A review of closed paid pulmonology claims over a seven-year period revealed the primary allegation asserted was failure to diagnose and treat. Most typically, such diagnostic errors were not the result of lack of knowledge or diagnostic ability on the part of the physician, but rather, as the graph below illustrates, were a product of communication breakdowns, poor documentation, and medication errors.
COMMUNICATION ISSUES: Clear and complete communication between providers and nurses is necessary to provide optimal patient care. Electing to treat a hospitalized patient over the phone was a recurrent criticism faced by physicians when a complication occurred. In nearly every case, the physician came under heavy scrutiny for failing to personally evaluate the patient, or for failing to obtain sufficient information to enable proper treatment over the phone.
A case that illustrates the failure to properly make clear the circumstances upon which communication should take place involved a 33-year-old patient who presented to the emergency room with shortness of breath, dysphagia and facial swelling. A CT revealed superior vena cava syndrome. She was admitted to the hospital by a pulmonologist and then underwent a successful percutaneous transluminal angioplasty, which was performed by an interventional radiologist. However, upon removal of the sheath, the patient’s blood pressure dropped from 161/90 to 81/50, she began seizing and then became unresponsive. After being resuscitated, the pulmonologist ordered her transferred to the ICU where she remained hypotensive. He did not personally evaluate the patient, and did not clearly communicate with the nursing staff regarding the patient’s situation. Through the night the patient deteriorated, no urine output was noted, and the patient became drowsy and confused. It was not until the patient had pulseless electrical activity, no verbal response and a BP in the 60’s, that the nursing staff contacted the physician. The lawsuit alleged that the physician and nurses failed to appreciate the significance of the severely low blood pressure and seizures; and further that they failed to collaborate regarding the patient who was clearly unstable after her procedure.
DOCUMENTATION ISSUES: The importance of maintaining a well-documented medical record, from both a patient care and a risk management standpoint, cannot be overstated. As the graph above illustrates, documentation issues were a factor in 27% of claims paid in Pulmonology. Most often, there was a failure to document completely the patient and/or family history, details of the physical exam, rationale for the diagnosis and treatment plan, patient education, and conversations with the patient and family regarding treatment recommendations.
MEDICATION ISSUES: Failure to monitor was the primary issue in cases involving allegations of medication error. Coumadin was the drug most commonly involved. One case involved a 51-year-old female who was admitted for treatment of a pulmonary embolus with a Heparin drip and Coumadin. Four days following admission, she was transferred to the ICU after a MRI revealed a retroperitoneal hematoma in the right lower quadrant of the pelvis. The pulmonologist who took over the care did not personally evaluate the patient, but instructed the nurses to continue the anticoagulants due to concerns about the pulmonary embolus. The patient died shortly thereafter from hypovolemic shock. The pulmonologist faced expert criticism for keeping the patient on the Coumadin without making any effort to disprove active bleeding by doing a contrast CT or following with serial hematocrits. His failure to personally assess the patient, or to document his rationale for his treatment plan, further compounded the problem.
Shelly Weatherly is Vice President, Risk Education and Evaluation Services for SVMIC. Ms. Weatherly graduated from the University of Tennessee School of Law, is a member of the Nashville and Tennessee Bar Associations, and has been with SVMIC for 26 years. Prior to joining SVMIC, Ms. Weatherly served as Law Clerk on the Tennessee Court of Appeals for the Honorable William C. Koch, as well as on the U.S. District Court for the Middle District of Tennessee under the Honorable Charles Neese. Ms. Weatherly leads SVMIC's Risk Education and Evaluation Services. Prior to 2015, she developed and administered the company's Risk Evaluation Services and earlier served as a Claims Attorney. She is a frequent speaker on risk management, liability assessment, and professional liability topics at medical professional association meetings, medical schools and residency programs, and industry seminars.
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