Malpractice Risks for Hospitalists

Mark Crane

Disclosures

March 21, 2013

In This Article

Bungled Patient Handoffs

Problems with the transfer of a patient from one doctor to another aren't unique to hospitalists, but they are one of the key reasons hospitalists are sued. Ineffective handoffs can increase the chance of failing to monitor a patient's worsening condition and missing an assessment that would be crucial to getting the right diagnosis and treatment plan.

In a recent case that Fitzgibbons reviewed, an abnormal test result was phoned in on a Friday night to a covering doctor. "The weekend covering doctor failed to call the appropriate consultant. A patient who should have made a full recovery is permanently disabled as a result," she says.

Handoffs are often called the "Achilles heel" of hospital medicine. "Discharge home, follow up with PCP in 2 weeks" isn't enough these days, Fitzgibbons adds. "Notify the patient's primary care doctor at the time of admission, preferably by phone. Send a copy of your dictated history and physical examination, and make sure the discharge summary goes there too."

"I'm just covering" is a trap, says Fitzgibbons. "Doctors filling in for the patient's attending physician will often leave a worrisome test result to be handled on Monday. That's a bad idea. If you're covering, you're responsible. A jury will see it that way too. Better to have the regular doctor complain that you didn't call his favorite surgeon than to have the patient spend 48 hours getting worse."

"We have to make sure we know who is following up," says hospitalist John Nelson. "The patient has been in the hospital for 4 days and is ready to go home. Some tests I'd ordered aren't back yet. There's always the risk for never seeing the results, or failing to relay them to the patient's primary doctor. It's too easy for something to fall between the cracks."

Hospitalists must track any tests they've ordered and transmit the new information to the primary doctor. "You can't just assume the information will be conveyed," says Fitzgibbons. Discharge summaries should include any medications given at discharge, with changes highlighted, as well as a list of any outstanding tests and reports that need follow-up.

Poor Documentation

As for all physicians, solid documentation is a key defense against litigation. As a hospitalist, you may have little choice in consultants, but documentation can help you protect yourself. "I know a hospitalist who was dropped from a lawsuit because his notes described his repeated calls to the neurosurgeon responsible for the delays in diagnosis and treatment of spinal cord compression," says Fitzgibbons.

"I have one case the defense is going to win simply because the hospitalists checked the right boxes on their progress notes during the last 3 days the patient was in the hospital," Fitzgibbons says. "The plaintiff is claiming that physical findings were ignored, but the chart says otherwise. And if an invasive procedure needs to be done, a chart with notes stating that 'patient is aware of risks' can make a plaintiff's attorney lose interest quickly.'

How to Reduce Your Risk for Being Sued

The Doctors Company recommends these practical suggestions:

Communicate clearly at key times. Admission to and discharge from the hospital are the most vulnerable times for communication breakdowns. But breakdowns also occur at transfer between hospital units, transfer to a consultant, and shift changes and during a clinician's days off and vacation. Hospitals and physicians should have a system in place to make sure that needed follow-up care is completed with each handoff.

Use standardized communication tools and protocols. To make sure there are no unresolved questions, each clinician should communicate -- and document -- the patient's diagnosis, current condition, recent changes, and anticipated changes.Such tools as Situation-Background-Assessment-Recommendation (SBAR) provide standardized questions to ensure that concise, focused information is gathered.

Compile checklists, and consult them often. Face-to-face discussions between doctors are ideal but often aren't practical. Checklists can be used to make sure you've obtained vital information, such as the patient's current medical status, medications, and testing (completed, pending, and planned).

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