A 49-year-old patient presented to an emergency department (ED) with complaints of eye pain, blurred vision, and unsteady gait. “A limited physical exam was undertaken, during which time the patient found the attending rude and dismissive,” says Sue Larsen, co-founder and chief operating officer of Astute Doctor Education in Laguna Niguel, CA.
When the patient expressed his concern that it might be something serious, the attending interrupted and told him not to overreact. The patient was discharged with a diagnosis of corneal abrasion, macular elevation, and hypertension retinopathy, but returned the next day with continued blurred vision, headache, and altered mental state. A CT scan revealed posterior and anterior artery stroke, leaving the patient permanently incapacitated.
“The patient and his family sued, sparked by the dismissive way in which he had been treated,” says Larsen.
In another case, a busy emergency physician (EP) arrived at a patient’s room for the initial exam, eager to move on to the next patient. “The patient wanted to ‘tell his story.’ However, the doctor was out of there quickly, after ordering a series of tests,” recalls Kathy Dolan, RN, MSHA, CEN, CPHRM, senior risk resource advisor at ProAssurance Casualty, a Madison, WI-based provider of professional liability insurance.
When the patient was finally reassessed, it was determined that additional testing was indicated. This resulted in a lengthy delay in diagnosis, treatment, and discharge, angering the patient and family. “The medical director and a nurse, with outstanding conversational skills, spent a great deal of time with the patient,” says Dolan. Together, they explained the chaotic nature of emergencies and apologized on behalf of the EP. A meal was delivered to the patient while she waited for the test results, and her family was provided lunch cards.
“The end result was an admission and a later transfer for her condition,” says Dolan. “It was an extensive effort to correct that initial meeting with the physician.”
Most litigation against EPs stems from poor communication, not lack of clinical competency, says Larsen. This is not readily apparent, however, as published cases typically focus on the precipitating clinical factors without giving details of the communication deficiencies that were involved in the patient’s decision to sue.
“When plaintiffs are asked what caused them to sue in the first place, generally they say it is because of how the doctor communicated with them,” Larsen says. “Rarely, however, do these specific drivers get reported with closed cases when they are written up.” Here are some approaches that can mitigate risk for EPs:
Use scripting to explain the process of the ED visit.
“ED nurses can explain that diagnosing illness in the ED will take time, and inform patients of average wait times for various tests and specialty consultation,” says Dolan. She gives this example of scripting to use at triage: “My name is Kathy and I am a nurse. I want to let you know that life-threatening situations and serious conditions will be cared for first, ahead of less serious illnesses and injury. We will be checking on you frequently, but if you feel something has changed, I will be happy to reassess your condition.”
Post white boards in patient rooms to let them know what was ordered, what has been returned and what still is being processed.
“This keeps the patient informed,” says Dolan. “If patients are placed in a room with no communication for hours on end, it can lead to problems.”
Encourage nurses to involve others if they detect unresolved issues at discharge.
“A perceptive staff member should stop the process and get the physician, nurse, and patient dialoguing on what the issue is,” says Dolan.
If a patient leaves the ED dissatisfied or has an unexpected bad outcome, make a follow-up phone call to address unresolved concerns.
“One of the main reasons that patients or family seek out legal counsel after an unexpected bad outcome is to get answers,” says John Tafuri, MD, FAAEM, regional director of TeamHealth Cleveland (OH) Clinic and chief of staff at Fairview Hospital in Cleveland.
If there is an unexpected bad outcome, the ED director could call the patient or family and ask, “Do you have any questions? Is there anything that you don’t understand?”
“Otherwise, they may go to an attorney to get those answers. Once an attorney is involved, there is likely to be a lawsuit,” says Tafuri. If the patient’s questions are answered upfront, on the other hand, they often won’t feel a pressing need to call a lawyer.
“If you are very specific, and give honest answers, most patients appreciate it,” says Tafuri. “Most patients are willing to give the physician the benefit of the doubt if he or she is honest and forthright.”
The EP who originally saw the patient isn’t necessarily the best person to make this call, adds Tafuri. Ideally, the call should be made by an ED director or a neutral person who would not otherwise be involved in the case.
There is always the chance that the individual who makes the call will be deposed about what was said. “But in my experience, a frank discussion at the time of the incident or a follow-up call to the patient or family mitigates risk,” says Tafuri.
In one such case, a 35-year-old healthy patient was brought in with a stable drug overdose. The EP intubated the patient and the nurse was instructed to administer charcoal via an Ewald tube.
“Unfortunately, the nurse placed a nasogastric tube into the lung, despite the intubation, and administered the charcoal,” says Tafuri. “The patient died within 10 minutes.”
Despite the objections of the nursing supervisor, the EP informed the family of exactly what happened and answered all of their questions. No lawsuit was ever filed.
“If the family had not been informed contemporaneously and later discovered that the patient had died of a misplaced tube by the nurse, a lawsuit would have been a virtual certainty,” says Tafuri.
- Kathy Dolan, RN, MSHA, CEN, CPHRM, Senior Risk Resource Advisor, ProAssurance Casualty, Madison, WI. Phone: (608) 824-8308. E-mail: firstname.lastname@example.org
- Sue Larse, Astute Doctor Education, Laguna Niguel, CA. Phone: (646) 783-1000. E-mail: SueLarsen@AstuteDoctor.com.
- John Tafur, MD, FAAEM, Regional Director, TeamHealth Cleveland (OH) Clinic. Phone: (216) 476-7312. E-mail:email@example.com..