Poor Change-of-shift Communication Triggered Successful Med/Mal Suits
December 1, 2015
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A patient with a vascular injury was flown from a remote community hospital to a tertiary care center, which accepted her into its vascular surgery service but asked that she first be taken to the ED for further evaluation.
“By the time the patient reached the tertiary care center, almost six hours had passed since the fall that caused her injury,” says W. Ann Maggiore, JD, an attorney at Butt Thornton & Baehr in Albuquerque, NM.
The patient arrived at the ED close to shift change and remained in the ED for another six hours before the vascular surgeon took her to the operating room. By that time, the popliteal artery had been completely transected, the gastrocnemius and soleus muscles were no longer viable, and an above-the-knee amputation was performed.
“The ED attending whose name was on the chart was named in the lawsuit, but adamantly denied that he had ever seen the patient,” Maggiore says.
The attending on the incoming shift similarly denied that she had seen the patient.
“During investigation of the case, no ED attending could be identified as having seen and assessed this patient,” Maggiore says.
The first ED attending had billed for seeing the patient, but no documentation of any assessment or notification of the vascular surgery service could be located.
“The vascular surgeon had gone home to sleep, expecting to be awakened when the patient arrived, but he was never notified of her arrival,” Maggiore says.
Only the ED attending who had billed was named in the resulting malpractice lawsuit, which was settled.
Both the patient’s bad outcome and the malpractice litigation could have been avoided, says Maggiore, “with clear and complete communication between the outgoing and incoming ED attending physicians.”
Information Not Conveyed
EPs failed to communicate a patient’s hypotension or hypoxia in one out of seven handoffs, according to a recent study analyzing 1163 patient handoffs during 130 ED shift rounds.1
The fact that vital sign communication in the academic setting was poor and often required “rescue” communication by a senior resident or attending, or by oncoming physicians’ requests for vital signs, is “notable,” says Arjun Venkatesh, MD, MBA, MHS, the study’s lead author and instructor at Yale University School of Medicine.
Venkatesh says that EPs should “recognize the patient safety risk introduced by communication errors, and utilize systems and care transition behaviors that combat this risk.”
Handoffs at change of shift are “without a doubt, a higher area of risk. Everyone accepts that,” says Michael B. Weinstock, MD, adjunct professor of emergency medicine at The Ohio State University College of Medicine and ED chairman at Mount Carmel St. Ann’s Hospital in Westerville, OH.
Weinstock contends that formalized handoff checklists are only used by “the rare EP. It’s easy to say we should do it, but it is not realistic in the practice of emergency medicine.”
He says malpractice cases involving handoffs are often rooted in these risk-prone scenarios:
- A physician assistant is caring for a patient, and the EP they are working with goes off shift.
“The new EP might not even hear about that patient,” Weinstock says. “That leaves the midlevel provider hanging out there without adequate backup.”
- Toward the end of a shift, EPs might avoid getting “too involved” with complicated patients.
“This is something we don’t talk about, but it’s the elephant in the room,” Weinstock says. EPs may stop seeing patients 30 minutes before the end of their shift, and when the new EP comes on, he or she might not see the patient for an additional 15 to 30 minutes. As a result, the patient might not be seen by any EP until they have been in the ED for 45 minutes to an hour.
“When we are overly concerned about a handoff, and don’t see the patient at all, then the patient isn’t getting any care,” Weinstock says. “This is way more dangerous than a handoff.”
- The oncoming EP doesn’t perform repeat assessments.
In one malpractice case involving an ED handoff, a 15-year-old girl who presented with right lower quadrant pain became septic and died from a ruptured ovarian cyst, which went undiagnosed. Both the oncoming and offgoing EPs were sued.
“At change of shift, the offgoing EP didn’t discuss some of the potentially life-threatening problems that had not been addressed,” Weinstock says. Also, the EP did not perform a repeat abdominal exam. Weinstock says that oncoming EPs should do these two things when assuming responsibility for a patient from the previous shift:
1. Perform a focused assessment.
“Sometimes patients tell different stories to different providers,” Weinstock notes. “It also allows you to see the progression of disease.” He says EPs should put a note on the chart stating that they are assuming responsibility for the patient and the results of the focused assessment.
2. Inform the previous EP of the patient’s test results and outcome.
This practice encourages outgoing EPs to continue evaluation of patients at the end of their shift, Weinstock says. This is because they are confident the oncoming EP will assume responsibility for the patient.
“They won’t wait to order a test because the results won’t come back before the end of the shift,” he explains.
Amy E. Goganian, Esq., an attorney at Goganian & Associates in Needham, MA, has seen cases in which the oncoming EP failed to ensure that ordered tests actually were performed, or failed to review test results that were placed during the previous shift but haven’t come back yet.
“EPs should look for results themselves and note any critical values, rather than assuming the nurse or someone else will bring it to their attention,” she says.
A stat MRI ordered by the outgoing EP became a central issue in one malpractice claim that named both EPs.
“The incoming EP was criticized for not aggressively following up and making sure the MRI took place as soon as possible,” Goganian says.
In such cases, documentation stating that the plan was discussed with the incoming EP strengthens the outgoing EP’s defense.
Incoming EPs can reduce risks by performing their own assessment after receiving the report.
“Possibly, they may pick up something that the outgoing physician did not,” Goganian says. “It’s not enough to rely on what your predecessor did or ordered.”
If the outgoing EP is waiting for test results to determine a patient’s disposition, the oncoming EP must be advised of this, “and it is critical that the departing physician chart the handoff,” says David S. Waxman, JD, an attorney in the Chicago office of Arnstein & Lehr.
Another malpractice case involved imaging ordered by the outgoing EP. The outgoing EP asked an ED nurse to have the incoming EP order the imaging; the incoming EP wrote the order as requested.
The patient was transferred to the floor after the imaging and did not return to the ED.
“In the case against the departing physician, her delegation of the order and failure to follow up on the bleed seen on the imaging comprised much of the case against her at trial,” Waxman says. “The incoming physician was almost sucked into the case.”
The incoming EP was dismissed only upon his showing that he did not actually take responsibility for the patient, but was merely putting the order in the system as a favor for the departing physician.
Plaintiff attorneys commonly cite the need for an offgoing EP to follow through on their own orders, Waxman notes. Often, these orders will not have been carried out by the time of shift change.
“It is imperative that the departing physician enumerate what has not yet been done and what needs to be addressed by the oncoming shift,” Waxman says.
REFERENCE
- Venkatesh AK, et al. Communication of vital signs at emergency department handoff: Opportunities for improvement. Ann Emerg Med 2015;66:125-130.
SOURCES
- Amy E. Goganian, Esq., Goganian & Associates, Needham, MA. Phone: (781) 433-9812. Fax: (781) 433-9818. E-mail: [email protected].
- W. Ann Maggiore, JD, Butt Thornton & Baehr PC, Albuquerque, NM. Phone: (505) 884-0777. Fax: (505) 889-8870. E-mail: [email protected].
- Arjun Venkatesh, MD, MBA, MHS, Yale University School of Medicine, New Haven, CT. E-mail: [email protected].
- David S. Waxman, JD, Arnstein & Lehr, Chicago. Phone: (312) 876-7867. E-mail: [email protected].
- Michael B. Weinstock, MD, Adjunct Professor, Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus. Phone: (614) 507-6111. E-mail: [email protected].
Clear communication needed between the outgoing and incoming ED attending physicians.
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