Re-evaluate your incident documentation system
Ensure your reporting is complete
Sherlock Holmes may have conducted his investigations based largely on hunches, but in today's high-tech, legally explosive environment, health care officials need to rely more on documentation than hunches.
Risk managers, in particular, need to ensure top-notch documentation of potentially liable incidences.
If your health care facility is like most others across the country, you probably are not doing as thorough a job of documenting potential claims as you should be, legal experts and forensic engineers tell Healthcare Risk Management.
Do you know what kind of information you should be documenting when a visitor to your hospital trips on broken pavement outside your facility and breaks her arm? What if a nurse slips on blood in the operating room and herniates a disk? Or if a patient slides off a gurney after a wheel breaks off? (See the related story on p. 100.)
"Frequently, you do not know if a claim or a lawsuit will be filed at the time of the incident," points out Theodore J. Guis, PE, president of Guis & Associates, a forensic engineering firm in Montville, NJ. But typically, the engineering experts aren't called in until a suit is filed, he says, which can be two years after the incident. "If there is not proper documentation, it gives me very little to work with," he notes.
When accidents occur, most hospitals rely only on incident report forms to document the occurrence. The forms often do not contain any other information except for the name of the patient, the time and location of the incident, and a brief statement of the facts surrounding the occurrence. While this information is sufficient to start an investigation, it does not document what actually occurred.
Additionally, by the time the investigation is launched, especially a pretrial investigation, evidence may be lost, conditions may change, and memories may dim, Guis says. Information from the incident report usually is not enough to defend a claim to the fullest possible extent. To limit the health care facility's exposure to claims, risk managers should understand the types of information available at the time and scene of an incident and how best to document that information.
Quantitative vs. qualitative documentation
There are two types of documentation that lawyers and forensic engineers -- who often are called in to reconstruct an accident scene -- use to formulate litigation strategy:
* Qualitative documentation. This is the type of information health care facilities typically gather. It may include the name of the injured party, a statement of the occurrence, and the names of witnesses. For example, an incident report that stated that a visitor tripped over a broken sidewalk contains qualitative documentation.
* Quantitative documentation. This information includes accurate measurements, Guis says. For example, quantitative documentation of the same incident might state: "The fourth slab of the sidewalk immediately to the west of the main entrance of the hospital, was raised by a tree root, which creates a vertical projection of three-quarters of an inch on the north side of the walk and slopes to one-half inch on the south side of the walk," Guis explains.
Pre- and post-accident documentation is essential. The biggest problem most lawyers and investigators face when trying to defend a claim is a lack of documentation. Good claims management includes thorough documentation of all standard procedures before an incident ever occurs, says risk specialist Richard Maggi, JD, of McDermott & McGee in Millburn, NJ.
Here are key steps to take in improving your documentation:
* Document employee training. Risk managers should ensure that an accurate record of training given to hospital employees from every department is maintained, along with continuing education efforts. Education of every employee should include risk management and safety, Guis says.
* Be consistent. While the type of documentation that will be kept will vary with the type of activity that may be related to an incident, consistency is key. "You want to be able to establish what you were doing at a time contemporaneous with your actions," Maggi says.
For example, emergency departments often are ripe source of incidents for hospitals. Plaintiffs' lawyers will look for a breach in standard procedures to show negligence. Therefore, it is important that hospital officials be able to demonstrate that no breach of standards occurred. The best way to show this is to document all your activities so that problems are clear.
Also, risk managers should ensure that documentation of all treatments or administration of medications should be recorded contemporaneously in the patient's file. When a consistent pattern of documentation is established, it is more difficult for a plaintiff to disprove it.
Similarly, routine hospital maintenance such as washing floors should be documented consistently. Therefore if a visitor claims to have slipped on a wet floor, hospital officials can check their maintenance logs to determine possible sources of information regarding the floor's condition. Hospital maintenance staff should keep regular logs or records of their work activities in predetermined areas of the hospital, Maggi says.
* Do post-accident documentation. No amount of record keeping will prevent an accident. But what you leave behind at the accident may be the difference between a plaintiff's verdict and a defense verdict. Providing more quantitative information about an incident, whenever possible, will help investigators and lawyers, Guis says. To provide this type of documentation, employees need to know what kind of information is most helpful to an investigator and defense attorney. The following information is essential, Guis says:
* Identify all people involved in the incident. This includes the victim, witnesses, employees present, attending medical staff, and security personnel.
Include the correct spelling of names, addresses, day and evening telephone numbers, Social Security numbers, badge or identification numbers (if applicable), dates of birth, and driver's license numbers.
"Remember, it can cost far more to locate one difficult witness three years later than to write down the information for 50 people at the scene," Guis says. He also suggests trying to record statements from all of the parties.
* Record the exact location of the accident. Again, try to use quantitative documentation of the incident, Guis stresses.
If a visitor slips near an area where a broken water pipe was found, the lack of exact description of where the fall occurred will work to the plaintiff's advantage. Instead of documenting the location of the falls as "subject fell near pharmacy," the report should state "subject fell 10 feet due east of pharmacy door and three inches from the west wall."
* Tag any evidence involved and preserve it. If a patient slides to the floor after a gurney collapses, the gurney needs to be preserved in that state. Investigators and lawyers can study the gurney and determine whether a design defect caused the collapse instead of a faulty hospital maintenance program, Guis notes. The biggest mistake hospitals make is to repair the broken equipment and put it back into service, he says.
"If you simply take the piece off and replace it, you don't know what kind of failure occurred," he explains. "You just know it was a failure."
* Take photos. Film is cheap, and pictures, as they say, speak volumes. Use 35 mm film because it is easier to make copies and enlargements, Guis recommends.
Try these technical tips
Take photographs of the overall area to locate the general area of the incident, then close in on the specific scene or defect. (See the related story on p. 101.) Try to include a ruler, yardstick, or other reference in the photograph to use in evaluating any claimed defect or condition, Guis says. If a ruler is not available, use any other item of a well-known and predetermined size will work, including a quarter or a dime.
Do not mix rolls of film with incidents. Secure the roll in an envelope of paper with a description of each frame, if possible, before it is developed.
* Record observations. While the observations will vary according to the incident, Guis says that the following information is almost always important: date and time of the incident; identification of the victim; clothing and footwear ofthe victim; the victim's relationship to the facility; weather conditions; other unusual and pertinent facts (i.e., that the smell of alcohol from the victim's breath was observed).
* Call an expert to the scene. If the incident is serious enough, consider calling a lawyer or investigator to the scene to collect his or her own evidence. The plaintiff often will call in an investigator immediately, leaving the defense with nothing to rely on except the other side's documentation.
Documentation is valuable no matter what it shows Even if the documentation is damaging to your side of a claim, it can be useful to try to encourage an early settlement. *
Be prepared: Develop a handy documentation kit
Your staff will not be able to document incidents properly unless they have the necessary tools, experts warn. To remedy that, prepare documentation kits for use throughout your facilities, suggests Theodore Guis, president of Guis & Associates, a forensic engineering firm in Montville, NJ.
The kit should contain the following items, according to Guis:
1. Written procedure summary for accident documentation.
2. A floor plan of the subject building on which the location of the accident can be documented.
3 . A 35 mm camera with flash. Consider stocking the kits with several disposable cameras for efficiency.
4. A 1-inch-wide tape measure in a bright color and with legible numbers that will show up easily in a photograph.
5. A brightly colored yardstick with legible numbers.
6. A small tape recorder with a recorded statement outline. Include several tapes and extra batteries.
7. A clipboard and paper.
8. Evidence tags.
9. Contact phone numbers for risk management, insurance, and other necessary parties. *
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