Global health

This case was settled on behalf of the family physician.
 

Risk management considerations

The prominent issues affecting this case included multiple failures to document the physician’s examination and diagnosis of the patient’s gout and provide patient education on the prescribed medications and required follow-ups. 
Another issue includes the physician’s failure to maintain patient records in an accessible manner to enable easier reference to the patient’s treatment timeline and allow timely continuity of care. 
Insufficient documentation can lead to significant liability issues, as well as continuity of care and potential financial issues. Although rules will vary from state to state, documentation standards in the medical record are an important factor for quality patient care in all states. The Texas Medical Board (TMB) Rule 165.1 says, an adequate medical record should be “complete, contemporaneous, and legible.” 1 Well-organized and complete medical records are necessary to maintain the integrity of a patient’s care plan. 
To ensure efficient accessibility of documentation, TMB rule 165 also states that “past and present diagnoses should be accessible to the treating and/or consulting physician.” 1 Providers should ensure that the patient records they maintain accurately reflect and support the diagnosis and recommended treatment at every patient encounter. 
To avoid adverse drug reactions, it is critical to review, reconcile, and discuss the risks/benefits, dosage, and instructions for any medications prescribed with the patient and/or their caregivers. One study found that providers informed their patients of important medication information less than 60% of the time, and informed patients of adverse effects less than one third of the time. 2 
Medications need to be reviewed at each appointment to monitor compliance, identify new medications or treatments since previous appointments, and determine the patient’s tolerance of these medications. Patients may be advised to complete repeat labs or contact the office for questions or concerns regarding new medications; however, it is best practice for the physician to have a follow-up system in place. Documentation of the physician’s instructions regarding follow up might have helped support the defensibility of this case.
According to the American Medical Association (AMA) Code of Medical Ethics, appropriate medical record management includes a physician’s obligation to “manage the records of current patients, but also retain old records against possible future need.” 3
Specific to this case, AMA states physicians should retain “information that another physician seeing the patient for the first time could reasonably be expected to need or want to know unless otherwise required by law” and should retain records of “significant health events or conditions and interventions that could be expected to have a bearing on the patient’s future health needs.” 3
Missing information in the patient record, such as a thorough assessment and diagnosis, education on new medications, and poor monitoring of patient follow up, created difficulty in defending this case.
In addition, this provider used an outside entity to manage patient records. Establishing a business associate agreement with electronic health record (EHR) vendors is critical for controlling and safeguarding EHR data (Mahler, 2016).  It is recommended to regularly perform self-audits, back-ups, and recovery processes to maintain the integrity of your medical records.4

Sources

1. Texas Medical Board. Texas Medical Board Rules Chapter 165 Medical Records. Rule 165.1(6)(C)(D). Available at 

https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1

. Accessed March 11, 2022.
2. Tarn DM, Heritage J, Paterniti DA, et. al. Physician Communication When Prescribing New Medications. Archives of Internal Medicine. JAMA Network. September 25, 2006. Available at 

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/410942

. Accessed March 24, 2022. 
3. American Medical Association. Management of Medical Records. Code of Medical Ethics Code 3.3.1. (B) (ii). Available at 

https://www.ama-assn.org/delivering-care/ethics/management-medical-records

. Accessed March 14, 2022.
4. EHR Contracts Untangled: Selecting Wisely, Negotiating Terms, and Understanding the Fine Print. The Office of the National Coordinator for Health Information Technology. September 2016, Available at  

https://www.healthit.gov/sites/default/files/EHR_Contracts_Untangled

. Accessed March 24, 2022. 

Laura Hale Brockway can be reached at 

laura-brockway@tmlt.org

.

Emma Louise can be reached at 

emma-louise@tmlt.org

.

Improper performance of pain management procedure

By Olga Maystruk, Designer and Brand Strategist, and 
Tamara Vasquez, Risk Management Representative

Presentation

On April 14, a 50-year-old man with a long history of chronic pain, spinal injuries and procedures, depression, and obesity, came to see Anesthesiologist A for pain management. The patient sought treatment for radiating neck and low back pain and migraine headaches. The patient’s medications included methadone, ibuprofen, paroxetine, tizanidine, and hydrocodone/acetaminophen (7.5/325). 

