Patient’s Medication History Was Pivotal Issue in Claim Against EP
Documentation of conversation with patient helped defense
When a patient who presented with a headache was asked about her medications by the emergency department (ED) nurse and again by the emergency physician (EP), she stated only that she was taking albuterol and fluticasone for asthma.
The EP ordered a CT and lumbar puncture, which were both normal, diagnosed the patient with viral meningitis, and gave her a steroid injection. "She also discussed pain meds with the patient," says Ashley Watkins Umbach, JD, a senior risk management consultant at ProAssurance Companies in Birmingham, AL.
The patient declined ibuprofen, and the EP administered an opioid narcotic analgesic instead. "The patient signed all of the discharge papers," she says. "She was walking out the door when she passed by the emergency physician, and said the reason she didn’t want [ibuprofen] was that she was on [warfarin]," says Umbach. "This was the first anyone had heard of [warfarin]."
The EP asked the patient to stay and let them check her international normalized ratio (INR) levels, but the patient refused. The EP emphasized the importance of following up with her regular provider to ensure that her INR level was within appropriate limits.
"The next day, the physician called the patient to check on her. She reminded the patient to check the INR levels, and documented this in the chart," says Umbach. This documentation ended up being helpful in the EP’s defense of a subsequent malpractice suit.
Several days later, the patient presented to another ED with low back pain and an elevated INR of 7.2. "The patient was diagnosed with an epidural hematoma and transferred to a hospital, where an orthopedic surgeon performed a laminectomy," says Umbach. The patient later sued the EP, claiming she had reported taking warfarin from the start of the ED visit.
"The emergency physician had not charted as well as she could have," says Umbach. "She had charted in bits and pieces during her shift, and the timeline was not clear."
It wasn’t apparent from the chart that the patient had already been discharged when the EP learned about the warfarin. The EP also didn’t chart that she offered to test the INR level while the patient was still physically in the ED, and that the patient refused.
However, the EP did document that she had called the radiologist to recheck the CT scan for evidence of a bleed, and that she called the patient the next day to remind her to check her INR level. "The jury could see that she appreciated the significance of the issue, and was looking out for the patient," says Umbach. "There was a defense verdict."
Standard of Care Varies
If an ED patient gives an inaccurate medication history and is harmed as a result, can the EP be held liable? "Because facts and circumstances differ in every litigated case, it is very difficult to speak generally about what is the standard of care for medication reconciliation in the ED," says Madelyn Quattrone, Esq, a senior risk management analyst at ECRI Institute in Plymouth Meeting, PA.
The resources of hospital EDs vary considerably, she explains. An urban or suburban hospital ED that has several hundred beds may have substantially greater resources than a facility with 20 ED beds and that has not yet adopted electronic health records and lacks sufficient pharmacy staff.
"The standard of care with regard to an ED physician and medication reconciliation may be intricately involved with the standard of care for the hospital," says Quattrone.
The question, says Quattrone, is "What should a reasonably prudent emergency physician have done in the same or similar circumstances, with regard to the safe prescribing of medication for the particular ED patient, in the particular circumstances in which the patient presented to the ED?"
"For medication reconciliation, a plaintiff’s expert might attempt to hold the hospital to best quality improvement practices for medication reconciliation in the ED," says Quattrone. This may involve use of an electronic health record and involvement of a dedicated pharmacist or pharmacy tech who rounds in the ED.
Document Reason for Overrides
"High-alert" medications, such as anticoagulants, narcotics, and insulin, have a greater risk of causing patient harm if they are used in error, says Cindy Wallace, a senior risk management analyst at ECRI Institute.
"The ED practitioner and the ED care team should be educated about the high-alert medications available in the ED, how errors happen with these medications, the steps the hospital is taking to avoid errors, and the staff’s role in error-reduction," says Wallace. For example, staff should independently double check the drug name and dose to confirm that it is the right drug and right dose before administering a high-alert medication such as heparin.
"Of course, adherence to recommended practices does not negate the need for good documentation," says Wallace. "The importance of accurate, timely, and complete medical record documentation cannot be overemphasized as a risk management strategy in the ED."
Poor documentation may be viewed by a jury as evidence of the provision of poor care. "Expert witnesses who review documentation for evidence of compliance with the standard of care may find inadequate documentation to support an opinion that the standard of care was met in a particular case," warns Wallace.
As more hospitals adopt electronic health records, they are building in alerts that, for example, prompt a practitioner to double check an unusually high or low dose ordered for a particular drug. "Here, documentation is essential if the practitioner chooses to override the alert," says Wallace.
An EP could be asked to provide the rationale for the override in a court case involving the care provided. "An electronic system that requires users to document reasons for clinical overrides may generate documentary evidence if the decision to override is later questioned in a malpractice case or in peer-review proceedings," says Wallace.
Sources
For more information, contact:
- Madelyn S. Quattrone, Esq., Senior Risk Management Analyst, ECRI Institute, Plymouth Meeting, PA. Phone: (610) 825-6000 ext. 5151. E-mail: [email protected].
- Ashley Watkins Umbach, JD, Senior Risk Management Consultant, ProAssurance Companies, Birmingham, AL. Phone: (205) 877-4481. E-mail: [email protected].
- Cindy Wallace, CPHRM, Senior Risk Management Analyst, ECRI Institute, Plymouth Meeting, PA. Phone: (610) 825-6000 ext. 5161. E-mail: [email protected].
