Medical Malpractice Bulletin – November, 2014

Perspective: Interruptions lead to mistakes in patient care
The ER is a busy place. So is the office of almost any physician. Having  uninterrupted time to address a patient’s problem is critical. Eliminating as many sources of interruption as possible is key to achieving that goal. Interruptions can lead to a lack of focus, a lack of focus can result in error, and error can lead to a malpractice suit. A recent article in EP Monthly on the topic is reviewed here.

EHR a factor in Ebola patient’s death? Maybe. Maybe not.
After the death in Dallas of Ebola patient Thomas Duncan, multiple sources reported that the Electronic Health Record was in part responsible for the poor communication between nurse and physician in the ER. Most emergency physicians can relate. Given the diversity of such record systems, one can readily accept that a notation by a nurse in one part of the record could easily be overlooked by a physician working in a different part of the same electronic chart. Although subsequent hospital media reports claimed the issue had nothing to do with the EHR, but rather a breakdown in communication between two human beings, this would not have been the first time that caregivers believed that putting information into an EHR is truly a form of communication. In the hospital’s retraction of its earlier statement, saying “there was no flaw in the system and the physician could indeed view information about Mr. Duncan’s travels from Africa.” Being able to view it and actually doing so are not the same thing. Just like association does not equal causation, the EHR is a repository of information, not communication. It is primarily a billing document. While touted as improving patient care, that goal remains elusive. 

Fecal transplant replaced by encapsulated fecal “meal”
This bulletin earlier reported on the novel “fecal transplant” approach to treat C. difficile infections. The treatment works by replacing fecal flora decimated (usually) by aggressive antibiotic treatment. (There remains an ongoing debate as to whether physicians or attorneys are the better donors.) Until now the delivery method has involved administration via a rectal tube. Last month JAMA reported that the treatment has become much simpler by encapsulating the donated “material” within a capsule swallowed by the patient. While the original treatment has been a godsend to many C. difficile patients, the newer method should prove much more “palatable.”

How often can appendicitis be treated laparoscopically?
A survey of physicians found an interesting array of opinions on the appropriate management of a classic case of appendicitis in a 12 yo boy. Among the findings:

  • 66% would not order imaging. 
  • 31% would order an ultrasound.
  • None would order a CT scan.
  • 95% would treat the patient operatively.
  • A single dose or short course of antibiotics would be used by all.
  • 89% felt comfortable waiting until morning to operate if the patient arrived at 11 p.m.
  • 95% would use laparoscopy, either 1 port (38%) or 3 port (57%)
  • 5% would use an open surgical approach.

Note that the results were published in the Journal of Laparoendoscopic Advances in Surgical Technique which explains the preference for that approach.

Are internal hospital incident reviews discoverable? Two states differ.
Last month a Kentucky court ruled that the internal hospital records of an inpatient incident are discoverable, based in part on the fact that the report was mentioned in the patient’s medical record. The AMA is reviewing the impact of the Kentucky ruling. This month, a case in New Jersey resulted in the (apparently) exact opposite conclusion.  A second review of the NJ ruling is here. Astute legal minds may be able to parse out a reason for a difference in these rulings. The medical mind cannot.

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