An MRI of the patient’s lumbar spine revealed degenerative disc disease at the L3-4 and L4-5 vertebrae with spinal stenosis at L4-5. A cervical spine MRI showed a C4-5 fusion but was otherwise normal. 

Physician action

On April 22, Anesthesiologist A performed a bilateral L4-5 epidural steroid injection (ESI). The patient did not return for a follow-up appointment one month later. 

However, the patient did return to the physician’s office on July 1. He reported mild pain relief for approximately ten days following the ESI. The patient’s motor strength was normal, 5/5 throughout.

Three weeks later during the next follow-up appointment, Anesthesiologist A and the patient discussed an epiduroscopy and Percutaneous Ablation and Curettage and Inferior Foraminotomy (PACIF) with a plan to refer to neurosurgery if the patient saw no relief. The patient agreed to the procedures.

On August 16, the patient was admitted for the epiduroscopy and PACIF at L5 on the right side. During the procedure, Anesthesiologist A encountered epidural space adhesions and could not obtain access to the neural foramen of L4-5 on the right. Due to minor but persistent bleeding, Anesthesiologist A decided to terminate the procedure and injected 5 ml of a hemostatic matrix in the area of bleeding and retracted the scope.

A neurosurgery consultation was obtained. Neurosurgeon A noted no neurological deficits on examination and indicated no need for neurosurgical intervention. 

Anesthesiologist A saw the patient the next day and noted weakness of the right leg. An MRI showed postoperative changes at L4-5 with an epidural collection resulting in mild stenosis starting at L4-5 and extending to S2, consistent with evolving traumatic epidural hemorrhage. The patient was discharged to home.

On August 21 during a follow-up telephone call, the patient reported inability to raise his big toe and foot on the right side. Anesthesiologist A referred the patient to Neurosurgeon B.

Neurosurgeon B performed electromyography and nerve conduction velocity tests on August 26. The patient had significant pain and weakness and expressed concern for injury in the past 10 days. 

The next day, the patient underwent decompression and laminectomy of L4-5 and L5-S1 with removal of the hemostatic matrix and an epidural hematoma. The patient was discharged the next day with an ankle foot orthotic.

Following physical therapy, the patient’s foot drop resolved; however, there may be elements of secondary gain in the future.

Allegations

The patient filed a lawsuit against the anesthesiologist alleging:

· performing a non-medically indicated and experimental procedure;

· improper performance of the procedure; and

· failure to obtain timely neurosurgical consultation.

Legal implications

While acknowledging common complications during surgery such as bleeding, experts for the defense expressed concern about the follow-up care. Additionally, one consultant was critical of the PACIF procedure itself due to it still being under development at the time. In this expert’s opinion, the choice of the procedure and injection of a hemostatic matrix made the treatment in this case fall below the standard of care. 
Expert consultants for the defense did not note any issues with the timing of the neurosurgical consultation.

Disposition

The case was settled on behalf of the anesthesiologist.
 

Risk management considerations

It is the duty of the physician performing a procedure to obtain informed consent from the patient. The discussion should include the patient’s condition, procedure being performed, risks and potential complications of the procedure, benefits, and alternatives. There should be adequate time in the discussion for the patient to ask questions, and the physician should respond to all questions as accurately as possible. 

Others may help with administering informed consent documents, witnessing the patient’s signing, and reinforcing instructions; however, it is the treating physician’s responsibility to explain the procedure(s), ensure that all questions and concerns are addressed, and the patient’s understanding and willingness to proceed is documented. The process of obtaining informed consent should be documented in both the office visit note and at the facility where the procedure is performed. In this case, the informed consent discussion was not recorded in the patient’s medical record. 

