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Cliff Rapp, Vice President of Risk Management FPIC
Reprinted with permission from First Professionals Insurance Company, Preventive Action, Fourth Quarter 2010, Volume 23, No. 4.
8-4-2 Defining Your Role   Most medical errors are attributed to system errors– not faulty medical judgment. System failures increase with medical complexity and the number of physicians involved even when involvement is tangential. Malpractice claims attributed to a failure to timely diagnose and treat patients that are being followed by multiple physicians is an alarming trend. A common root cause of these claims is faulty coordination and management of care – easily prevented with fundamental risk management practices. The most prevalent type of error in medical malpractice claims is not medical at all. (1) Surprisingly, claims that are absent a medical error are the most frequent type of claim. One example of claims that are absent a medical error is those involving the failure to supervise or monitor the patient’s case. When the root cause of claims is attributed to a lack of coordination and management, even the strongest defense may not prevail. Although every case is unique, juries tend to adopt higher expectations in direct relation to the size of the medical team.   System failures, such as faulty communication of clinical concerns and stat test results contribute to the number of adverse events, resulting in severe patient injury and costly medical malpractice claims. Inadequate documentation of the entire process often undermines the defensibility of otherwise acceptable medical judgment.   Delay in diagnosis continues to remain one of the most prevalent allegations in malpractice claims. (2)Among the most frequent causes are lost or misdirected diagnostic test results. A common root cause in these cases is the failure to address abnormal test results in a timely manner. The unfortunate end result is often an absence or delay in treatment to the point of irreversible damage to the patient – and to a defense. In a survey of 42 academic medical centers across the United States, factors that contribute to medical error were identified and include order entry, decision making, and complex systems.(3)   Delineation in physician responsibility and care is a fundamental risk management measure that is essential in complex medical cases and those with a sizeable medical team. Consultations, orders and reports should clarify your specific role in the care and treatment of the patient and document its parameters. Recall this caveat as the medical team morphs. Failure to act on abnormal (diagnostic) results is a common source of medical error. (4)   _______________   Case Synopsis Delay in Diagnosis and Treatment: Wrongful death action of a 52 year-old female due to an alleged failure to diagnose and treat an aortic dissection. Although the case was defensible in terms of medical causation-the patient’s chances of surviving the dissection were virtually nonexistent upon her initial presentation-the lack of delineation in the medical management and coordination of care among the healthcare team necessitated settlement. Medical records could not support which physician was responsible for pursuing emergent diagnostic work-up or acting on the results of same. Consequently, aortic dissection was not included as a differential diagnosis, the patient was misdiagnosed with pancreatitis and surgical intervention was delayed. _________________   Risk Management Guidelines:  

• Determine who the primary attending physician is: direct communication accordingly.

• Clarify the reason for your participation and the extent of same.

• Define your role and document the date and time of initial and final contact and contributions in the care and treatment delivered.

• Do not assume responsibility for management beyond parameters.

• Document follow-up efforts and communication of test results.

• Verify when outstanding diagnostic studies, labs, and consults are complete.

• Clarify that on-call physicians, covering physicians, and physician extenders under your supervision are fully apprised and have delineated their respective care and treatment.

 • Advice the patient and/or family member(s) of your participation in the medical team and the extent of same – document such disclosure.

• Document discussions with other clinical team members, including your understanding of your role and the parameters of your care.

• Provide directions for the daytime office and after-hours communication pathway of stat diagnostic test results and emergent orders.

•Document the chart in a way that clearly supports your medical rationale.

• Seek legal or risk management guidelines when uncertain how to proceed from a liability standpoint.

  (1)Physician Insurers Association of America. Research Department. PIAA Risk Management Review Combined Specialties. 2006 Edition. Rockville, MD 20850 (2)Closed PIAA Cumulative Data Sharing Report. Closed Claim Data 1985 to 2006. (3)University HealthSystem Consortium, Performance Improvement Benchmarking Survey Results. Oak Brook, IL: Author, 2000 (4)The Patient Safety Handbook. Youngberg, B.J., Hatlie, M.J., 2004. Jones and Bartlett. Sadbury, MA 01776   The information above does not establish a standard of care, nor is it a substitute for legal advice. The information and suggestions contained here are generalized and may not apply to all practice situations. It is recommended that legal advice be obtained from a qualified attorney for a more specific application to your practice. This information should be used as a reference guide only.   Cliff Rapp is a licensed healthcare risk manager and Vice President of Risk Management for First Professional Insurance Company, a leading professional liability insurer. Mr. Rapp is widely published and a national speaker on loss prevention and risk management.