By Jock Hoffman, CRICO
For those of us left only to watch in horror on Marathon Monday, heeding Fred Roger’s advice
to “look for the helpers” gave us countless selfless acts to observe.
Many of those spectators and race participants who rushed to the aid of
the bombing victims were “off duty” physicians and nurses. Even though
many had never experienced similar circumstances, their instincts and
bravery saved lives and reduced injury severity. To all of you who
instantly engaged your dedication and training to literally begin
Boston’s healing process, and to all who put in extra hours and extra
shifts to care for the flood of victims, thank you.
Certainly no one who jumped in to help was thinking about their own
risks, but it is worth noting that legal and insurance “Good Samaritan”
protections are in place. Doctors and nurses in Massachusetts (and other states)
who perform emergency aid in the immediate aftermath of an accident,
natural disaster, or crime, are protected from malpractice liability
(unless their actions are wanton or reckless). In addition,
Massachusetts law
allows hospitals to temporarily employ clinicians credentialed
elsewhere in order to safely manage extraordinary events. And for a bit
more reassurance, at least for CRICO-insured physicians, their medical
professional liability coverage follows them wherever they practice
within the scope of their license. In concert, these protections support
those people who act heroically without hesitation—as we all saw on
April 15th when we looked for the helpers.
Additional Reading
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
We can assume that health care providers make fewer mistakes on those days when they are not overly busy, easily distracted, constantly being interrupted,
stressed, or dealing with personal issues, a leaky water heater, or
their car’s check engine light. You know those days, right?
Of course, health care providers generally do function safely and
effectively under challenging conditions. From the relative “quiet” of a
private practice to the more frenetic pace of EDs, L&D units, ORs,
understaffed labs, and overbooked imaging suites, health care delivery
is carried out in an environment that would likely immobilize many
non-health care professionals. Physicians and nurses, however, learn
how to filter out numerous everyday distractions and navigate around
routine diversions without compromising their vigilance to the patient’s
care and safety.
Almost all of the time.
But even those of you who thrive amidst organized chaos can become
preoccupied with a nagging concern, take on one task too many, or let
down your guard. Of course, this is when you are most vulnerable to
making errors, or to not catching your mistakes quickly enough to rescue
the situation. This is when you need an extra ounce of vigilance to
prevent patient harm and, perhaps, an allegation of malpractice.
So what throws you off your game?
- A new piece of equipment, new software, a new form to be filled out?
- A schedule snafu, a change in team members, a workplace dispute?
- A patient who reminds you of a loved one…or resembles a crabby neighbor?
- The day before or after vacation, or the first or last day of being on service?
- A pending malpractice case or a near miss?
- Traffic, a fight with your spouse, too many meetings?
- Something in the mirror that doesn’t look right, or a new and undiagnosed pain or ailment?
Many adverse events stem from seemingly small missteps in the
patient’s care. Self awareness of what might set you up for a
substandard performance is an important step in developing strategies to
compensate and perhaps avoid those little mistakes that can have big
consequences.
ADDITIONAL READING
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
Through the lens of medical malpractice, the efficacy of PSA testing
is only a sidebar to the factors that prompted someone to allege a
missed diagnosis of prostate cancer. Most often, such cases hinge on how
the test results and the patient were managed by the patient’s primary
care provider (PCP) once PSA testing was initiated. In some instances,
the patient was unaware that a PSA test had been ordered or uniformed of
the results (or both). Here are some recent CRICO data.
While the debate about PSA testing continues to generate recommendations and counter recommendations,
PCPs can look to a couple of recently closed CRICO malpractice cases
for practical lessons that can reduce the likelihood of being sued by
patients who contend their prostate cancer diagnosis was missed or
delayed.
Of course, it should all begin with a physician-patient discussion about
testing. But once the decision to test has begun, PCPs cannot afford to
leave the follow-up tasks to memory, other providers, or the patient.