A defense consultant questioned the use of ibuprofen which was on the patient’s medication list three days before surgery. It was noted that ibuprofen should have been stopped seven days before the procedure as it is a platelet inhibitor and increases the risk of bleeding. The American Society of Regional Anesthesia (ASRA) recommends that discontinuation of ibuprofen before a procedure occur for a duration equal to at least five half-lives of the drug.1 

The same defense consultant stated that the patient underwent an unnecessary invasive procedure and the use of a hemostatic matrix deviated from reasonable treatment. When applicable, reasons for any variation from routine procedures should be thoroughly documented in the patient record.

Lastly, there were issues with limited follow up and monitoring of the patient. Five days after the procedure, the patient called with right foot weakness, but the patient was not re-evaluated by neurosurgery until six days later. Records reviewed did not include documentation of follow-up appointments or care.

For continuity of care, clearly communicate to the patient your follow-up plan and expectations, then document when follow-up care and appointments are accomplished. Document this communication in the record, along with participants in the discussion, dates, locations, and times. In this case it may have warranted a communication between the treating physicians to expedite follow-up care with neurosurgery rather than having the patient wait an additional six days.
 

Source

1. McCormick Z, Popescu A, Smith C. Risk of Bleeding with Non-Aspirin Non-Steroidal Anti-Inflammatory Drugs Before Spine Procedures. Spine Intervention Society Factfinders for Patient Safety. Spine Intervention Society. March 2018. Available at 

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/factfinder_2018_03_nsaid

. Accessed March 24, 2022.

Olga Maystruk can be reached at 

olga-maystruk@tmlt.org

.

Tamara Vasquez can be reached at 

tamara-vasquez@tmlt.org

. 
 

Improper patient transfer: EMTALA case study

This case study describes the application of EMTALA (the Emergency Medical Treatment and Active Labor Act) to a clinical situation.The events in this case took place in late 1986, and this was the first case in which a physician was fined for violating EMTALA. 1

Please see related article 

“EMTALA: Requirements for on-call physicians”

Presentation

A pregnant woman arrived in the emergency department (ED) at Hospital A at 4 p.m. She was at or near term with her sixth child. She was experiencing one-minute, moderate contractions every three minutes and her membranes had ruptured.

Two obstetrical nurses examined the patient and found she was in labor and had high blood pressure. The patient had received no prenatal care, did not have a physician, and did not have health insurance.

Physician action

The obstetrical nurse called Ob-gyn A, who was on-call to treat unassigned obstetrics patients. When Ob-gyn A was told of the patient’s history and condition, he told the nurse that he “didn’t want to take care of this lady.” He asked the nurse to prepare the patient for transfer to Hospital B, which was 170 miles away. Ob-gyn A said he would call back in five to 10 minutes.

The obstetrical nurses told the nursing supervisor and hospital administrator of their belief that it would be unsafe to transfer the patient. When Ob-gyn A called back, the nurse told him that according to hospital regulations and federal law, Ob-gyn A would have to examine the patient and arrange for Hospital B to receive her before she could be legally transferred.

The nurse also asked for permission to start magnesium sulfate. Ob-gyn A told the nurse to begin administering the medication only if the patient could be transported by ambulance.

Ob-gyn A arrived at 4:50 p.m. and examined the patient. The examination revealed that the patient had ruptured membranes, was dilated 3 cm, and the fetus was “smaller than usual.”

Her blood pressure was 210/130 mm Hg and the physician was concerned the patient had been hypertensive throughout her pregnancy.

He arranged for the patient’s transfer to Hospital B, which was better equipped to handle any complications that might occur as a result of the mother’s hypertension. The nurse was ordered to begin magnesium sulfate and have the patient transferred by ambulance.

At 5 p.m., the nurse showed Ob-gyn A the hospital’s EMTALA guidelines, but he refused to read them. He told the nurse that the patient represented more risk than he was willing to accept from a malpractice standpoint.

The nurse explained that the patient could not be transferred unless Ob-gyn A signed a hospital form titled “Physician’s Certificate Authorizing Transfer.” Ob-gyn A signed the form, but did not complete the certificate. He told the nurse that until the hospital “pays my malpractice insurance, I will pick and choose those patients that I want to treat.”

