Transcript FTCA: Lessons Learned

The FTCA and You
(aka How to avoid getting sued
before it ever happens)
FTCA –
The Federal Tort Claims Act
FTCA 101
• Provides medical malpractice coverage to
providers and staff at community health
centers, as well as the VA, IHS, military
hospitals and other federal facilities
FTCA 101
• Since 1992
• Saves malpractice costs for FQHCs
• Provides a degree of legal “immunity” to
providers at FQHCs
FTCA 101
How the game is played…
• Jane Doe decides that her chronic back
pain is your fault
• Jane Doe calls a lawyer that she saw on
daytime TV ad
• Lawyer files suit in county or state court
alleging malpractice
FTCA 101
How the game is played…
• Provider receives subpoena
• Provider panics, cusses, etc…
• Medical Director notified ASAP
• Medical Director contacts FTCA guardian
angels at US Department of Justice
FTCA 101
How the game is played…
FTCA coordinators contact local lawyer to clarify
certain key issues…
1. Because the provider is covered by the FTCA,
all suits must be filed in federal court
2. The provider is represented by the US
Department of Justice… and they don’t look
kindly upon frivolous lawsuits
FTCA 101
How the game is played…
FTCA coordinators contact local lawyer to clarify
certain key issues…
3. They can’t sue the provider or their family…
The US government becomes the sole
defendant.
4. An independent medical review board will
consider the merit of the claim prior to any
proceedings
5. If a case is filed and pursued, there will be no
jury trial. A federal judge would hear the case.
No jury = No sympathy card… and minimal
damages for pain and suffering.
FTCA 101
Most frivolous lawsuits are dropped
within the first week
FTCA 101
Even if it proceeds…
And Uncle Sam loses or agrees to settle…
Your personal assets are protected
However… you’d still get a “ding” in the
National Practitioner Data Base
Practical Advice on How to Avoid
Getting Sued in the First Place
Cardiovascular Disease
• Chest pain should always be investigated.
• Assume that it is heart disease until
proven otherwise.
• Document management of risk factors and
adherence (or lack of) to treatment.
• Maintain a high index of suspicion in
patients with diabetes, the elderly and
women.
Cardiovascular Disease
• Hypertension: enhanced emphasis in
reaching goals for selected populations,
i.e., diabetes, pre-existing heart disease.
• Extremities: document pulses, look for
infection in patients with diabetes and
those who use tobacco (peripheral
vascular disease).
Medications
• Ask about allergies and the nature of the
problem.
• Ask again and again (every visit).
• Be alert to drug interactions and
document your conversation with patients.
• Consider the use of an electronic source of
pharmacologic information.
Medications
• Anticoagulants: risk of hemorrhage; drug
interactions with antibiotics and others
• Narcotics: sedation, risk of falls
• Antibiotics: allergies
• Digoxin: check dose in the elderly, nausea
• Statins: obtain CPK and follow it, tell them
about myositis and the symptoms
Medications
• Lithium: increased levels with dehydration,
certain meds and renal failure
• Do not refill until you are sure of the dose.
• Monitor for adverse effects (consider
standing order for blood tests).
• Bring medications to every visit.
Abdominal Pain
• High index of suspicion, particularly in
elderly.
• If not sure or severe, admit and obtain
consultations.
• Think abscess, pancreatitis, gallstones,
bowel ischemia, appendicitis
Infections
• Urinary Tract Infections: think
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pyelonephritis/bacteremia-fever, flank pain,
nausea, tachypnea, relative hypotension.
Look for skin lesions, respiratory rate and subtle
evidence of severe disease (sepsis).
Skin infections: suspect deep involvement when
pain is out of proportion to what you see.
Look for clues that may dictate admission.
Back Pain
• Look for alarm signals
• Recent trauma, history of cancer
• Bowel and/or urinary incontinence or
retention (cauda equina)
• Fever (epidural abscess)
• Cancer (epidural met and spinal
compression)
• Weight loss (malignancy)
Cancer
• Colon: bleeding, pain, change in bowel
habits
• Bladder: hematuria
• Lung: lung nodule, never assume that it is
benign unless you are sure; refer
• Ovarian: abdominal enlargement,
constipation
• Cervical: HSV, HPV
Breast Cancer
• Investigate all breast symptoms.
• Perform mammography.
• Palpable lesions must be investigated even with
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a normal mammogram.
Nonpalpable lesions with an abnormal
mammogram should be investigated.
Follow up and tracking if decide not to
intervene.
Obtain consultations when in doubt.
Pulmonary
• Evaluate shortness of breath; think of
pulmonary embolism
• Treat acute asthma according to
guidelines; early use of steroids, monitor,
admit, if necessary
• Follow up on abnormal chest x-rays,
particularly in smokers or former smokers
CNS
• SAH: severe headache (never had it),
neck pain; do CT and LP, if needed, neuro
consultation
• Headaches: alarm signals: new onset in
elderly, progressive, cancer history, neuro
signs, papilledema
Metabolic
• B12 deficiency (elevated methylmalonic
acid with low-normal level): neuropathy,
cognitive dysfunction, anemia
• Anemia: look for iron deficiency and, if
present, check for occult GI blood loss
• Electrolytes: diuretics (low sodium)-elderly
females
Extremities
• Document your exam (neuro, vascular)
during lacerations.
• If trauma and a lot of pain, think
compartment syndrome.
• If there is infection and a lot of pain, think
necrotizing fasciitis.
Extremities
• Trauma: Obtain x-rays to look for a foreign
body
Referrals
• Tracking to prevent lost reports or
nonadherence to consultations.
• Try to implement for x-rays, mammograms
and labs.
Patient Communication
• One of the most important factors.
• Call for follow up when ill and just seen.
• Call when new medications are started and you
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have a concern.
Express empathy and compassion.
Do not make inappropriate or judgmental
comments.
Become a good listener.
Do not blame for nonadherence to treatment.
Legibility
• All prescriptions and medical records must
be legible.
• Consider use of transcription or other
electronic means.
• The medical record is to document facts,
not criticize other providers (bad idea).
Office Environment
• Courtesy, respect of staff towards patients
• Training and monitoring
• Define unacceptable behaviors at the CHC
(includes providers)-Performance
Management
• Define disruptive behavior
Preventive Strategies
• Communicate with patient.
• Show respect and courtesy.
• Alert them if they are going to wait more
than 15-20 minutes.
• Develop referral tracking system.
• Do not make derogatory comments
toward patients.
Tracking
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Mammograms
Pap smears
PSA’s
Chest x-rays
• CT scans
• MRI’s
• Blood tests
ER
• Develop good relationships with the ER to
facilitate follow up.
• Develop protocols to obtain ER records of
your patients.
• Do not make negative comments about
the ER staff or the management.
Recommendations
• Read daily and develop high clinical knowledge.
• Maintain a high index of suspicion when dealing
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with certain situations.
Call your patients when they are being treated.
Develop referral tracking systems.
Write legibly.
Do not make negative comments about others in
the medical record.
Keep in mind common high risk situations.
Thanks