Medical Malpractice Bulletin – May, 2013

Perspective: Handoffs And Consults: Who’s In Charge?
By Charles A. Pilcher MD FACEP

During transitions in patient care, a lot can go wrong. Almost all of the potential risk in these situations is the result of poor communication. But why is the communication so poor?

Much of it is the result of misplaced assumptions, unrealistic expectations, and what could be called “cultural incongruity,” i.e., misunderstanding between the two parties involved related to how and where they are most accustomed to doing business and to whom they are most often responsible. The ED physician is at home in the ER. The surgeon is at home in the OR. The hospitalist is at home in the ICU. While one might assume that a consult or a handoff is a straightforward transaction, most physicians have learned the process from experience, not training. And that experience varies from culture to culture. Hospitals may or may not have policies addressing consults and handoffs, yet the expectation that every physician knows them is unrealistic.

The first of 2 essays addressing this discusses “Consults.” What constitutes a consult? How might the consultant and the ED physician inter-relate? And can the risks in the transaction be avoided. Click here to read “Perspective: Handoffs And Consults: Who’s in Charge? Part I: Consults. [Part II addressing “Handoffs” will be published next month.]

In other news:

“‘Emotional distress” redefined: Mother wins suit agains radiologist who failed to inform her of fetal abnormalities 
The Pennsylvania Supreme Court recently ruled that a mother who experienced emotional distress can sue her physician, despite the absence of any physical event leading to the distress. The case involved the failure of the physician to prepare the mother for the shock of her newborn’s deformities.

Doctors being blamed for drug overdose deaths.
This article discusses recent lawsuits, as well as preventive measures that physicians can take to avoid the risks associated with the prescription of opiods, sedatives, and other mood-altering drugs.

OR staff rudeness could jeopardize patient outcomes.
Personality and behavior is at the root of a great number of malpractice lawsuits. Some would even argue that this is as often the genesis as the quality of  care. Rudeness is more than just an irritation. It can directly impact the quality and safety of patient care. A recent commentary in the Archives of Surgery addresses behavioral issues in the OR. While a survey found that over 85% of nurses have witnessed disruptive outbursts by surgeons, nearly 50% of physicians said the same of OR nurses. There’s also a quote from a 2009 article listing the items that have been thrown at nurses, ranging from scalpels to power tools.  Click here to read more about the “Barbers of Civility.”

The stroke debate rages on
Here’s a collection of just a few of the current articles debating the value, timing, and alternatives to intravenous tPA in stroke:

  • Stroke Endovascular Therapy After Thrombolysis May Not Benefit Ischemic Stroke Patients. This study found no benefit to stroke patients by adding an additional invasive procedure – similar to stenting of a coronary artery for heart attack – to the tPA that a stroke patient had already been given. Click here for a link to the Guidelines in NEJM, or here for a summary from Medscape or here for a nice review from ACEP News.
  • New guidelines say tPA can be used 4.5 hours after onset of stroke symptoms. But the marginal results would not meet the legal standard of likely to improve “on a more probable than not basis.” The new guidelines can be found here  and a Medscape summary of the new guidelines can be found here.
  • Not everyone agrees. In fact, debate continues among many reputable physicians who believe that tPA itself adds nothing significant to the treatment of stroke. A point-counterpoint discussion of the issue can be found here (PRO) and here (CON).A future “Perspective” is being prepared to address some of this debate.

A future “Perspective” is being prepared to address some of this debate.

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