Ob-gyn A went to care for another unassigned patient and the nurses arranged for the transfer. The patient’s blood pressure was 173/105 mm Hg at 5:30 p.m.; 178/103 mm Hg at 5:45 p.m.; 186/107 at 6 p.m.; and 190/110 mm Hg at 6:50 p.m.

At 6:50 p.m., the patient was wheeled to the ambulance. Ob-gyn A did not re-examine her before she was taken to the ambulance and he did not order any medication or life support equipment for the patient during transfer. An obstetrical nurse and two emergency medical technicians accompanied the patient.

Approximately 40 miles into the 170-mile trip to Hospital B, the nurse delivered the baby in the ambulance. She directed the driver to a nearby hospital to obtain pitocin. While at that hospital, the delivering nurse called Ob-gyn A, who ordered her to continue to Hospital B despite the birth.

In accordance with the patient’s wishes, the ambulance returned her to Hospital A where Ob-gyn A refused to treat her. He ordered that the patient be discharged if she was stable and not bleeding excessively. Another ob-gyn examined and admitted the patient. Three days later, the patient and her baby were discharged in good health.

Legal implications

As a result of the events in this case, HHS determined that Ob-gyn A violated EMTALA by ordering a woman with hypertension and in active labor with ruptured membranes transferred from the ED of one hospital to the ED of another hospital 170 miles away.

The physician was assessed a penalty of $25,000. Ob-Gyn A appealed the decision, claiming that the patient received all the care that she was due under EMTALA because he stabilized her hypertension sufficiently for transfer and she was not in active labor when she left the hospital in the ambulance.

An administrative law judge (ALJ) upheld the fine, but reduced it to $20,000. The HHS appeals board affirmed the ALJ and the United States Court of Appeals for the Fifth Circuit affirmed the HHS appeals board decision.

Based on a review of the expert testimony heard by the ALJ and the appeals board, the court found that the record showed “substantive, if not conclusive evidence” that the patient’s hypertension was an “emergency medical condition” as defined by EMTALA. Therefore, the patient required stabilization before transfer. The court found that the evidence supported the determination that Ob-gyn A did not provide stabilizing treatment and violated EMTALA.

The court also focused on Ob-gyn A’s decision to authorize the transfer. Accordingly, there were two reasons why the transfer was inappropriate. First, Ob-gyn A did not weigh the risks and benefits of the transfer, making the decision to transfer inappropriate. “Every reasonable adult, let alone physician, understands that labor evolves to delivery, that high blood pressure is dangerous, and that the desirability of transferring a patient with these conditions could well change over a two-hour period. [The physician’s] indifference to [the patient’s] condition for the two hours after he conducted his single examination demonstrates not that he unreasonably weighed the medical risks and benefits of transfer, but that he never made such a judgment.” 2

The second reason the transfer was considered inappropriate was because the accompanying personnel were only fully qualified to deliver the baby in the absence of complications. The nurses and EMTs were not qualified to perform a cesarean delivery or treat other complications from the patient’s hypertension that could have developed. Additionally, Ob-gyn A did not order a fetal heart monitor or other specialized neonatal equipment for the ambulance. 2

Source

1. Institute of Medicine. H
ospital-Based Emergency Care: At the Breaking Point. 2007. Washington, DC: The National Academies Press. Available at 

https://doi.org/10.17226/11621

. Accessed December 8, 2021.

2. 
Burditt v. U.S. Dept. of Health, 934 F.2d 1362 (5th Cir. 1991). Available at 

https://casetext.com/case/burditt-v-us-dept-of-health

. Accessed December 9, 2021.

About the Author

Laura Hale Brockway is the Vice President of Marketing at TMLT. She can be reached at laura-brockway@tmlt.org.

