A Simple Callback Might Stop Malpractice Suit

Measuring the number of ED malpractice claims that are avoided by calling patients post-discharge is difficult, acknowledges Jeanie Taylor, RN, BSN, MS, vice president of risk services for Emergency Physicians Insurance Company (Epic) in Roseville, CA. "It is hard to measure what did not occur, so the effectiveness of callback programs from a claims perspective is largely anecdotal," she says.

However, Epic promotes a callback program to all of its insured ED groups as a way to reduce risk. "We firmly believe that liability risk is reduced through an effective callback process, especially if the process focuses on high-risk patients who are discharged," says Taylor.

Emergency physician (EP) groups routinely report cases to Epic in which a bad outcome was avoided through its callback process. "Probably the most common situation we hear about is a patient who was discharged with abdominal pain who relays ongoing symptoms during the callback, and is diagnosed with appendicitis when they return to the ED for another visit, as advised during a callback," says Taylor.

In this scenario, the EP is viewed as the one who caught the appendicitis during the callback, instead of the provider who missed the appendicitis in the initial visit, says Taylor.

High-risk Patients

"Callbacks are a great way to catch misdiagnoses or missed diagnoses, to address misperceptions of care, and to get in front of potential legal issues," says Taylor. "Plus, they boost patient satisfaction in the process."

Taylor says it's important to have carefully scripted language for staff completing the calls. "You don't want to create any additional liability by having staff provide bad advice," she says. "Clinical staff is ideal for the callbacks. The facility must verify their competency in completing the calls."

She recommends these practices:

• Make sure all staff doing callbacks are trained on how to manage ongoing concerns the patient brings up during the call;

• Develop protocols so staff know how to handle issues that come up during the calls;

• Ensure that an EP is available to answer questions and speak with patients when needed;

• Document the call in the permanent medical record;

• Call patients discharged following treatment for higher-risk conditions such as chest pain, abdominal pain, pediatric fever, fractures, or headache, as well as patients the EP is especially concerned about; and

• Callback patients who leave against medical advice or without completing treatment.

"We all know that patients who leave the ED against medical advice are high risk, both for an adverse event and the likelihood of pursuing a claim," says Taylor. Calling them the next morning might diffuse the situation if they left angry. It lets them know you are concerned and creates a safety net by encouraging them to return to complete treatment, she explains.

Taylor adds that a plaintiff's attorney with a case in which a patient experienced a bad outcome after leaving the ED against medical advice would likely not be pleased to read in the medical record that the physician or facility called the patient back the next morning to make sure they were O.K. and to invite them back to complete treatment. "In some situations, this, in itself, might influence the plaintiff attorney's desire to pursue a case," she adds.

Opportunity to Get Personal

Callbacks might be particularly beneficial in mitigating the unique legal risks faced by EPs because they lack the personal relationship with patients that primary care physicians develop over time, says Taylor. "This less personal relationship opens the door for patients to file a claim against a provider they don't know and sometimes don't believe cares about them," she explains.

When the patient gets a call from an ED representative who says, "Dr. Smith saw you yesterday in the emergency department and asked me to call and see how you are doing today," it "makes the relationship more personal. It delivers more than the patient expected," says Taylor.

Taylor says the ED callback should focus on how the patients are doing, whether they understand the discharge instructions, and whether they filled their prescriptions, instead of asking if there is anything that would keep them from rating their care as excellent.

"This line of questioning is much more specific and productive," she says. "When patients are asked rating questions, they know the facility is only trying to boost their satisfaction ratings, versus really caring about their health."


For more information, contact:

• Jeanie Taylor, RN, BSN, MS, Vice President, Risk Services, Emergency Physicians Insurance Company, Roseville, CA. Phone: (530) 401-8103. E-mail: jtaylor@epicrrg.com.