Successful Claims Against EPs Involving Abnormal Findings After Patient Left ED
No process to reconcile inconsistent reports
A recent malpractice claim involved a patient who presented to an emergency department (ED) with severe abdominal pain for which abdominal and pelvic CT scans were ordered by the emergency physician (EP). "The radiologist verbally advised the EP that the patient had diverticulitis. However, the written report also included findings of free air and a perforated colon," says Brenda C. Tuck, RN, MSN, CPHRM, a senior risk resource advisor in ProAssurance Companies’ Washington, DC, office.
The patient had been discharged from the ED before the written report was available, and no one from the hospital contacted the patient with an update. He presented to a second hospital three days later, where he was diagnosed with sigmoid diverticulitis with contained perforation, a pericolonic abscess, and diffuse ileus requiring a sigmoid colectomy with colostomy and Hartmann’s pouch.
"The hospital failed to have a policy in place to reconcile inconsistencies between verbal and written radiology reports," says Tuck. "This delayed the diagnosing and surgical repair of the perforated colon, resulting in the development of an infection."
In a claim with a similar fact pattern, a patient presented to the ED with complaints of weakness and dizziness. He reported undergoing a coronary artery bypass graft approximately three weeks prior to the ED visit, says James S. Keeler, MEd, RN, ARM, CPHRM, a senior risk resource advisor in ProAssurance’s Richmond, VA, office. A portable X-ray was normal, and a CT was ordered to rule out subdural hematoma.
"The EP says he went to the radiology department and received a verbal interpretation of no acute changes,’ which he documented on the ER record, and discharged the patient," says Keeler.
The preliminary, handwritten, untimed report by the radiologist identified a 2 cm lesion near the pituitary midline. "It is unknown when this report was on the chart and available to the EP," says Keeler. "The hospital ED quality analysis said at the time of this event, a procedure for radiology report discrepancies was in effect for plain films but not CT scans."
Over several years, the patient developed significant vision problems and was ultimately diagnosed with ischemic optic neuropathy and permanent vision loss. "Not until over three years after the initial ED visit did an ophthalmologist order a CT scan, and identified the pituitary tumor, with a referral to neurosurgery and eventual transsphenoidal hypophysectomy," Keeler says.
The EP did not obtain a report from radiology prior to discharging the patient, and the hospital did not follow up on the abnormal radiology results.
"All subsequent treating physicians indicated the pituitary tumor caused the vision loss, and if diagnosed earlier, the patient could have been monitored and operated on sooner, preserving some of his vision," Keeler says.
Pressure to Discharge Quickly
A recent malpractice claim involved the EP sending a pregnant patient home before the result of a urinalysis came back. The patient was never informed that the result was positive for infection, and 48 hours later, delivered twins at home. "The final diagnosis was preterm labor due to pyelonephritis — a complication of a bladder infection that should have been diagnosed and treated two days earlier," says Stephen A. Barnes, MD, JD, an attorney at McGehee Chang Barnes Landgraf in Houston, TX. "The ED physician was sued and settled."
In another case, a pneumonia patient was discharged from the ED before a CT scan of the chest came back showing a massive pleural effusion and mediastinal shift. "The patient was not contacted until hours later, and the patient was now too weak to return," says Barnes. "Additional hours were lost attempting to get the patient to the ED by ambulance. On arrival, the patient coded and later died."
EPs are under pressure from administrators to discharge patients as quickly as possible, says Barnes, "but it is never a good idea to save an hour or two by discharging a patient with pending test results."
The majority of EDs simply have no infrastructure available to ensure follow up of such test results, says Barnes, or to answer these questions:
• Who will contact the patient when the results come back?
• What if the patient does not answer or respond?
• If the patient needs a prescription or other therapeutic intervention, which physician will be responsible for providing such care?
"While these are all questions that are very important if one discharges a patient with pending test results, they are made absolutely irrelevant if the emergency physician properly insists on complete data prior to discharging a patient," says Barnes.
To avoid "failure to follow up" claims, says Barnes, EPs "should trust no one regarding follow up, because the jury will believe that you should have trusted no one." EPs can consider these practices to avoid claims involving abnormal findings reported after the patient leaves the ED:
• ED staff and radiologists should be very familiar with all hospital policies involving reconciliation of inconsistencies between verbal and written radiology reports.
"Frequently held team meetings with ED staff should include other departments such as radiology and laboratory personnel," says Tuck, adding that such meetings should always cover these items:
-a discussion of communicating late lab results and final radiological findings;
-how these communications are to be clearly and consistently documented.
• When a patient’s test abnormality is discovered after the patient has been discharged from the ED, the patient should be informed via written, electronic, or telephone contact.
"The contact should be clearly documented, along with any unsuccessful attempts to contact the patient," says Tuck. "Certified mail is one method utilized to provide a verified attempt to relay information."
• Have a dedicated team of registered nurses and support staff to follow up on issues arising after patient discharge from the ED.
"The team’s primary purpose is to improve care transitions and communication with patients and primary care providers for patient safety, as well as to avoid legal liability," says Keeler. These are key responsibilities:
-reviewing patient charts and test results;
-phoning patients to give them test results and go over relevant post-discharge issues;
-contacting primary care providers;
-reporting relevant health data to government agencies;
-monitoring patients who leave before being discharged.
-bringing documentation concerns to the attention of EPs.
"In addition to reducing legal liability associated with failure to follow up, this type of program can improve the quality of patient care and improve satisfaction among patients and primary care providers," says Keeler.
When the test result is important in making or ruling out an acute diagnosis, however, by the time the patient or primary care provider is contacted, "it is simply too late," says Barnes. "I cannot stress enough the importance of an EP reviewing a complete set of data before ruling out an acute diagnosis and sending the patient home."
Sources
For more information, contact:
- Stephen A. Barnes, MD, JD, McGehee Chang Barnes Landgraf, Houston, TX. Phone: (713) 864-4000. E-mail: [email protected].
- James S. Keeler, MEd, RN, ARM, CPHRM, Senior Risk Resource Advisor, ProAssurance Companies, Richmond, VA. Phone: (800) 282-6242 ext. 6454. Fax: (205) 868-6380. E-mail: [email protected].
- Brenda C. Tuck, RN, MSN, CPHRM, Senior Risk Resource Advisor, ProAssurance Companies, Washington, DC. Phone: (202) 969-3101. Fax: (202) 969-3116. E-mail: [email protected].