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Failure to diagnose pulmonary embolism

by Olga Maystruk, Designer and Brand Strategist, and
Jennifer Templin, Risk Management Representative

Presentation

On January 5, a 51-year-old woman came to the emergency department (ED) of a large hospital with excessive vaginal bleeding, progressive diarrhea, and dizziness over the past three days. The patient was obese with a BMI of 30.9 and had a history of smoking. She reported that the onset of her bleeding was consistent with her menstrual cycle but heavier than usual.

The patient had visited an urgent care center the day before with the same symptoms. At the center, she received a prescription for losartan and multivitamin with iron.
 

Physician action

The emergency physician ordered a chest x-ray and pelvic ultrasound. The x-ray showed mildly enlarged cardio mediastinal silhouette with no acute abnormalities. The ultrasound revealed an enlarged uterus and numerous fibroid tumors, the largest measuring 6.5 x 5.5 x 3.5 cm.

Additional lab tests were also performed. Partial thromboplastin time was 14.4, within the normal range of 12.0-15.0. The patient’s heart rate was slightly elevated, and her respirations (R) and oxygen saturation range (O2 sats) were recorded at 20 (normal adult respiration is 12-18 breaths per minute) and 94% (normal O2 sats are between 95-100%). Her heart rate and O2 sats were consistent with severe anemia and significant blood loss. The patient was given oxygen via nasal cannula.

The emergency physician’s differential included anemia, dysfunctional uterine bleeding, elevated troponin levels, tachycardia, dysmenorrhea, endometriosis, uterine fibroids, malignancy, menorrhea, and a possible non-ST elevation myocardial infarction. The patient was admitted to the hospital under the care of an internal medicine physician. Ob-gyn and cardiology consults were ordered.

On January 6, the internal medicine physician consulted with a hematologist, cardiologist, and ob-gyn. The internal medicine physician noted raised troponin levels and hemoglobin at 7.2. The cardiologist reviewed the electrocardiogram (EKG) that revealed sinus tachycardia, voltage criteria for left ventricular hypertrophy, and inferior MI of an undetermined age.

The EKG also showed T-wave abnormalities with both inferior and anterolateral T-wave changes which may have been ischemic or due to repolarization abnormality. The patient’s troponin levels were out of range at 0.33 and 0.24 (normal range 0.00 – 0.10), and an ultrasound showed multiple fibroids.

Upon his examination of the patient, the cardiologist documented a minimal troponin leak and abnormal EKG. His differential diagnosis was myocardial infarction, severe anemia, hypertension, cardiovascular disease with left ventricular hypertrophy 2° hypertension, and congestive heart failure. He noted that the patient could be managed on an outpatient basis with a 2-D echocardiogram (echo) and nuclear stress test.

The cardiologist stopped the losartan and hydrochlorothiazide treatments and switched the patient to metoprolol SR 25 mg a day. The ob-gyn ordered estrogen 25 mg IV every four hours x 3 doses to control the bleeding in addition to six units of platelets. The patient’s O2 sat was at 93%.

On January 7, the ob-gyn signed off on the patient’s care due to vaginal bleeding subsiding to normal levels. He planned to follow the patient on an outpatient basis. The internal medicine physician wrote an order for discharge at 8 a.m. with instructions to follow up within two weeks. The cardiologist signed off on an oral order for the discharge at 9 a.m. The patient left the hospital at 11:53 a.m.

At 10:30 p.m. that night, EMS was called to the patient’s home where they found the patient lying supine in her driveway. A family member reported that she stopped breathing in the car and that he attempted to revive her with CPR. EMS continued CPR and attempted to place an IV and obtain a blood pressure reading, but were unsuccessful. The patient was given 2 mg epinephrine, intubated, and transported to the ED.

Upon arrival, the patient was hypotensive and in shock. Following resuscitative efforts, the on-call surgeon pronounced the patient dead. The autopsy stated the cause of death to be pulmonary embolism (PE) due to deep vein thrombosis associated with obesity and uterine enlargement caused by uterine fibroids and adenomyosis.
 

Allegations

The patient’s family filed a lawsuit against the cardiologist, internal medicine physician, and hospital. Allegations included:

· failure to administer appropriate testing for PE;

· failure to follow up on echo results; and

· prematurely discharging the patient.
 

