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The risk of giving advice to patients by phone should be well known to risk managers, and most have educated staff about what not to say to patients with questions. Add in the automated answering systems that urge patients to call 911 for emergencies, and you should be well covered in this area, right? Not necessarily. Advice by phone may be a liability risk that is flying low and under your radar.
Try taking a stroll through your labor and delivery unit one night, and you might be shocked by what you hear nurses saying to patients on the phone, says Monica Berry, BSN, JD, LLM, DFASHRM, CPHRM, regional director of risk management with SSM Health Care of Wisconsin in Madison, and past president of the American Society for Healthcare Risk Management.
The liability risk comes in two forms, Berry says. In the first concern, a patient calls and asks for information. Most organizations have some type of help or referral line that is staffed by personnel trained to answer these questions and refer the callers on to the appropriate help. But obstetrical (OB) calls often are referred directly to the OB unit. "Then the OB nurse may attempt to help the patient figure out whether to come in, stay home, or go see their physician," Berry says. "The patient is giving information she thinks is important, but unfortunately the nurse may hear it differently. The patient also might not appreciate the significance of some signs and symptoms."
Documentation always needed
So the nurse is trying to render advice for a patient she doesn’t really know and basing that advice on incomplete information. That constitutes a major liability risk but might happen every day in your OB department, Berry warns.
The second question involves documentation. If those phone calls to the OB unit are permitted, or if they make their way to an OB nurse despite hospital policy to the contrary, the nurse should always document the call carefully. "They should document the caller’s concerns, what information was provided to the nurse, and what advice was given," she says. "You can always use that log book if the patient has a bad outcome."
The OB unit is a primary concern for such phone calls, but it is not the only risk, Berry notes. Similar scenarios occur in the emergency department (ED) as well. People call and ask if they should come to the ED, and the nurse taking the call doesn’t have the necessary background about the patient to understand the significance of the signs and symptoms relayed.
Many risk managers encourage ED staff to play it safe and tell the patient to come to the ED if there is any doubt whatsoever, which Berry says can be a safe strategy. No matter what advice is given by phone, ED staff always should document it well.
Discharged patients different
Another issue involves the patient who has been discharged but calls back to the unit with a question. Should the nurse answer the question? Berry says yes, but he or she should also refer the patient on to the private physician, especially if the questions persist. "You want them to avoid being put in an awkward spot because the patient isn’t there any more, and the nurse may not know the whole story," she says. "And document it. Always."
Berry suggests that the best policy on phone advice is to have a referral line or a nursing hot line for patients with questions — a controlled situation. But if you choose to allow such calls to go straight to the OB unit or the ED, Berry says you should educate staff about the right and wrong ways to handle such calls.
For starters, she would explain the difference between talking with a patient recently discharged from your unit vs. talking with someone you’ve never met. "If you have interfaced with the caller and they’re calling back for clarification, it’s a good idea to go ahead and clarify their discharge instructions or help them understand when to call their doctor, but I think the policy should limit it to the purpose of clarification," Berry says. "If it is an individual you have never had contact with, the policy should be more restrictive."
Complete ban not required
It may not be necessary to completely ban giving advice to those callers, however. It may be possible to give some advice as long as the nurse emphasizes that the decision regarding coming to the ED, for instance, lies with the patient. The nurse must make clear that he or she is not instructing the patient not to seek care. "They can tell the caller that, If you think this is serious enough, come to the emergency room. If you don’t think it’s that serious, contact your family physician,’" Berry says. "That may not be what a caller wants to hear if they hoped you would make the decision for them, but you just can’t allow that."
Despite the best intentions, nurses can easily let their guard down when they pick up the phone and someone is asking for advice, she says. Nurses, by nature, tend to want to help others and they have substantial knowledge at their disposal, so their inclination is to tell the caller what they think would be helpful. But it is up to the risk manager to educate them about why that is so dangerous, Berry says.
Diplomacy required for rebuke
She recommends including education and the risks of phone advice in annual risk management inservices. And what do you do if you’re walking through the ED one day and hear a nurse tell a caller that he doesn’t need to come in for treatment, and that the wait would be really long anyway?
First, don’t dismiss it as an isolated incident. If you happened to hear one nurse say it, chances are good that more are saying the same thing. Some diplomacy may be necessary, though. Avoid making the nurse feel bad for simply trying to helpful. "If you know the employee, you could approach him or her directly. But if not, it might look like a slap on the hand, and that’s not a good idea," Berry says. "Then I would approach the unit director or manager and tell that person what I heard. I would explain why that’s not a good idea and that the person might need to be educated on this risk."