions (What actions were taken or are required? Provide rationale.)
T: Timing (Level of urgency and explicit timing and prioritization of actions)
O: Ownership (Who is responsible (person/team), including patient/family members?)
N: Next (What will happen next? (i.e., anticipated changes, plans, contingency plans))
Test Results Received after Discharge
The primary issues surrounding follow-up after discharge are handling of test results, incidental findings, and discrepancies. Included in this process is communication with patients and their primary care physicians. It is vital to have processes for managing test results and communication.
Develop a defined protocol to ensure:
Receipt of labs and other studies after patient discharge
Communication of results and/or discrepancies to the patient and primary care provider
Document:
Notification of the patient and primary care provider in the medical record
Unsuccessful attempts to contact patients and primary care providers
Documentation Tips for Emergency Medicine Physicians
Each of the cases in this article illustrates the importance of documenting thought processes and decision-making rationale. When a physician's care comes into question, lack of documentation can significantly diminish a physician's ability to support his or her treatment of the patient met the standard of care.
In addition to supporting the defense in malpractice litigation, a complete medical record promotes quality patient care by providing a comprehensive patient history and facilitating continuity of care among all members of the healthcare team. Strong documentation supports the extent of the physician's patient evaluation and treatment, including the level of complexity of medical decision making. Strong documentation is thorough, patient-specific and demonstrates the physician's thought process.
Examinations, re-evaluations, impressions and plans are well-documented. For example, a thorough examination of a headache includes the degree, type, location and duration of the pain.
Clinical decisions (e.g., additional studies, hospital admission) that follow exams and re-evaluations are clearly documented.
"Active" and "resolved" issues in a patient's medical history are consistently and clearly delineated.
There is evidence that a physician accesses prior patient records and reviews nursing notes.
There is clear documentation of consultation reports obtained, discussions with other physicians, transfers to a higher level of care (e.g., to stroke centers), referrals to establish care with primary care physicians, observation, counseling, patient agreement/consent and refusal, and time-outs.
The medication order list clearly displays the drug name, dose, route, frequency and indication.
A change to the record is appropriately entered as addendum (e.g., culture results that are received following a patient's discharge).
Communication with nursing is done through an order, so it appears as a consistent, easily located component in the chart.
Physicians sign off on all nurse practitioner and physician assistant chart entries, demonstrating proper supervision of the allied health professionals who work in their emergency medicine groups.
Scribes consistently enter their name to the note, under "Scribed by."
Caution re: Disclaimers in EHRs
Some hospital electronic health records (EHRs) contain a disclaimer for dictated ED chart entries stating that those entries might contain errors and omissions due to voice recognition software. Keep in mind that although disclaimers acknowledge the possibility of error, they do not prevent a person from filing a claim alleging negligent care and treatment. Moreover, such a disclaimer can imply that the provider is not taking responsibility for his or her documentation. The treating provider is obliged to review what has been transcribed into the chart for accuracy before signing off on that entry.
Emergency Medicine Physicians Involved in Triage
Hospitals and emergency medicine groups are increasingly considering involving physicians in triage, with the goal of improving ED flow and patient satisfaction.
These alternative triage methods fall under different names and concepts, including Triage Rapid Initial Assessment by Doctor (TRIAD), Physician in Triage (PIT), rapid medical evaluation, rapid medical assessment, team triage, and front-end triage. Desired outcomes of introducing these methods to EDs include shorter patient wait times (i.e., "door-to-doctor"), fewer incidents of patients leaving without being seen, shorter lengths of stay and reductions in ordering of unnecessary diagnostic tests.a
An article published by the Pennsylvania Patient Safety Authority reviewed studies on different triage systems, including having physicians involved in triage. The authors stated several advantages to the physician-involved model:a
Many simple medical conditions could be treated, and patients discharged, directly from triage.
Patients were admitted faster when a physician identified an appropriate medical condition during triage.
Treatments for symptom control (e.g., pain management) were initiated in triage, leading to symptom relief by the time a patient was evaluated by an attending physician, eliminating the time consuming need for reassessment before discharge.
Prompt and succinct communication between a triage physician and other attending ED physicians streamlined care in complicated cases.
Literature on the subject of alternative triage methods also recognizes that EDs have redesigned their physical spaces (e.g., intake areas) and arranged for supplies, equipment, and point-of-care testing to be within close proximity of the physician and others on the triage team.b Team roles are also well-defined. For example, physician-in-triage staffing could include - in addition to the physician - RNs, techs, registration personnel, and lab and radiology staff.c
Claims Perspective
NORCAL Claims personnel have not, to date, seen a case in which triage relative to an ED physician's involvement was an issue. Potential issues that could occur in ED claims include failure to attend promptly to a patient and/or expedite care to a more seriously ill/injured patient. Cases naming more than one ED physician traditionally involve change of shift and hand-off issues. For example, the first ED physician makes a diagnosis and starts a course of treatment, and subsequent ED physicians and specialists continue on the same track rather than making their own independent assessments. This might not be a problem if the first physician is correct, but if not, poor outcomes can occur. Another issue that can arise is a difference in patient evaluation between what the triage nurse observes and what the ED physician observes when first seeing the patient.
Risk Management Perspective
A system in which physicians perform triage (or other triage systems designed to improve patient flow, such as rapid medical evaluation) should be well-defined, include multidisciplinary involvement and agreement, and take into account environment design that supports safe and efficient workflow.
