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A recent malpractice case involved an elderly man who was diagnosed with a gastrointestinal (GI) bleed by an emergency physician (EP), who determined that the patient should be admitted. While the patient was being held in the emergency department (ED) waiting for an available inpatient bed, another EP came on shift.
After about an hour, the patient was brought upstairs. "Once in the room, his condition precipitously declined and the patient died," says Scott O’Halloran, JD, an attorney in the Tacoma, WA, office of Williams Kastner, who defended the hospital in the resulting malpractice suit. "There was absolutely no documentation in the patient’s chart by the oncoming EP."
The first EP was sued, and the plaintiff failed to realize that a second EP was on duty during the period immediately before the patient left the ED.
"It wasn’t even until two days before trial that the first EP went back and looked at his shift notes for that day, and realized that he wasn’t even on shift at the time that the patient declined," says O’Halloran. The plaintiff wrongly assumed that the first EP was caring for the patient the whole time, since the EP had never documented that he had transferred care to the oncoming EP.
The case alleged that the patient was wrongly diagnosed with an upper GI bleed, which was in fact a lower GI bleed — a more problematic and acute situation that they argued called for more emergent care.
"They still had that argument against the first EP, but their second argument was that the patient was left unattended in the ED," he says.
The plaintiff argued that it made little difference which EP was on shift at the time, as the hospital was vicariously liable for the actions of all the EPs. "But the court ruled that the responsibility was on the plaintiff to have discovered this information," says O’Halloran.
Regardless, the case went to trial, and resulted in a defense verdict. O’Halloran says the claim could have been avoided altogether if there had been a better handoff.
"The case spotlights the need for good documentation by the offgoing EP and the oncoming EP, to pinpoint at what point the oncoming EP is taking responsibility for the patient," he says. If the oncoming EP had been named in the suit, the case would have been much harder to defend, O’Halloran adds.
"Since there was no documentation that she was even aware the patient was in the ER, she would have a tough time establishing that she even looked at the patient," he says.
Another malpractice case involved a patient who presented with difficulty breathing and a swollen tongue. The EP correctly diagnosed him with an allergic reaction.
The patient’s condition appeared to improve after an antihistamine and steroid were given, and the EP put in the order to discharge the patient. After the oncoming EP came on shift, the patient remained in the ED for about 45 minutes. "The ED nurse commented in the record that the patient was still having problems swallowing," says O’Halloran. "But the oncoming EP assumed the patient wasn’t their responsibility since the patient was already discharged, so the EP never came in to see the patient."
The patient returned to the ED several hours later with worsening symptoms. "The EP was unable to do a tracheotomy in time, and the patient died," says O’Halloran. There were several allegations in the resulting malpractice suit, which was settled, "but the one that worried us a lot was the period of time in which the patient was discharged, and was clearly not improving, but nobody really examined him," he says.
Reliable information transfer, proper documentation, and patient acceptance are essential components of handoffs in the ED, says Robert Broida, MD, FACEP, COO of Physicians Specialty Limited Risk Retention Group, a captive professional liability insurance company serving the Canton, OH-based Emergency Medicine Physicians medical group.
"Rounding" handoffs, in which the outgoing EP personally introduces the incoming EP to each patient, are best for the patient and information transfer, but are time-consuming, notes Broida.
"The large variety of data-based techniques, such as EDIS solutions and Safer Sign Out, are great for information transfer, but outgoing physician fatigue and patient satisfaction are not well-addressed," says Broida. Broida says the best solution is the "Do-Over."1
"Here, the incoming physician treats the patient as an entirely new encounter," he says. "They perform and document a full evaluation from the ground up."
The key to this process is that the oncoming EP feels personally responsible for the patient, says Broida. "This is lacking to some degree in all other methods where the patient is viewed as belonging’ to the departed physician," he adds.
Damian D. Capozzola, JD, of The Law Offices of Damian D. Capozzola in Los Angeles, CA, says change of shift is "rife with vulnerabilities and potential legal exposure" for EPs.
The EP whose shift is ending may assume that the incoming EP will conduct certain tests or investigate particular diagnoses. The incoming EP may incorrectly assume that the prior EP either already did so or had a reason for not doing so.
"When you add to that the chaotic environment that can pervade an emergency room, it becomes very difficult to avoid information slipping through the cracks," says Capozzola.
Plaintiffs’ attorneys may be especially attracted to change of shift lawsuits for precisely this reason, he says.
"They present the attorney with the opportunity in litigation to present a compelling timeline of all the things that were not done," says Capozzola. The attorney can allege that the departing EP was more concerned with getting back to his or her personal life than assuring the patient was adequately cared for by the incoming EP.
"Even better for the plaintiff’s counsel, the involvement of two physicians may mean two separate insurance policies to pursue," says Capozzola. "If the physicians start to point fingers at one another, which may be a natural reaction for each physician, the plaintiff’s counsel will further benefit."
Capozzola says EPs should take extra care to document information at the end or beginning of a shift.
"EPs should keep in mind that at some point they may need contemporaneous documentation to defend either the steps that were taken to hand off the patient with the benefit of all information obtained thus far, or what steps were taken to treat the patient in light of the information obtained at the start of the shift," says Capozzola.
Handoffs are "obviously a very vulnerable time" in the ED, says Corey M. Slovis, MD, professor and chairman of the Department of Emergency Medicine at Vanderbilt University Medical Center in Nashville, TN. "The outgoing EP feels pressure to tie everything up as quickly as possible, and the incoming EP may be distracted by all that’s waiting for him or her to do as they begin the shift, and is not listening carefully. That itself is a setup for error," says Slovis.
Patients being signed out to an oncoming EP "have the potential to bring out the worst in us," says Slovis. "Signouts really ought to get the best care — they ought to have two EPs looking at them. But sometimes they really just have one, and somebody’s name."
Oncoming EPs may fear getting "too involved" with a patient who is already scheduled to be discharged or admitted. "It’s so much easier to just let them leave, instead of pulling that thread that could unravel everything," says Slovis. "Even though the patient was signed out to us, we don’t always own’ that patient."
Slovis says EPs should consider these practices to reduce risks of handoffs:
• Use a pre-agreed, organized signout plan in which the patients who need the most thought and attention are presented first.
"And as the EPs go through it, besides the little blurb about what’s wrong, two things need to be done on every single signout," he says. Oncoming EPs must answer the questions "What’s pending?" and "What do I need to do prior to safely discharging or admitting this patient?"
• For any patient who has anything potentially serious wrong who is within an hour or so of being discharged or admitted, or any patient in the middle of a comprehensive workup, the oncoming EP should go see the patient.
"Spend 30 to 60 seconds going in to see the patient, so you have a visual image of how that patient looked at the time of signout," says Slovis.
• For any patient being discharged after a significant workup, the oncoming EP should indicate that he or she evaluated the new test results and thinks that the patient is now stable for discharge.
• The outgoing EP should indicate at what time the care of the patient was transferred to the oncoming EP.
"There needs to be a clear change in responsibility," says Slovis. "And the oncoming physician needs to know that anything that happens subsequent to that signout is going to be on them."
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