Legal implications

The case presented several documentation issues for the defense. First, there was a nursing note from January 6 about a message on the cardiologist’s answering service regarding the patient’s brain natriuretic peptide (BNP) level of 936 pg/ml (normal is less than 100 pg/ml) and that the patient desaturated when walking without oxygen. The cardiologist did not recall receiving this message.

Another nursing note from January 7 indicated that the cardiologist was notified of the patient’s BNP test results before the patient’s discharge. The cardiologist did not recall discharging the patient and mentioned calling the hospital to follow up on the echo. The hospital, however, did not have a record of that call.

Aside from documentation inconsistencies, two of three cardiology experts who reviewed the case for TMLT were supportive of the cardiologist’s treatment methods. They observed that the patient presented several health issues that made it hard to diagnose PE, especially since the most common PE symptoms such as shortness of breath and chest pain were not present.

However, the third cardiology expert felt that the standard of care was not met in this case. This consultant was critical of the cardiologist not following up on echo results and not considering PE based on the patient’s x-ray and test results.

An emergency medicine expert assessing the case argued that the cardiologist did indeed meet the standard of care and instead put responsibility of the outcome on the internal medicine physician and ob-gyn.

A cardiologist consultant for the plaintiff was critical of the cardiologist for failing to consider a diagnosis of PE based on the patient’s clinical presentation. This consultant felt the cardiologist could have ruled out PE with testing, such as D-dimer, venous Doppler, chest CTA, and echo. Had the cardiologist taken these measures, the consultant argued that the patient’s condition could have been improved through anticoagulation therapy, thrombectomy, or placing an inferior vena cava filter.

Plaintiff consultants were also critical of the nurses for not being more persistent about reaching the cardiologist with the patient’s abnormal test results.
 

Disposition

The case was settled on behalf of the cardiologist and the hospital. The outcome of the case against the internal medicine physician is unknown.
 

Risk management considerations

Proper and timely patient charting and documentation is vital for quality patient care, and can be a physician’s best defense in the event of a claim. In the hospital setting, when each provider adequately documents their evaluation, treatment, and management of conditions, it also helps to ensure a continuity of care. Documentation becomes even more important, as some patients require more consulting physicians. Ensuring that each consulting physician is advised of any testing and treatment can help with ruling out differentials and developing appropriate treatment plans.

Effective communication between physicians and hospital staff is also key for providing optimal patient care. In this case, the lack of communication and appropriate follow up on test results, may have led to the patient being discharged too early. According to the Agency for Healthcare Research and Quality, “communication issues are the most common root cause of sentinel events (serious and preventable patient harm incidents).” 1

Given that the patient’s BNP level was outside the normal range and that the patient desaturated while walking without the use of oxygen, additional attempts to ensure that the cardiologist received this information might have been beneficial.

Additionally, if the cardiologist did not receive the results of the ordered tests, it would have been prudent for the cardiologist to follow up. Had the cardiologist been aware of the BNP test results, further testing and treatment may have been warranted and the patient’s discharge delayed.

Ensuring a patient is appropriately discharged can lead to better outcomes and lessen the chance that a patient will return to the emergency department. While there are several key elements noted to be essential in discharge planning, physicians and patients alike must be aware of any pending test results before discharge.

In this case, there were test results that had been communicated to the hospital staff but not to the cardiologist, or the cardiologist could not recall receiving the test results. Either way, it is recommended that the discharging physician make sure that pending and treatment-determining test results are received in the patient record and read before the patient is discharged. 2
 

Sources

1.Communication between clinicians. Agency for Healthcare Research and Quality. September 2019. Available at 

https://psnet.ahrq.gov/primer/communication-between-clinicians

. Accessed March 12, 2021.

2.

Alper

. Hospital Discharge and Readmission. UpToDate website. Updated March 10, 2021. Available at 

https://www.uptodate.com/contents/hospital-discharge-and-readmission

. Accessed March 17, 2021.

