By Charles A. Pilcher MD FACEP
November, 2013
The harder and faster one works, the more prone one becomes to mistakes. That’s no different for physicians than for anyone else. And an increasing body of research is beginning to substantiate the magnitude of the problem with actual numbers. This became an issue over a decade ago when resident work hours were restricted after physician fatigue was found to be leading to errors. Nurse staffing levels have become enough of a concern that 14 states have enacted restrictions on how many patients a nurse can care for. A March 2013 article in JAMA Internal Medicine by Michtalik et al. reported on the results of a survey of hospitalists on the matter of workload and mistakes. The results showed:
- 40% of physicians reported that their typical inpatient census exceeded safe levels at least monthly;
- 36% of these reported a frequency greater than once per week;
- Although physicians reported a safe workload of 15 patients, 40% reported exceeding their own safe numbers at least monthly.
- 22% reported ordering potentially unnecessary tests, procedures, or consults because of not having adequate time to evaluate patients in person.
- Over 20% reported that their average workload likely contributed to patient transfers, morbidity, or even mortality.
Other issues included not fully discussing treatment options, delayed admissions and/or discharges, and decreased patient satisfaction.
Also, Dubin et al. presented a research paper (not yet published) at the ACEP Scientific Assembly in Seattle in October addressing ED crowding and physician inexperience as a source of error. They reviewed 69 physician errors made by 22 different emergency physicians and found that a census increase of less than 10% was present in those cases where an error was made, and that the frequency of error was increased among those physicians with less experience working under high volume conditions.
The implication of this for med mal attorneys is that workload makes a difference.
Both defense and plaintiff attorneys need to know how busy the ED or clinic was at the time of the patient’s presentation. Defense attorneys can use it to defend an allegation that the involved physician was too busy, might have cut corners, or reached a hasty diagnosis or disposition. They can point out that “there were only 2 other patients in the department, and both were discharged and waiting for a ride home. Dr. Jones was able to devote his full attention to Mr. Smith.”
On the other hand, plaintiff attorneys will always bring it up if the census was high and the wait time long.
Thus, both sides should routinely request the patient log for the date of the incident. It can become a significant part of the discovery process and assist in pursuing a more vigorous defense, a more aggressive prosecution, or an earlier settlement, if appropriate.
Readers should remember that change of shift or other transitions in care are also critical points in a patient’s evaluation. This was discussed earlier in Handoffs: Part I and Handoffs: Part II.