During the course of ED malpractice litigation, metadata are becoming an issue in one way or another. It can help ED providers, hospitals, or plaintiffs prevail, assuming the information can be interpreted correctly.
“It may be difficult to determine the facts of the case because metadata can be very confusing,” says Ken Zafren, MD, FAAEM, FACEP, FAWM, clinical professor in the department of emergency medicine at Stanford University Medical Center. Zafren also is an EP at Alaska Native Medical Center in Anchorage and former emergency programs medical director for the state.
Metadata are especially useful in ED claims alleging delayed evaluation or treatment of a time-dependent diagnosis. This information is used to confirm or disprove that there was a delay. In one such case, an EP ordered morphine for a patient who had suffered a previous severe reaction to morphine that was documented in the ED chart. “The patient’s family had told the nurses and the doctor that the patient nearly died one time after receiving intravenous morphine,” Zafren says.
Nonetheless, the EP ordered morphine to be given intravenously to the patient, who was complaining of severe chest pain. According to the metadata, morphine was ordered at 7:07 a.m. The patient developed supraventricular tachycardia at 7:10 a.m., for which he received multiple doses of adenosine. “The family member who accompanied the patient said he had an almost immediate reaction after receiving the morphine,” Zafren notes.
However, the metadata indicated that the morphine was administered at 7:55 a.m. “This is unlikely, not only due to the urgency of treating severe chest pain and the family member’s account, but also because the metadata show that the pharmacist voided the order for morphine at 7:30 a.m.,” Zafren explains.
It is unlikely that an ED nurse would have administered morphine after the order was voided, Zafren says. After 7:10 a.m., the patient continued to deteriorate hemodynamically and developed further arrhythmias and hypotension. He became unresponsive and required intubation, and was admitted to the ICU for several days.
Both sides attempted to use the metadata to their advantage. The defense used it to claim that the patient had not had a reaction to the morphine. The plaintiff’s expert countered that the metadata showing that morphine was administered 48 minutes after the order and 45 minutes after the onset of supraventricular tachycardia most likely were incorrect. “In the end, the metadata were helpful to the plaintiffs,” Zafren adds. “The case settled for an undisclosed amount.”
In another malpractice case, metadata also proved devastating to the defense. Neurological checks were ordered to be performed every 15 minutes on a patient who was taking aspirin, clopidogrel, and warfarin and who fell, striking his head. The chart indicated the neuro checks occurred at exact 15-minute intervals (on the hour, and 15, 30, and 45 minutes after the hour).
The metadata revealed that all the entries were made by the same nurse hours later, after the patient had died already at a nearby hospital due to intracranial hemorrhage. “The metadata were not believable,” Zafren says. Based partly on the late documentation that appeared to have been fabricated or at least altered, the physician defendant settled on favorable terms for the plaintiffs.
On the other hand, metadata can help the defense team by showing that the standard of care was met. A fatal case of pediatric cardiomyopathy involving ED care showed that everything was handled correctly. The case was reviewed by three experts, including Zafren. “The plaintiff’s attorney was not surprised when I told him that the care the unfortunate child received was exemplary because the other two experts had already told him the same thing,” Zafren recalls.
The plaintiff attorney wanted to be absolutely sure there had been no breach in the standard of care. This way, he would know he had done everything possible for the understandably very distraught family. “The metadata showed an amazingly robust and timely response to a child who was deteriorating very rapidly,” Zafren says. “A lawsuit was never filed.”
The plaintiff attorney asked Zafren to write a short letter stating what he had found after reviewing the care, that the standard of care was met (although the patient died). This information was a possible source of comfort to the family. “I think it is easier to accept the death of a loved one due to a disease or injury in spite of receiving the best care than to know that the patient might have survived with better care,” Zafren offers.