Failure to recognize sepsis

By Gracie Awalt, Marketing Associate, and Anthony Passalacqua, Risk Management Representative
 

Presentation

On November 3, a 30-year-old woman came to a hospital emergency department (ED) in labor. She was admitted and estimated to be 36 weeks pregnant.

She had been scheduled for a cesarean delivery on November 19, but that date was changed due to low amniotic fluids on a recent sonogram. This was the patient’s second pregnancy. Her first child was also delivered by cesarean.

Physician action

Ob-gyn A performed a low transverse cesarean delivery, noted as uneventful. On November 6, the patient had a temperature of 99 degrees and an elevated pulse rate. The patient was kept overnight.

In the early morning on November 7, she vomited undigested food and was seen by Ob-Gyn B. He noted that the patient was feeling better later that morning. By lunch time, she had retained her lunch, moved with ease, and showed no signs of distress. The patient and her newborn were discharged at 5 p.m.

On November 8 at 7:48 p.m., the patient came to the ED of a different hospital with nausea and vomiting for three days. She reported having a small bowel movement, but no diarrhea or constipation. The patient’s blood pressure was 128/79 mm Hg; pulse was 124; respiratory rate was 20; and temperature was 99 degrees. She rated her pain at 6 out of 10.

Emergency Medicine Physician A noted the patient’s abdomen was soft, with normal bowel sounds and no distention or tenderness. The physician’s differential diagnoses included anemia, infection, dehydration, and electrolyte imbalance. EM Physician A testified that she believed the patient’s symptoms were consistent with viral gastroenteritis.

The patient’s white blood cell count was normal with a bandemia of 65%. A CBC showed mild anemia with hemoglobin of 10.4. The patient’s complete metabolic panel showed “sodium 136, chloride 96, bicarbonate 19, BUN 51, creatinine 1.37, normal glucose, and normal LFTs and lipase.”

The patient was given two liters of normal saline, and EM Physician A re-examined the patient at 11:57 p.m. After consuming a rehydration drink, the patient reported no further vomiting.

On November 9, the patient was discharged at 1:12 a.m. with a prescription for hydrocodone and ondansetron. She was instructed to continue drinking fluids and to follow up with Ob-gyn A. The patient’s vital signs at discharge showed her blood pressure at 102/58 mm Hg; her pulse at 78; respirations at 18; and a 98% oxygen saturation.

The patient continued to report nausea and chest pain to family members. On November 11, the patient experienced stomach swelling. According to the patient’s father, she did not want to call her doctor or go to the ED. She wanted time for her medications to work.

On November 12, the patient’s family called for an ambulance twice. When the first ambulance arrived, the EMT told the patient that she would be fine, and that a trip to the hospital was not necessary. The first ambulance was sent away without examining the patient. However, a second ambulance was called, because the patient’s temperature exceeded 100 degrees, and she looked very pale. This ambulance transported her to the hospital on November 13 with significant abdominal pain.

Upon arrival in the ED, the patient’s blood pressure was 66/38 mm Hg, with a 130-pulse rate and respirations of 30. Her oxygen saturations were 90% on oxygen. She received fluid resuscitations. Examination revealed abdominal tenderness with rebound, guarding, and distention. It was believed the patient was bleeding intra-abdominally.

An ultrasound showed free air in her abdomen, and a massive blood transfusion protocol was initiated. After developing acute respiratory failure, the patient was intubated and taken to the operating room for an exploratory laparotomy.

The patient was ‘’found to have a perforation primarily of the right colon and cecum, but marked peritonitis with diffuse enteric contents throughout the peritoneal cavity, which resulted in an additional perforation of the small bowel.” Her small and large bowel were also gangrenous. Excised areas of the bowel were sent to pathology.

After surgery, the patient was transferred to the ICU. She arrested on November 14, but returned to spontaneous circulation. She required pressor drips to support her vital signs and dialysis due to renal failure. She developed disseminated intravascular coagulation (DIC), and she went into severe metabolic acidosis on November 16. The results of a brain stem exam revealed no cerebral activity.

