Transcript Failure to Communicate

Disclosure
• Neither I nor any member of my immediate
family has a financial relationship or
interest with any proprietary entity
producing health care goods or services
related to the content of this CME activity.
• My content will not include discussion /
reference of any commercial products or
services.
• I do not intend to discuss an unapproved
investigative use of commercial products /
devices.
Preventing Malpractice
Lawsuits in Pediatrics /
Pediatric Emergency Medicine
STEVEN M. SELBST, M.D.
A.I. duPont Hospital for Children
Wilmington, DE
Jefferson Medical College
Philadelphia, PA
Closed Claims- Average
Indemnity 1985-2006
•
•
•
•
•
•
•
•
•
Neurology
Neurosurg
Ob-Gyn
Pediatrics
Intern Med
Emerg Med
Gen Surg
Ortho Surg
Fam Med
$302,181
$300, 843
$267,711
$261,231
$182,297
$158,401
$158,237
$148,053
$139,966
1st
2nd
3rd
4th
11th
15th
17th
19th
21st
Source: Physician Insurers Assoc of America, 2006
Malpractice Lawsuits
• 1/3 AAP
members named
• ED = high risk
• 85% suits involve
“off-hours”
• Most settle out of
court
• 10% reach jury
High Risk Cases
Pediatric Emergency Medicine

Meningitis

Appendicitis

Fractures

Testicular Torsion
Selbst SM, Friedman MJ, Singh SB Ped
Emerg Care, 21:165-169, 2005.
High Risk Cases
Pediatric Emergency
Medicine
•
•
•
•
Wound complications
Medication errors
Myocarditis
Dehydration
Why people sue

Bad outcome

Negligent care

Poor communication
Why people sue

Monetary needs

Anger/revenge

Guilt/displaced blame

“Save next patient”

Relatives

Greed
Lawsuits and The ED
Why Us?
Long waiting times
Impersonal registration
Brief contact with physician
Rapport not established
Physician strain
The Legal Process
Is it Malpractice?
• Bad outcome or bad practice?
• Was there a:
–Duty to treat
–Breach of duty
–Injury related to this
• Role of an expert
Standard of Care
What a
reasonable
practitioner, in
that specialty,
under those
circumstances,
would do
Risk Management Strategies
1.
Practice good medicine
2.
Communicate well
(patients, staff, consultants)
3.
Document the good care
Practice Good Medicine
• Act reasonably
•Consider mother’s concerns
• Observe if worrisome history, exam
• Focus on persistent vomiting, lethargy
• Arrange follow-up
• Look for improvement
Practice Good Medicine
• Follow policies and protocols
– Often sought by attorneys
– Make sure they are reasonable
– Defend deviation from guidelines
• Supervise trainees
– Lack of supervision-- medical errors
Singh H, et al. Arch Intern Med 2007;167:2030
Case Illustration
13 Year Old Male
cc: Abdominal pain
Allergy - none
Medications acetaminophen
Exposure - none
PMH - none
History (Nurse)
RLQ pain since last AM
Nausea, vomiting
Walks with obvious pain
NPO, no BM 2 days
Fever to 102
Resp easy, awake, guarding abdomen
Ambulates, off stretcher, no difficulty
History (Physician)
Began yesterday when woke
Throwing up, nausea
Pain mostly RLQ
Better with movement
Past history of pain with urination
Urine clear, no blood
Vital Signs
Temperature
103.9
Pulse
98
Respirations
24
Weight
44.6 kg
Blood pressure
122/82
Physical Exam
HEENT
Benign
Lungs
CTA
Heart
RRR
Abdomen Positive BS, tender R and LLQ
Mild-moderate involuntary guarding
No rebound, no mass
Rectal
Vault empty, no stool
Abdominal X-Ray
Small calcified mass - pelvis
Possible appendicolith vs renal stone
Official reading: “Appendicolith
cannot be ruled out”
CBC
WBC
9.76
Segs
83
Hgb
14.7
Bands 14
Hct
41.6
Lymph
2
Plts
233
Baso
1
UA
Sg
< 1.005
PH
6.0
Protein, glucose Negative
Bili, blood
Negative
Nitrates
Negative
Ketones
Trace
Impression
Probable renal lithiasis
Plan
Repeat UA
Acetaminophen
IV NS
Re-evaluation
PO taken well
Less pain
Mild abdominal tenderness
Impression: renal colic vs AGE
Discharge Instructions
Encourage oral fluids
Strain urine,
save any stones
Ibuprofen
Your Thoughts?
Case Illustration
Triage at 2000
16 yr old girl
Trouble breathing
45 minutes
PMH asthma
•
•
•
•
Alert, dyspnea
Numbness hands & feet
Lungs clear
T- 39.2
P- 112
RR- 40
BP- 112/90
Physician Hx at 2020
C/O left shoulder, LLQ pain
Began while driving
Numbness, tingling fingers
Difficulty breathing resolved
Now C/O pain everywhere
Saw psychologist in past
Exam
•
•
•
•
•
•
Alert, anxious, appears upset
Skin- warm, dry
Neck- supple
Heart/ lungs- normal
Abd- soft, LUQ tender
Extrems- 2 + pulses, FROM
Course 2130
•
•
•
•
•
•
•
Feels fine- “wants to go”
“Histrionic patient”
Abd soft
Joints FROM, no swelling
CXR negative
Assessment- Viral syndrome
Plan- recheck 3-4 days
Your Thoughts?
Communicate Well
Case Illustration
 16 year old “feeling terrible”
 3 ED visits in 5 days
 Dx flu, atypical pneumonia, stress
 Mother wants admission
 Mother escorted out of ED
 Admitted elsewhere with pneumonia
Failure to Communicate
70 % of lawsuits involve
communication style, clinician attitude
• Inadequately explained diagnosis,
treatment
• Failed to understand patient/family
perspective
• Discounted, devalued patient/family views
• Patient felt rushed
Beckman HB. Arch Int Med 154:1365-1370, 1994
Failure to Communicate
Families who sue are dissatisfied with
patient-doctor communication.
– 13% doctor would not listen
– 32% doctor does not talk openly
– 48% doctor attempted to mislead
– 70% doctor did not warn about
outcome
Hickson GB, et al. JAMA 267:1359-1363,1992.
Failure to Communicate
Unsolicited patient complaints
about physicians are significantly
related to lawsuits.
Hickson GB, et al. JAMA 287: 2951-2957, 2002.
Communication Skills

