Medical Malpractice Bulletin – September, 2016

September, 2016

Perspective: How do patients feel about medical error?
By Charles A. Pilcher MD FACEP

“I told them about my fever and pain ever since I went to the hospital, and no one paid attention to my symptoms.”

“The patient suffered a severe postoperative infection that was not diagnosed for 5 days resulting in a large draining abdominal wall ulcer that persisted for over 2 months.”

“When I told her I felt my throat was closing she took the Red Robinson suctioning device, handed it to my daughter and said, ‘suction your mother’ and left the room.”

“Care providers need to listen to family members, parents and friends. We know our loved ones better than anyone else. If we tell them something isn’t right they should stop and ask us questions. We see the little changes before they become apparent to others.”

“She [physician] replied, ‘Of course it was my fault, it was entirely my fault. Who else’s fault could it have been?’  This made me think the world of her. I didn’t take it as an apology, and I didn’t think it indicated mistake or negligence. I took it as a statement that my doctor felt responsible for me.”

The above are just a few of the comments included in a study by Southwick et al. published in BMJ Quality & Safety. Many of these errors never appear in the medical record or get reported as an “incident.” The authors emphasize “the potential efficacy of patient-initiated surveys for providing meaningful feedback and for guiding improvements in patient care.”

As expected, the study found that most errors involved diagnosis and treatment, the same issues that keep our medical malpractice “system” thriving. Would patient safety not improve if we could eliminate these issues before they become lawsuits? Read the rest of my “Perspective” on this study here ->

UPDATE: CT IS reliable to exclude subarachnoid hemorrhage (SAH)

Last month I included a report that concluded that an LP remains the standard of care and is necessary following a negative CT seeking to rule out SAH.  Since then I discovered a  “meta-analysis” by Dubosh et al. that concludes the opposite, i.e., given current technology, an LP is not necessary if a CT ordered to rule out SAH is negative. That apparently defines a “moot point.”

High-sensitivity troponin-T test (HSTTT): What’s its role in ruling out myocardial infarction (MI)

Here’s a compendium of articles addressing the effectiveness of ruling in or ruling out an acute MI using the new HSTTT, a troponin assay that is sensitive in the first hour:

  • Mueller et al. in the European Heart Journal report that the HSTTT can reduce the need for stress testing and/or angiography and speed the discharge of patients in the ED for evaluation of possible acute coronary syndrome (ACS). CT angiography may be a reasonable alternative in patients with an elevated HSTTT and an equivocal history.
  • Chew et al. in Circulation found that the HSTTT did not significantly alter treatment or outcomes and should be accompanied by specific policies or protocols when utilizing it in clinical decisions regarding care of patients with ACS.
  • Carlton et al. report in JAMA Cardiology that a negative high-sensitivity troponin-I (not T) test can safely allow the discharge of 18.8% of potential ACS patients with a normal EKG presenting to the ED. However, levels that are above the threshold for concern need a more robust evaluation, as a higher level does not necessarily correlate with an MI or other ACS.

Most importantly, when using this test, physicians must remember that things other than a coronary artery occlusion can present with chest pain and ACS symptoms, among them pulmonary embolus, aortic dissection, myocarditis and other lung problems.

Informed consent and the “objective person” standard: Which prevails?

A regular reader of the Medical Malpractice Bulletin recently sent this comment after a discussion about informed consent and what role it can play in medical malpractice cases.

Informed consent cases, in my view, are almost never viable cases, although physicians seem to obsess about them a lot. In most states, including Washington, the “objective person” standard is used. That means a claimant who says “I never would have had the procedure had I really know of this or that risk” is not persuasive, because the jury has to decide what a reasonably prudent patient would do. And very few juries conclude that a relatively small risk would have meant that a person would ignore the advice of the doctor regarding the particular procedure. After all, everyone is told that a risk of anesthesia is death, and that doesn’t dissuade people from undergoing all kinds of elective procedures, even minor ones.  For example, bowel perforation during a colonoscopy usually cannot be proven to be the result of negligence, regardless of the consent issue. I have turned down dozens of such cases over the past couple of years.

Consistent with the experience of other attorney readers, my own experience generally bears this out – with a few notable exceptions. The University of Washington “Ethics in Medicine” webpage has a nice summary of the issue. Comments on this topic are welcome.

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