The Perils of Practice

Transcription

1 The Perils of Practice Staying Out of the Courtroom and Off Social Media Miriam (Mimi) Clemons, JD, MBA Asst. Vice President - Claims and Director of Memphis Operations SVMIC Claims With A Loss By Location last five years Multiple locations 13% Other 7% Practitioner's office 19% Hospital 61% Claim Data and Trends in the ED TIME PERIOD # CLOSED CLAIMS # PAID CLAIMS % PAID TO CLOSED AVGE CLAIM PMT (IN 2011 DOLLARS) % $226, % $ % $266, % $354, % $374,070 Source: American College of Emergency Physicians, Summary of Malpractice Claim Data and Trends from Three Sources, an Information Paper, October

2 Communication is KEY!! 1. Team Communication physician, nurse, EMS 2. Handoff and sign-out among providers 3. Communication between provider and patient 4. Communication of discharge instructions Source: American College of Emergency Physicians, Summary of Malpractice Claim Data and Trends from Three Sources, an Information Paper, October Poor Communications = Errors 44% - Direct breakdown in communications with patients or among colleagues during care 33% - Communications via Medical Record 21% lack of correct information in the medical record 12% inaccessibility of medical records 23% - Follow up issues with patients/colleagues Why People Sue Bad Outcome Perception of Negligent Care Poor Communication To Save the Next Patient To Relieve Guilt for Own Role in the Outcome Money Source: Keeping Your ED Out of the Courtroom: The Medical Legal World of Pediatric EM, Steven M. Selbst, MD, Presented at Jefferson Medical College, Philadelphia, PA 2

3 Harm + Bad Experience = Lawsuit Good care + GOOD communication = LOWEST risk of lawsuit Good care + BAD communication = HIGHER risk of lawsuit BAD care + BAD communication = ALMOST CERTAIN risk of lawsuit How Patients Hear Us Tone of voice (38%) Words (7%) Body language (55%) Effective Handoffs Attending Physicians Resident Physicians Consulting Physicians PAs and NPs RNs and LPNs Medical Assistants Lab & Radiology Staff EMS Personnel 3

4 Handoffs and Sentinel Events According to the Joint Commission, about half of all sentinel events, mistakes resulting in death or serious patient injury, involve errors that occur during handoffs in care. Handoffs are one of the riskiest procedures in the Emergency Department. Misperceptions Source: Attributed to Allan Greenspan, Federal Reserve Chairman, in Handoffs in High Risk Environments NASA, Nuclear Plants, Railroad Dispatch Centers, Ambulance Dispatch Center Factors critical to Success: Q&A uncovered important facts or findings Standardized handoffs At-a-glance visual displays Source: Shari Welch, MD, FACEP, The Handoff, ACEP Quality Improvement and Patient Safety,

5 Improving Sign Outs The Safer Sign Out Checklist 1. Record 2. Review 3. Round 4. Relay Information to the Team 5. Receive Feedback Source: Safety Leadership Group of Emergency Medical Associates, PA, PC of Maryland, in cooperation with the American College of Emergency Physicians Sign Out Best Practices Pre-Round (off-going clinician) Inform the patient prior to sign out Confirm Mutual Understanding (both clinicians) Any questions or suggestions? No misperceptions Minimize interruptions Establish a reliable QA process Source: Safety Leadership Group of Emergency Medical Associates, PA, PC of Maryland, in cooperation with the American College of Emergency Physicians Handoffs Between EMS and Emergency Department Pre-Handoff Phase Incoming to ED Situational Awareness Handoff Phase Team at the Bedside Vitals, History, Meds, Allergies Post-handoff Phase ED Team Takes Over Medics Still Present 5

6 Admission Orders Outpatient Unit, Inpatient Orders? Ambiguity leads to liability Who s responsible for the patient? Where does the ED provider s responsibility end? 50% of Emergency Physicians are still writing admit orders Source: ACEP, Writing Admission and Transition Orders Policy Resource and Education Paper (PREP), July 2013 Why Write Orders? Continuity of Care Convenience of the Admitting Physician Contracts Communication Crowding Issues Transition Orders Not formal admitting orders Time limited 2-4 hours Document transition discussion with attending in the medical record Do not order tests treatment to take place beyond the transition period Call the attending for further orders or clarification. Source: ACEP, Writing Admission and Transition Orders Policy Resource and Education Paper (PREP), July

7 Who s Responsible? Emergency Physician - 1. Only while the patient is physically present in the ED 2. AND under their care, 3. AND prior to being accepted by an admitting physician. 4. Exception - a medical emergency while patient is still physically in the ED. Who s Responsible? Attending Physician 1. After they have accepted responsibility for admission, 2. Regardless of the patient's physical location within the hospital. 3. Once accepted, the patient is an inpatient. 4. Emergency Physicians don t treat inpatients. Source: ACEP, Writing Admission and Transition Orders Policy Resource and Education Paper (PREP), July 2013 Defined: Boarding The practice of holding patients in the emergency department or a temporary location for four hours or more after the decision to admit or transfer has been made. Source: The Joint Commission; Patient Flow thru the Emergency Department, December 19,

8 Effects of Boarding Overcrowding Ambulance refusals Lower quality of care Prolonged patient waiting times Greater length of stay Decreased patient satisfaction Source: The American College of Emergency Physicians, Definition of Boarded Patient, January Passing the Baton An incomplete handoff between two parties who are moving very fast. Who s monitoring the patient? Writing orders? Reality may not match hospital policy What Does a Jury Think? Juries will go with the simplest theory: If the patient is physically in the ED, then the ED staff is still responsible for caring for them. 8

9 Case Examples yom overdoses on multiple meds and remains in the ED o ISSUE: who should write the orders? o What can the ED doctor order? yom with suspicion of bowel obstruction, admitted to a room o ISSUE: should ED physician still be on the hook even after admission to floor? Case Examples, cont d yom admitted directly from his doctor s office through the ED o ISSUE: What role does the ED staff play? yom with hyponatremia that was corrected too rapidly. o ISSUE: Extended stay in the ED but who was monitoring the patient and his labs? Technology and Social Media When in Doubt, DON T 9

10 Technology in Daily Use Social networking Blogging Online Forums Media Sharing Sites Cellphone Photography Google and other Search Engines Texting ing Pros and Cons ACTIVITY PROS CONS ing with patients Accessibility Ambiguity in the Message Checking Social Media Observing Patient Undermines Patient Trust Online Education Supplemental Info Reliability, Accuracy Physician Blogs Advocacy Venting Texting and ing Communicating Confidentiality Source: Online Medical Professionalism - Patient and Public Relationships: Policy Statement from the American College of Physicians and the Federation of State Medical Boards, Annals of Internal Medicine, 2013:158: Online Activity Do not friend your patients or accept friend requests from them Set security settings for maximum privacy Monitor photos that OTHERS post of you Consider your intent when checking for information on patients Patient-targeted Googling Maintain the integrity of professional relationships 10

11 And in Conclusion What is Your Lawyer s Diagnosis? Questions or Comments? Mimi Clemons, JD, MBA Assistant VP Claims and Director of Memphis Operations [email protected] or