Emergency medicine physicians: Could these be your cases?

• A 35-year-old presents with shortness of breath and numbness to the legs. CXR and EKG are normal. She is discharged to see her doctor in two days, but is found dead at home. Autopsy reveals a dissecting aortic aneurysm.
• A 15-month-old is triaged to fast track and seen by a physician assistant for fever, lethargy, and ear pain. Treatment includes Augmentin. The next day the patient is admitted with pneumococcal sepsis and meningitis with severe brain damage.

Emergency physicians have a scary job, with each patient a potential landmine for bad outcomes and malpractice. Exactly how risky is our job?

In a study by The Doctors Company of 332 emergency medicine malpractice claims that closed between 2007 to 2013, 57 percent of claims alleged failure to diagnose such conditions as stroke, myocardial infarction, spinal epidural abscess, pulmonary embolism, necrotizing fasciitis, meningitis, testicular torsion, subarachnoid hemorrhage, septicemia, lung cancer, fractures, and appendicitis. The study did not differentiate between physicians and allied health professionals seeing patients in the ER, and although several patients may not have been actually seen by a doctor, the risk and malpractice cause is assigned to the emergency medicine profession.

Problematic treatment was alleged in 13 percent of cases, with examples such as lack of C-collar in a patient who ended up with paraplegia, improper electrolytic correction causing osmotic demyelination syndrome, failure to screen for drug overdose, and failure to address change in mental status. Allegations of improper performance of treatment (5 percent of claims) involved intubation, chest tube placement, and wound management that failed to recognize a foreign body.

Why did these errors occur? The Doctors Company does an in-depth analysis using a Comprehensive Risk Intelligence Tool (developed by CRICO Strategies) that found that 52 percent of malpractice cases were due to lack of obtaining all the clinical information that was available. This included not noticing important information in the health record and not ordering a required test, leading to an incorrect diagnosis or premature discharge.

Handoffs are a major liability risk that affects both emergency medicine physicians and other specialists. In the study, poor communication between providers contributed to patient injury in 17 percent of cases. Communication with patients and family was a factor in 14 percent of cases, involving issues such as poor follow-up instructions and language barrier.

Patient responsibility was also considered when analyzing claims for the factors that contribute to injury. This included lack of patient compliance with follow-up instructions and prescriptions, as well as patient obesity preventing the ability to obtain a CT scan or MRI.

System improvements in the practice setting can help prevent these types of medical errors. Here are some suggestions, and I am sure many physicians would have other tips to add to this list:

• Avoid first-impression or intuition-based diagnoses. Keep your differential diagnosis broad and open to make sure you think of all possibilities. For example, instead of “alcohol intoxication,” think “altered mental status” so that you don’t ignore other potential causes.
• Be alert for symptoms that should be red flags, such as lethargy in pediatric patients or lower extremity numbness in patients with back or chest pain.
• Avoid handoffs when possible, because they are risky. When handing off a patient to a fellow emergency physician or hospitalist, be sure to identify the tests that are pending and require follow-up. Structured protocols such as Safer Sign Out are helpful in standardizing sign-out communication.
• Have a protocol in place for difficult airway intubations.
• Be aware of the risk of retained foreign body in a wound. Before signing off physician extenders for suture repair, make sure you have supervised several cases and visualize the entire wound before it is closed. Use x-rays liberally for radiopaque objects such as glass.
• Pay attention to potentially suicidal patients. Some EDs routinely screen all patients for suicide risk. At a minimum, ask all patients with prior history of suicide attempt, psychiatric concerns, drug ingestion, and alcohol intoxication about suicide risk.
• Be aware of possible prescription medication addiction. Prescription-related deaths are the most common unintentional deaths in our country, more common than motor vehicle accidents. Opioid prescriptions should not be given to patients with chronic use, even if their prescription was lost or stolen or their doctor is out of town. Patients with chronic pain are usually educated with medication agreements that outline their responsibilities. The risk of chronic use is death, and the benefit of long-term opioid use for musculoskeletal pain has not been proven. Opioid and benzodiazepine combinations should be avoided. If you see medication interactions, alert your patient to avoid taking these together and discuss with their provider.
• Document patient compliance, such as whether the patient knows about and takes prescribed medications and whether the patient has followed up with his or her doctor.
• Provide specific follow-up instructions for nearly every patient: who, when, and return precautions.
• Include family members and document translation when talking to patients.
• If you have allied health professionals seeing patients independently, make sure you support a culture that allows for presenting even the simplest questions to a doctor.
• If you sign a chart from an allied health professional and are concerned about having your name on the chart, call the patient and encourage return for any concerns.
• Work with your EHR system to make sure important information is accessible and accurate. If there is a specific issue that would affect your patient care, document it in the record.

The Doctors Company study is helpful in not just identifying malpractice risks but also helping to prevent them. The data helps identify where the landmines are for liability risks. We can learn from this study how to minimize malpractice risk and improve patient care.

Roneet Lev is director of operations, Scripps Mercy Hospital Emergency Department, San Diego, California, and a member of SanDiegoSafePrescribing.org.

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