Malpractice Case: Here's Where Procedure Errors Often Occur

Gordon T. Ownby


November 02, 2018

Medscape Editor's Key Points:

  • While practice staff are often involved in completing paperwork, patients look to the physician for answers when something goes wrong.

  • Even if you think paperwork has been completed, it's best to check to avoid errors in patient care.

  • Ensure that everyone in the practice understands their duties and responsibilities up front, and review procedures regularly to solidify understanding of all necessary tasks.

Proper Delegation Can Help Avoid Litigation

In the complicated maze of medical referrals and authorizations, a physician's reliance on a competent staff to work with benefit providers to complete any necessary paperwork is eminently reasonable. In the end, though, the patient will look to the physician as the one ultimately responsible for completing the task.

An elderly man had a longstanding history of significant cardiac problems. More recently, the patient's cardiologist diagnosed him with sick sinus syndrome, atrial fibrillation, cardiomyopathy, and congestive heart failure. Though that cardiologist referred the patient to an electrophysiologist for an implantable defibrillator, the patient did not have the device placed.

A year later, the primary care physician referred her 76-year-old patient to Dr. C, another cardiologist, for severe ankle edema. At a medical group office where he sees cardiac referrals once a week, Dr. C performed an electrocardiogram on the patient. The test showed atrial fibrillation and a left bundle branch block. Dr. C admitted the patient to the hospital, where the prognosis for the patient was poor and guarded. With an ejection fraction of 15%, pulmonary hypertension, mild to moderate left ventricular dysfunction with moderate regurgitation and mitral regurgitation, Dr. C recommended placement of a defibrillator and pacemaker. The patient said he wanted to think about it.

In his letter to the patient's primary care physician, Dr. C wrote that he had requested authorization from the IPA [independent practice association] for placement of the defibrillator and pacemaker.

Five months later, Dr. C saw the patient and noted that he was doing well on cardiac medication but still had edema in both lower extremities. Dr. C altered the medications, advised the patient to modify his diet, and said that he was still waiting for authorization to insert the defibrillator and pacemaker.

Two weeks later, Dr. C was advised by the medical group that the patient did not need authorization for the defibrillator and pacemaker. Dr. C scheduled the patient for the procedure in 3 weeks' time. On a visit to Dr. C 10 days before the scheduled procedure, the patient expressed concern about the device because he was worried about an electrical shock while driving. Three days later, the patient died. The death certificate attributed the death to cardiopulmonary arrest, cardiomyopathy, and diabetes mellitus. As it turned out, Dr. C was mistaken in his belief that the medical staff had handled the authorization request for insertion of the defibrillator and pacemaker.

In her lawsuit against Dr. C for wrongful death, the patient's widow claimed that Dr. C and his staff failed to timely request authorization for the procedure to place the defibrillator and pacemaker, and that the physician fraudulently misrepresented to the patient and his wife that the authorization had been submitted.

Had Dr. C followed up on the matter, the widow claimed, he would have discovered that the medical group staff had never submitted the authorization and that the procedure would then have been performed, preventing the patient's death. At trial, the plaintiff's attorney put Dr. C on the stand to testify on his contract with the IPA, which indicated that he would familiarize himself with the IPA's program and that he would properly fill out and follow up on authorization requests.

During his testimony, however, Dr. C explained that the patient had multiple comorbidities and that while the defibrillator might help the plaintiff, it would not likely extend his life. On the stand, Dr. C stressed that the device would only prevent a certain type of cardiac death, a fatal arrhythmia. It would not prevent a myocardial infarction or death caused by cardiomyopathy.

In the end, the jury found in favor of Dr. C.

Physicians and their staff should be clear on their procedures for the processing of referrals, authorizations, and other critical communications. Coming to a specific understanding on the allocation of duties and responsibilities can help avoid lengthy explanations later.

This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories. The article was originally titled "Delegating in the Medical Office: Trust and Verify."


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