Patient satisfaction is key
 Consider professional training,
role playing
 Patient advocate helps
 Triage and registration important
Communications Skills
ED Physician

Unhurried appearance

Dress, posture, manners

Demonstrate compassion
 Apologize for wait time

Listen well

Speak clearly, simply

Hide your own anger
Communication Skills
• Tell family what to expect
• Keep family informed
• Don’t demean others
• Avoid joking, stray comments
• Calm angry families
Discharge Instructions
•
When to see PCP
•
When to return immediately
•
Review written instructions
•
Obtain signature
Medical Record
• Your best
defense
or
• Plaintiff’s best
witness
Recommendations for
Documentation
Carefully Document
• History of illness / injury
• Physical exam & vital signs
• Time of exam, orders, procedures
• Patient change or improvement
–“Tell the chart”
Recommendations for
Documentation
Carefully Document
• Conversations with consultants
• Reports of procedures, tests
• Diagnostic impression, thought
process
• Discharge instructions
• Disposition
Recommendations
For Documentation
 Show a concerned, professional
note
 Avoid inflammatory remarks
 Carefully note correct body part
 Document injuries with diagrams
Additional Recommendations
for the Medical Record
Do Not:

Black out or erase
 Engage in “battles” on paper
 Use insensitive terms
 Use unnecessary terms
 Alter the chart later
Advantages of Telephone
Management
• Many for the patient
• Some for office practitioner
• None for ED physician
Liability Case – Telephone
Mother called: 13-month-old baby, 3 day
hx of chickenpox . Now fever, bruising.
Office staff did not bring in for visit.
Child died from group A strep sepsis
following varicella.
Office has no record of phone call.
•
Settled for $400,000
Liability case – Telephone
Mother called: spoke with nurse in office
on Saturday. Teenage son had scrotal
pain. Nurse said doctor would call back.
No one called back until Monday. Testicle
lost from torsion, subsequent ischemia
and necrosis.
The plaintiff was awarded $150,000.
ED Telephone Advice
Mock Scenario
D. Issacman, et al Pediatrics 1992
5 week old - fever, signs of meningitis
87% EDs gave advice
28% did not ask age
60% advised same day evaluation
28% did not recommend evaluation
Disadvantages of Telephone
Management
•
•
•
•
•
•
Complete history is difficult
Physical exam is impossible
Many distractions in ED
Instructions may be misunderstood
Documentation is difficult
Follow- up is difficult
Indications for Telephone
Management
•
•
•
•
Poisonings
Life-threatening emergency
Help patient get access to care
Patients who just left ED
Always tell patient to come to ED
ISSUES OF CONSENT
Treating Minors Without
Parents
• Temporary custodians may
lack authority
• Allowed for emergencies
• Should attempt to contact parents
• Telephone consent should
be witnessed
15 year old boy
• Unaccompanied by parent
• C/O inguinal adenopathy
• Concern about GC
15 year old boy
• Should he be seen without parent?
• Should parent be informed of
diagnosis?
• Suppose mother gets bill, wants
info?
Treating Adolescents Without
Parents
Teaching Points
•
They often present without parents.
•
They often don’t want parents to
know of visit.
•
State laws for treatment vary.
Problems Related to Treatment

Medical issues
-Delay in care could harm patient
-History from teen may be incomplete
 Billing issues
 Ethical issues
Emancipated Minors Do Not
Need Parental Consent
 Married (past or present)
 High school graduate
 Pregnant (past or present)
 Self-employed
 Served in armed forces
 Living independently
Parental Consent Not Needed

Any medical emergency
 Venereal disease
 Pregnancy / abortion
 Contraceptive services
 Drug, alcohol abuse services
4 year old Choked on Peanut
•
•
•
•
RR 44, slight retractions
Decreased BS on right
CXR consistent with FB
Difficult IV, Mom angry,
wants out
4 year old Choked on Peanut
• Should mom be allowed
to leave AMA?
• Should you get court order?
• What are the dangers of
leaving AMA?
Leaving Against Medical Advice
Teaching Points:
Parents Have Rights to Refuse Treatment
•
Best to avoid this situation
•
Establish rapport with parents
•
Another physician may help
•
Document the scenario / sign forms
•
Invite them back
When Leaving AMA
is Not Permitted
•
Suspected child abuse
•
Life-threatening situation
•
Patient / parents are
disoriented
Teaching Points
•
•
•
•
•
Use caution- chest pain, abd pain
Use caution if child can’t ambulate
Care given by others impacts you
Change of shift is dangerous time
If consultant needed, insist on help
Teaching Points
• Vomiting is not always
GI
pathology
• Postpone LP if infant in distress
• Ask for help with complex wounds
• Read the notes of others
• Describe patient improvement
in discharge note
Bottom Line
 Listen to & talk with your
patients
 Provide high-quality care
 Document carefully