The literature reviewed does not indicate specific risks to patient safety when physicians perform triage. A primary risk management concern in any setting is ensuring that patient care does not fall through the cracks. In the ED, patients can be lost to follow-up if the patient leaves without being seen or without having evaluation and treatment completed. If staff does not execute clear hand-off communication, it can contribute to diagnostic error. Lack of defined responsibilities can also compromise care. For example, ED and radiology personnel need to be clear about who follows through on discrepancies.
The following risk management considerations are offered to address these concerns:
Determine who (i.e., RN, PA or MD) sends the patient to the next spot (level dependent upon the emergency severity index).
See: Emergency Severity Index (ESI): A Triage Tool for Emergency Department. Implementation Handbook, 2012 Edition. A Triage Tool for Emergency Department Care. Version 4. Available at: www.ahrq.gov... (accessed 3/2/17).
Ensure a clear hand-off process.
Develop a well-defined tracking process that starts the minute triage occurs and tracks where the patient is in the process, especially after the patient has been triaged, examined, and had tests ordered (e.g., patient is in results waiting area). This is particularly important during changes of shift.
Develop a policy for dealing with patients who leave without being seen. This policy is especially important if the patient has already started the evaluation and treatment process. A patient's information should be obtained as early in the process as possible to allow for appropriate follow-up if the patient then leaves.
References
a. Welch S, Davidson S. Exploring new intake models for the emergency department. Am J Med Qual. 2010 May-Jun;25(3):172-80.
b. Managing Patient Access and Flow in the Emergency Department to Improve Patient Safety. Pa Patient Saf Advis 2010 Dec;7(4):123-34.Available at: www.patientsafetyauthority.org... (accessed 3/10/2017).
c. Metzger N, Gunnett M, Prante C, Daly K, Friedberg B, Rivas J. Emergency department triage: a physician in triage (PIT) collaborative process. CEP America. News and Resources. 7/24/14.
Holding Orders
Emergency medicine physicians often find themselves in the position of writing basic "holding orders" to maintain the patient until the admitting physician assumes care. These orders generally cover antibiotics, pain medication and dietary needs, and it is generally understood that another physician (e.g., a hospitalist) will write the admission orders. This practice can present potential risk exposure, however, if it is unclear to the patient and/or the patient's family which physician has responsibility for the patient during the interval.
Emergency medicine physicians can take steps to protect themselves by working through medical staff and hospital administration channels:
Confirm that the hospital has a policy, approved by the medical executive committee, of limited holding orders.
To ensure that holding orders are appropriate for the patient's status, and that they facilitate safe care, refer to professional associations such as the American Academy of Emergency Medicine (AAEM)d and the American College of Emergency Physicians (ACEP)e for guidance. Both of these organizations emphasize that holding orders - and the timeframe in which they apply - be well-defined.
References
d. American Academy of Emergency Medicine. Position Statement on Admission Orders. December 2001. Available at: www.aaem.org... (accessed 3/2/17).
e. American College of Emergency Physicians. Writing admission and transition orders. ACEP Policy Statement. April 2010. Available at: www.acep.org... (accessed 3/2/17).
A number of factors raise liability exposure for emergency medicine physicians: Some conditions and injuries are difficult to diagnose definitively; treatment is episodic, so there is usually not the benefit of a prior relationship with the patient or access to medical records; patients tend to present with high-acuity conditions that require quick evaluation and analysis in order to institute treatment; patient flow is unpredictable, and high volume can exacerbate a chaotic work environment; treatment might require the involvement of multiple clinicians; and the emergency medicine physician can never be certain that a patient will follow through with instructions for care and treatment.
Much seems to be out of the provider's control; however, building strong systems around delivery of quality medical care can help improve patient outcomes and protect emergency medicine providers from potential allegations of negligence. Such systems include concise hand-off processes to ensure continuity of care. Communication and documentation are crucial for healthcare providers to do their jobs effectively and ensure that patients are not lost to follow-up. Documentation during the patient encounter - particularly of information gathered, assessments and plans, and the rationale for decisions - goes a long way to support patient care and defense of that care in the event of a claim.
| Special thanks to Jane Mock, Risk Management Specialist, for authoring this article, and Frank Curry, MD, 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.
Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from four liability insurers. Ann Emer Med 2007 Feb; 49(2): 196-205.
Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Quality and Safety. 2012;21(7):535-557. Available at: www.ajustnhs.com... (accessed 3/10/2017).
Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. The Journal of the Royal College of Physicians of Edinburgh. 2011;41(2):155-162.
Graber ML. Educational strategies to reduce diagnostic error: can you teach this stuff? Advances in Health Sciences Education. 2009;14(Supplement 1):63-69. Available at: www.isabelhealthcare.com... (accessed 3/10/2017).
Trowbridge RL. Twelve tips for teaching avoidance of diagnostic errors. Medical Teacher. 2008;30(5):496-500.
Institute for Healthcare Improvement (IHI). SBAR Toolkit. Available at: www.ihi.org... (accessed 3/3/17).
Agency for Healthcare Research and Quality (AHRQ). Pocket Guide: TeamSTEPPS. Available at: www.ahrq.gov/teamstepps... (accessed 3/3/17).
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