Outside Evaluations Identify Risk-prone Practices in EDs
Stephanie C. Sher, Esq., an attorney with Stevens & Lee in Lancaster, PA, says that outside evaluations of an emergency department (ED)’s processes can identify risk-prone practices that could result in bad outcomes and malpractice claims.
"In collaboration with a quality and safety consulting firm, we are often asked to evaluate ED operations from both a clinical and process standpoint," says Sher. A thorough analysis of patient flow, clinical protocols, and policies and procedures can often identify areas of weakness or exposure in which recommendations can be made for decreasing that exposure, she explains.
Because this is a collaborative effort between Stevens & Lee and SE Healthcare Quality Consulting, all findings are protected by attorney client privilege to the extent allowed by local state law. Here are some risk-prone practices frequently seen in the EDs:
• Inappropriate handoffs.
With ED overcrowding and the frequent scarcity of inpatient beds, patients will often remain in the ED across multiple shifts, with multiple care providers overseeing their care. "It is important to have effective handoffs between shifts, as well as from the ED to the admitting physician," says Sher.
Significant diagnostic results are often overlooked because of ineffective handoffs. "We recommend use of checklists as communication tools," says Sher. Sher also recommends using electronic health records to ensure that subsequent providers are aware of what occurred during the patient’s ED course. "As more patients move to post-acute settings directly from the ED, the discharge summary becomes a communication tool to enhance those types of transitions," she says.
• Incomplete or ineffective documentation.
"This can be an area of weakness and/or exposure by not being comprehensive enough to justify the rationale between the presenting complaint and the subsequent treatment plan," says Sher.
With a series of physicians covering a patient during a prolonged ED stay, it is important to document a differential diagnosis and proposed plan of care, in addition to having a verbal discussion at the time of handoff. This helps to avoid the scenario in which there are differing opinions reflected in the notes that can be easily picked up on by a plaintiff’s attorney in the event a claim is filed.
"This is a pathway for the plaintiff lawyer," Sher says. "It’s always beneficial to the plaintiff when providers are pointing fingers."
• Failure to follow policies regarding supervision of advance practice professionals.
EDs are increasingly using advanced practice professionals to address volume surges. "This is not a new issue, but it is becoming a much more common practice to have advanced practice providers functioning very independently in a fast track’ type of setting," says Sher.
EDs generally have these policies in place, but compliance is often the problem. "That is something that is very important from a risk perspective," says Sher. "Things are getting done, and done effectively, but not necessarily in accordance with protocols."
• Lack of documentation of phone calls made to other physicians.
ED clinicians sometimes call a patient’s physician to get background information on the patient, but there is no documentation of the conversation. In subsequent malpractice litigation, the provider claims he or she never knew the patient was in the ED and never got a call.
"This can impact not only the care provided in the ED, but also the follow-up care provided in the outpatient setting," says Sher.
• Failure to follow up with the patient about test results after the patient has left the ED.
"If the X-ray is read in the ED but the official — abnormal — reading comes back the next day, they’ve got to be sure they’ve followed the protocol, notified the patient — and documented that the process was followed," says Sher. This is especially true at night, when often the ED providers will read their own films and/or EKGs.
"It is critical to have a consistent system in place to follow up with patients to provide significant findings in a manner that facilitates ongoing continuity of care," says Sher.
For more information, contact:
- Stephanie C. Sher, Esq., Stevens & Lee, Lancaster, PA. Phone: (717) 399-6647. Fax: (610) 371-7361. E-mail: [email protected]