Malpractice – Top Diagnoses | How to Not Get Sued

October 11, 2018

Written by Clay Smith

Spoon Feed
Malpractice suits against emergency physicians have some common themes.  This post will help you understand them in brief.

Why does this matter?
Emergency physicians were 15th of 25 specialties for malpractice suits.  There is a 7.5% annual risk of being sued in the ED.  Overall, our risk is moderate and about the average of all specialties.  But no one wants the expense, time, and hassle of a suit, even if found not at fault.  What are the danger diagnoses and ways to reduce this risk?

Let’s be careful out there…

Red flag diagnoses:

• Chest pain or missed acute myocardial infarction is second most common but has the highest pay out.

• Missed fractures are the most common but pay out less than MI.

• This is followed by abdominal pain or missed appendicitis, wounds/retained foreign bodies/tendon injuries, intracranial bleeding, aortic aneurysm, and rarely pediatric fever/missed meningitis

The most common issues that increased risk:

• diagnostic error (test not ordered or misinterpreted; cognitive error)

• poor documentation

• poor communication with patients

• provider history of ≥2 patient complaints or prior malpractice suit

• non-EM board certification

• failure to follow up on pending diagnostic testing

• provider sleep disruption

• ED crowding/ nursing flow.

Ways to mitigate this risk:

• Tort reform has reduced prevalence and cost of suits.

• Communication is most important, even more so that the injury sustained.

• Reassessment prior to discharge is key, especially if intoxicated.  Document the following: “stable vital signs, clinical sobriety, ability to care for oneself, no new complaints, and the complete evaluation of all documented triage complaints.”

• Careful documentation is needed in the ED note and discharge instructions including: purpose of the instructions, diagnosis/expected course, potential complications, how to use medications, and follow-up.

• Use clinical practice guidelines, which are comparable to having an expert witness if taken to court.

• Use broad or generalized diagnoses (i.e. “abdominal pain” vs. “gastroenteritis” with subsequent risk of missed appendicitis.)

• Caution with discharge AMA – ensure patients are: informed of risk, have decision-making capacity, and do not need involuntary psychiatric commitment.

• Don’t abandon AMA patients.  If they must leave, show you did all you could to set them up for success, i.e. prescription for antibiotic, aiding in follow-up, calling the primary physician, etc.

• Follow up of pending diagnostic studies ordered in the ED, especially x-rays.

• Reassessment, especially of intoxicated patients

Source
Malpractice in Emergency Medicine-A Review of Risk and Mitigation Practices for the Emergency Medicine Provider.  J Emerg Med. 2018 Aug 27. pii: S0736-4679(18)30648-6. doi: 10.1016/j.jemermed.2018.06.035. [Epub ahead of print]

Open in Read by QxMD

Another Spoonful
A similar pediatric study came out this month as well.  The most common red flag diagnoses were: “cardiac or cardiorespiratory arrest, appendicitis, and disorder of male genital organs.”  Error in diagnosis was the most common contributing factor.  Open in Read by QxMD