Medical Malpractice Bulletin – August, 2016

Perspective: Who is responsible for the ED “boarder”?

By Charles A. Pilcher MD FACEP
August, 2016

A patient in the ED with a GI bleed is awaiting transfer to an inpatient bed. The ED doc has informed the hospitalist and believes the patient now belongs to the hospitalist. When the patient’s condition deteriorates 2 hours later and no one has been clearly identified as being in charge of the patient, who is responsible when the patient dies? This is one of those transitions in care where a clean handoff is crucial but may not be sufficient. Read more ->

Virtual or “e-visits”: What is the malpractice risk?

As technology develops, more and more patients want their physicians to provide virtual health care or “e-visits.” These might include email, text, FaceTime, Skype, a dedicated secure portal, etc. Physicians themselves are often supportive of the concept. But implementation has been slow due to 1) lack of a financial model to support such an approach, 2) issues regarding privacy and security and 3) documentation challenges. Since the invention of the telephone, attorneys, physicians and insurers have argued over what was or was not said in a telephone conversation between a doctor and a patient whose outcome resulted in litigation. Current technology just extends the debate into a new realm. For those interested in developments in the field, here are some resources:

Electronic Health Record (EHR): Blessing or curse?

Electronic health records (EHR) have become standard in hospitals and most outpatient practices. Anyone who has worked with them is intimately familiar with both the positives and negatives of such documentation. Positives include ready access to old records, readability, ease of information entry, triggers/alerts for preventive health screening and decision support, drug interaction notifications, etc. Negatives include the ease of over-documentation, the temptation to copy/paste without editing, the mass of data that obscures the truly important information, inconsistent entries from one section of the chart to another, the lack of “color” that is the heart of the doctor-patient interaction, etc. When charts for patients involved in med mal lawsuits are reviewed, almost all contain elements of seriously questionable documentation, often impugning the integrity of the provider and almost always to the advantage of the plaintiff. Here are links to several articles on the topic.

Subarachnoid hemorrhage (SAH): Diagnosis and standard of care

Meurer et al. recently published guidelines in the Journal of Emergency Medicine on the diagnosis of subarachnoid hemorrhage substantiating the fact that when an SAH is suspected (as with a “thunderclap headache”) an LP is necessary even if the CT is normal. The authors believe this remains the standard of care. Some have advocated plain CT alone. As technology has improved, more SAH’s are being found with this modality alone, but it is still not 100%. CT angiogram is also considered effective but is best (98% sensitive) for picking up aneurysms >3mm and can miss non-aneurysmal SAH. The latter modality should be used only if the patient refuses an LP or the LP is equivocal. A plain (aka “dry”) CT alone is not enough to exclude SAH.

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