Patient Discharged; Then Abnormal Result ID’d?
Bad process could get EP sued
As part of the workup for a young woman with abdominal pain, the emergency physician (EP) ordered radiographic studies of the patient’s abdomen, and general surgery and OB/GYN consults. The on-call radiologist first read the studies as unremarkable.
The general surgeon ruled out appendicitis, but the OB/GYN, who was moonlighting shortly after having completed residency, did not feel comfortable reading the studies and asked that the patient be held for observation until he had an opportunity to speak with the radiologist. “As luck would have it, the patient was discharged before the radiologist could take a second look at the studies,” says Robert J. Conroy, JD, an attorney at Kern Augustine Conroy & Schoppman in Bridgewater, NJ.
The patient died from a ruptured ectopic pregnancy sometime after being discharged from the ED. When the radiologist later re-read the studies, she discovered evidence suggestive of an ectopic.
“As with most systems failures, there was no one around to say, ‘Stop, let’s think about this.’ If there had, the patient would have never been discharged without the OB/GYN signing off,” says Conroy, who defended the EP in the subsequent litigation. “The outcome was a substantial cash payout, and the OB/GYN physician was reprimanded by his state board.”
Did you send an ED patient home with a normal finding based on a preliminary reading of an X-ray or CT scan, and later learn that an abnormal result was identified based on the final interpretation?
The biggest liability risks for EPs in this scenario involve any area in which the patient’s care would have changed based on the test result, according to Randy Pilgrim, MD, FACEP, CEO and chief medical officer of Schumacher Group in Lafayette, LA. “The risk is that the patient either received treatment that wasn’t helpful, received insufficient treatment, or may have received harmful treatment,” he says.
Pilgrim says the ED’s system should do these things using “closed loop” communication processes:
• Ensure that anything that was ordered has a final and confirmed result;
• Ensure that this information is promptly communicated to the ED;
• Ensure that the patient is informed of the finding and given instructions for treatment and follow-up.
“Patients will typically forgive you if they can tell that the right thing was done as promptly as anyone could have done it,” says Pilgrim. “Patients are not very forgiving if there is no process in place at all, or if an existing process was not followed and it resulted in injury or loss of opportunity for health.” Here are risk-prone areas in ED processes for communication of abnormal findings to discharged patients:
• Communication might be delayed due to an incomplete handoff of information.
A patient’s cervical spine film is initially read as normal during the wet read by a radiologist or EP, but during the final read, is found to have an abnormality, which is identified on the radiologist’s dictation. However, no phone call or conversation occurs with an ED care provider.
“So the chart shows the abnormal finding, and the EP can only claim that no one told him or her,” says Pilgrim. “Closed-loop communication” is needed, he advises, meaning the radiologist communicates the finding, confirms that the EP received the finding, and, in turn, the patient confirms that he or she received communication and a proper plan of action.
Pilgrim once cared for a patient with a normal initial reading of a CT scan of the neck, but the final reading identified an unstable cervical fracture. The radiologist who did the over-read never notified the ED, assuming the first radiologist had already reported the abnormal finding.
Due to some persistent suspicion, Pilgrim decided to go back and re-read the CT, saw the abnormal finding, and immediately notified the patient. “Thankfully, I found out about it in time. The problem was one of process and effective communication,” he says. “What we really needed was prompt, closed-loop communication, followed by standard-of-care treatment and crisp documentation.”
• Hospitals sometimes lack a process for communicating abnormal results to an EP that can provide additional care or re-contact the patient.
When the patient is no longer in the ED, the abnormal finding might be entered into a medical record without the ED provider being notified.
“It never gets to a physician, midlevel provider, or a nurse who can act on that information, as it might have if the patient was still in the ED,” says Pilgrim.
Each ED should have a way of dealing with significant changes in interpretation, says Charles Emerman, MD, professor and chairman of the Department of Emergency Medicine at MetroHealth Medical Center and Case Western Reserve University in Cleveland, OH. “The exact way that occurs will be institution-dependent, but the final common pathway should be a way for the patient and/or their doctor to know of the changes,” he says.
If the hospital doesn’t have a good process for communicating abnormal findings, “the EP’s liability increases and, ultimately, it makes you work harder to overcome the process problem. That’s the bottom line,” says Pilgrim. For instance, to overcome a bad process, EPs might have to come in to review certain radiology, lab, or EKG reports from prior shifts. Lots of work, but necessary if the process isn’t optimal.
“In most cases, reasonable judges, jurors, or mediators will understand that the EP does not solely design or control hospital processes,” says Pilgrim. “However, they often believe that EPs should have played a role in advising or improving system-related issues.”
A plaintiff attorney might ask the EP, “How good is the ED’s process for informing you about abnormal or changed laboratory tests?” “If the answer is, ‘Well, it’s terrible,’ the next question may be, ‘What did you do to address the process so your patients get the best care you were capable of delivering?’” says Pilgrim. “If your answer is, ‘Nothing,’ you may appear to be an indifferent physician who is more willing to blame the hospital than invest in good patient care.”
• The ED patient might allege he or she wasn’t informed.
The question is whether the EP made reasonable efforts to communicate, and whether those efforts are reasonably documented, says Pilgrim.
If the EP’s recommendation is for the patient to see his or her primary care physician and the patient doesn’t have one, give the patient a specific address of a community health center to follow up with and document it in the chart, recommends Garzon. This kind of documentation might not prevent a lawsuit, but it makes the EP’s case much more defensible, she explains.
Garzon recently defended an EP named in a lawsuit alleging the patient was never notified that blood cultures drawn in the ED grew out methicillin-resistant Staphylococcus aureus a few days later. The procedure at that hospital was for the pharmacist to get all of those lab results, talk to the EP, get any new or changed orders needed, and call the patient.
“They had a form where they documented that the patient was called in the patient’s chart,” says Garzon. “The patient disputed that the form was accurate.”
The pharmacist was deposed and was able to produce a log book that she kept, separately from patient charts, that showed what number was called, when, and how many times, and what the response was. The log book showed that she called the number that the patient had provided three times and left messages each time, with no return calls. “After that deposition, the plaintiff dropped the hospital and ED physician from the case,” says Garzon.
• The patient’s chart may be unclear about when the abnormal finding was identified.
“The EP’s documentation should reflect the preliminary interpretation upon which they based their decision,” says Emerman. “That way it is clear, prior to the lawsuit, what information they had and when they had it,” he says.
Sources
For more information, contact:
- Robert J. Conroy, JD, Kern Augustine Conroy & Schoppmann, Bridgewater, NJ. Phone: (908) 704-8585. Fax: (908) 704-8899. E-mail: [email protected].
- Charles L. Emerman, MD, Professor and Chairman, Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH. Phone: (216) 778-3577. Fax: (216) 778-5249. E-mail: [email protected].
- Angela Gardner, MD, FACEP, Assistant Professor, Division of Emergency Medicine, Department of Surgery, University of Texas Southwestern Medical Center, Dallas. E-mail: [email protected].
- Michelle M. Garzon, JD, Williams Kastner, Tacoma, WA. Phone: (253) 552-4090. Fax: (253) 593-5625. E-mail: [email protected].
- Randy Pilgrim, MD, FACEP, CEO/Chief Medical Officer, Schumacher Group, Lafayette, LA. Phone: (337) 354-1105. Fax: (337) 262-7280. E-mail: [email protected].
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