Malpractice case studies present an important opportunity for providers
to learn by exploring what went right, what went wrong, and what could
have been done differently. Staff from CRICO’s Patient Safety Department
continually select and develop case studies (of closed claims or
lawsuits) that offer teaching opportunities. More than 80 such case
studies are available on the CRICO web site. Clinician facilitators who
choose to incorporate abstracts from malpractice claims into their
clinical presentations may want to read the suggestions offered in Ten Tips for Presenting Closed Claims Abstracts for Grand Rounds.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
A recently published study measuring the scope of care in an ambulatory practice (Harvard Vanguard Medical Associates) notes that a typical (full-time) general practitioner annually manages more than 1,100 different diagnoses, medications, lab tests, referrals, imaging studies and procedures; some do many more than that. That is both a testament to the complexity of primary care and a yardstick for the risk inherent in a profession that combines so many variables.
Malpractice claims and suits alleging a diagnostic error in a (non-ED) outpatient setting account for 67 percent of all CRICO cases based on care rendered since 2002. Roughly half of those involve cancer, but more than 50 different types; an additional 50 non-cancer diagnoses make up the other half. For 75 diagnosis-related cases involving Emergency Department patients from the same time period, more than 30 different final diagnoses were listed. Clearly, patient safety cannot focus too narrowly on particular case types but, rather, needs to address the potential pitfalls in the diagnostic process for all patients, especially outpatients.
There is, however, value in applying to a broader set of circumstances, generalizable lessons drawn from a subset of high-severity claims, particularly those alleging a failure to diagnose breast, colorectal, or prostate cancer.
Self-detected symptoms
Whether or not you can detect what the patient has indicated (e.g., breast lump, bloody stool, abdominal pain) he or she expects to be followed to conclusion. Leaving a self-detected complaint unresolved (in the patient's mind) may foster distrust. A subsequent diagnosis may be considered "missed" by a patient who believes he or she wasn't taken seriously from the beginning.
Patient risk factors
An insufficient or outdated history (personal and family) can inhibit risk-stratified screening—and timely referrals for high-risk counseling. Patients may need to be prompted and guided through the process of providing an informative history.
Test results
Following an ordered diagnostic test through to a conclusion requires both the ordering physician and other clinicians involved in the process to confirm that it was conducted, and that the results were interpreted, communicated to all pertinent parties, and discussed with the patient. Unconfirmed assumptions put both patient and providers at risk.
Follow-up
A follow-up plan has to become a follow-up action. Documentation, especially when shared with the patient and family members, helps, but only if it is structured with alerts to missed appointments or milestones.
Referrals
A referral treated as a one-way engagement exposes you and your patients to diagnostic delays if anything alters the intended course of events. Make sure to coordinate a closed-loop communication process with clinical colleagues, and clarify for the patient the roles of each of his or her providers.
Managing expectations
Any doubts you have that you will be able to translate a patient's complaint or symptoms or test results into a concrete diagnosis need to be balanced against the patient's expectations. Sharing the limits of the diagnostic process with a patient may help maintain his or her trust during a period of anxiety, and ultimately protect you against an allegation of substandard practice.
Given the vast amount of information patients expect their physicians to learn, retain, and appropriately apply, those physicians who complement their routines and memory with decision support tools are likely to make fewer missteps along the diagnostic path.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
Health care constantly intersects with challenging decisions, perhaps none more unsettling than the choice between waiting, or acting on an ambiguous presentation. If the patient is not physically present (e.g., on the phone or emailing), then the provider has even fewer cues to guide that decision. When the remote communication of history, symptoms, and status involves third parties (parent, interpreter, answering service, etc.) the risks associated with making a “wait” or “don’t wait” decision increase significantly. Such situations are even further complicated if the patient (or spouse or parent) is hesitant to leave home for the doctor’s office or the nearest emergency room barring a sense of urgency. Physicians and nurses who routinely have remote care encounters are encouraged to review this case study from a recent CRICO malpractice claim.
Malpractice case studies present an important opportunity for providers to learn by exploring what went right, what went wrong, and what could have been done differently. Although these cases often represent negative and emotionally charged circumstances, positive learning can emerge from examining them. Staff from CRICO’s Patient Safety Department continually select and develop case studies (of closed claims or lawsuits) that offer teaching opportunities. More than 75 such case studies are available on the CRICO web site. Clinician facilitators who choose to incorporate abstracts from malpractice claims into their clinical presentations may want to read the suggestions offered in 10 Tips for Presenting Closed Claims Abstracts for Grand Rounds.
Additional Material
Original Source, Strategies for Patient Safety
