One in Three ED Suits Involve Poor Communication
Can patients truthfully claim that ED staff ignored their complaints and communicated poorly with one another?
“In litigation, patients’ families love to talk about how ‘No one would listen to me!’ to garner sympathy and paint the ED nurses and doctors as rushed and uncaring,” says W. Ann Maggiore, JD, an attorney at Butt Thornton & Baehr, PC, in Albuquerque, NM. “This is a very familiar refrain, and juries don’t react well to it.”
One out of every three ED malpractice claims involved breakdowns in communication by physicians, nurses, or both, according to an analysis of 1,304 cases occurring from 2006 to 2010 from Crico Strategies’ Comparative Benchmarking System database.
“Effective communication is critical when providers are managing multiple patients with diverse needs,” emphasizes Gretchen Ruoff, MPH, CPHRM, program director of patient safety services for Crico Strategies, a Cambridge, MA-based patient safety and medical professional liability company. (To request a paper or electronic copy of the report, Malpractice Risks in Emergency Medicine, go to http://bit.ly/Rsd5Ov.)
Multiple providers might be involved in the care of ED patients without a clear diagnosis, notes Ruoff. “If the problem is not immediately clear, those are the patients who spend the most time in the ED,” she says. “The process of ruling out life-threatening diagnoses and zeroing in on the right diagnosis occurs over a longer span of time than a patient with a high-acuity trauma.”
Various consultants might be involved, says Ruoff, and “all of those loops need to be closed, while each provider is balancing multiple patients.”
Over-reliance on electronic medical records (EMRs) as a primary means of clinical communication increases legal risks for EDs, according to Ruoff. “This has reduced face-to-face interaction and led to a loss of natural ‘touch points’ for providers to synthesize independent bits of knowledge about their patients, especially at change of shift,” she says.
Ruoff recommends that ED caregivers use “diagnostic huddles” to improve communication and reduce liability risks. “Providers can come together and make sure they know all of the information about the patient, not just the view of the screen they are looking at,” she says.
Crico’s researchers wrote the report partly because of findings from an emergency medicine leadership council held in 2012, which analyzed ED malpractice cases and found many were linked to breakdowns in communication among caregivers due to over-reliance on EMRs and other factors. “So we started looking at the data through that lens,” says Ruoff.
Having conversations about diagnostic questions enhances clinical decision-making, advises Ruoff. “Huddling as a group of caregivers with the intent of ensuring awareness of the patient’s situation and the developing plan of care is critical,” she says. “It doesn’t hurt to do it as much as possible — at the beginning and end of every shift.”
Extra Set of Eyes and Ears
“The ED is at extremely high risk for communication errors because of the environment,” says Maggiore. “Shift change is a particularly high-risk time.”
Information that is brought in by emergency medical services personnel, for example, must be documented and communicated to the ED receiving nurse so that the nurse has information about the scene and any treatment that has been rendered to the patient prior to arrival, says Maggiore.
“Communication between shifts is critical, as is the communication between paramedics and ED staff,” she emphasizes. If paramedics have given medications in the prehospital setting, and this is not communicated to the ED staff, duplication can occur.
“If an outgoing shift has given medications and not documented this properly, the incoming shift may administer additional medications,” adds Maggiore.
Even a non-clinical person is able to make important observations, such as that a patient has stopped moving, stopped breathing, is heading out the door in a hospital gown, or has pulled out a line or tube, says Maggiore.
“In the ED, an extra set of eyes and ears can’t hurt,” she says. “It is important to let these people know that their observations are important, and that if they see something going on with a patient that doesn’t look right, that they should let clinical staff know right away.”
To insure that information is taken seriously and acted upon, some hospitals have initiated “Speak Out” programs, in which everyone on staff is trained to be observant and to report anything that doesn’t look right, notes Maggiore.
“Family members are encouraged to be observant, and to speak out if there is anything that doesn’t look as it should,” says Maggiore. “Any time a patient’s or family member’s concerns are not handled in a respectful way, the road is paved for a lawsuit if the patient has a poor outcome.”
Sources
For more information, contact:
- W. Ann Maggiore, JD, Butt Thornton & Baehr, PC, Albuquerque, NM. Phone: (505) 884-0777. E-mail: [email protected].
- Gretchen Ruoff, MPH, CPHRM, Program Director, Patient Safety Services, Crico Strategies, Cambridge, MA. Phone: (617) 679-1312. E-mail: [email protected].
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