A review of SVMIC hospitalist closed claims from 2008 – 2015, where a loss was paid on behalf of an insured, reveals three basic areas that contributed to the indefensibility of the claims. These issues are illustrated in the graph below:
COMMUNICATION ISSUES: Effective communication is essential in establishing trust and building good patient rapport, which in turn plays a role in a patient’s perception of the quality of care received and helps ensure compliance. National data, as well as our data, suggests that patient handoffs between physicians continues to be a significant source of liability for hospitalists. Communication breakdowns occurred in 69% of the reviewed claims, with the majority of these claims being breakdowns between physicians. Case examples include:
In one case, an elderly patient with a non-displaced fracture was transported to an ED without orthopedic services. The hospitalist admitted the patient for pneumonia and stabilized the extremity with a short leg posterior splint including ACE wrap. After discharge, the patient was seen by an orthopedic surgeon who discovered a large pressure blister and ulceration which eventually resulted in osteomyelitis and a below the knee amputation. A lack of documentation as to the nature and extent of the neurovascular examinations of the extremity made it difficult to defend against the plaintiff’s allegations that both the hospitalist and hospital nurses failed to properly evaluate the patient’s neurovascular condition during the hospitalization.
In another case, a 65-year-old patient became hypotensive following a total abdominal colectomy. The patient continued to deteriorate throughout the night and the nurses notified both the hospitalist and the on call surgeon. The hospitalist remained at the bedside but the surgeon did not come in even though he was notified of the patient’s status periodically throughout the night. The patient coded in early morning and was taken to surgery where an arterial bleed was found. The patient suffered an anoxic brain injury. Finger pointing ensued. The surgeon, as the principle target in the suit, said the nurses led him to believe the hospitalist had matters under control and blamed the hospitalist for not communicating with him directly.
MEDICATION ISSUES: Medication errors were present in 38% of the reviewed cases. Medication reconciliation and prescribing at discharge continue to pose significant risk for hospitalists. The case below exemplifies this risk:
After undergoing a total knee replacement, a 46-year-old patient developed a hematoma necessitating additional surgical procedures and antibiotic therapy. The hospitalist ordered Gentamycin and discharged the patient to home health for two more weeks of home infusion therapy with the antibiotics. The orthopedic surgeon continued to refill the Gentamycin; neither physician had ordered any monitoring protocol. Two months later, the patient developed debilitating symptoms of dizziness and imbalance. A referral to the ENT determined the patient had sustained vestibular damage, most likely from the Gentamycin. The hospitalist, having been the one to order the antibiotic initially, bore the brunt of the responsibility for failing to appreciate the risks of aminoglycoside toxicity, inform the patient of those risks and to order monitoring blood tests upon discharge.
DOCUMENTATION ISSUES: Maintaining a well-documented medical record, from both a patient care and a risk management standpoint, is crucial. As the graph above illustrates, documentation issues were a factor in 38% of claims paid for hospitalists. Of those, including the cases cited above, most had inadequate documentation, which can negatively impact the ability to defend the care provided to a patient. Most often there was a failure to completely document the extent and details of an examination; rationale for the diagnosis and treatment plan; and patient education and telephone calls.
Carolyn Akland is a Program Development Specialist in the department of Risk Education and Evaluation Services for SVMIC where she develops educational programs based on the lessons learned through claims analysis. Ms. Akland graduated from St. Olaf College with a BSN and from the Massey School with an MBA. She worked as a nurse in clinical, quality, military and business settings before joining SVMIC in 2003 as a Risk Evaluation Specialist.
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