The patient’s family withdrew medical care that day, and the patient died at 6 p.m. Her death certificate listed the cause of death as “intestinal perforation with onset of 4-5 days, peritonitis, septic shock and brain death.” No autopsy was performed.

Allegations

A lawsuit was filed against EM Physician A and the hospital. It was alleged that she failed to recognize symptoms of sepsis, and that she should have admitted the patient on November 8. The allegations included gross negligence.

Legal implications

EM Physician A testified that when she saw the patient on November 8, her symptoms were consistent with viral gastroenteritis, not an infection. EM Physician A attributed the patient’s elevated BUN and creatinine levels to dehydration, and the patient’s bandemia to physical stress from the recent cesarean delivery and repetitive vomiting. EM Physician A did not believe the patient’s lab results and symptoms indicated sepsis.

Defense consultants offered mixed opinions about this case. One consultant stated that EM Physician A ordered appropriate labs, while another consultant believed a CT scan should have been ordered, and that a bedside ultrasound would have shown fluid in the patient’s abdomen. Both consultants thought that the patient was septic.

Both the pathologist and surgeon who treated the patient thought that she developed Ogilvie’s syndrome, causing the perforation in her small intestine. However, the pathologist did not believe Ogilvie’s syndrome could be diagnosed based on her one episode of vomiting and nausea. The surgeon stated that the patient’s symptoms and vital signs did not warrant further testing. But if  imaging had been performed, it would have likely shown Ogilvie’s or an ileus. The surgeon thought that EM Physician A was prudent in recommending that the patient see her ob-gyn in 24 hours if symptoms continued.

The plaintiff’s expert criticized EM Physician A for not addressing the patient’s “very abnormal” electrolytes and complete blood count results, as well as the “grossly abnormal” white blood cell count. This expert also criticized the defendant for not ordering further testing to identify the bacterial infection and for not admitting the patient to the hospital for observation.

An expert for the defense stated that EM Physician A correctly diagnosed the patient given her  symptoms. This expert believed that the clinical presentation of the patient was the most important mechanism for determining sepsis. This expert also believed that the documentation did not support the patient having a bowel perforation.  

Disposition

This case was settled on behalf of EM Physician A and the hospital.

Risk management considerations

Communication and documentation issues are frequently a focus of medical malpractice suits. In this case, the hospital staff failed to communicate to the physician that the patient had nausea 
with vomiting. Omissions in documentation can lead to adverse outcomes; the physician may have changed his diagnosis if he had been aware of the patient’s vomiting. 

Another communication breakdown occurred between the patient and hospital staff during discharge. The patient and her father did not inform the hospital staff that she was still experiencing nausea and chest pain at discharge. It was crucial for the patient to report these ongoing issues, which may have prevented her discharge from the hospital.         

Following up with a patient after a major event such as an ED visit or surgery is crucial not only for patient safety, but also patient satisfaction. The Patient Safety Network of the federal Agency for Healthcare Research and Quality recommends following up with patients within the first 72 hours after discharge. Having clinically trained staff with a pre-determined triage check list can help you identify complications before they become serious. Instructing a patient to follow up with their general practitioner may delay care, especially if there is a public health crisis such as a pandemic or natural disaster. Staff should be trained to ask the physician about appropriate timing of a patient’s follow-up appointment, and if the scheduled appointments may delay treatment. If so, it is important to suggest alternatives to the patient, such as returning to the ED if necessary. (1)

Source

1. Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. Patient Safety Network.  Agency for Healthcare Research and Quality. March 1, 2012. Available at 

https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call

. Accessed October 13, 2021.

Preparing the Case

Before you begin writing, follow these guidelines to help you prepare and understand the case study:

1. Read and Examine the Case Thoroughly

. Take notes, highlight relevant facts, underline key problems.

· Focus Your Analysis

. Identify two to five key problems.

. Why do they exist?

. How do they impact the organization?

. Who is responsible for them?

· Uncover Possible Solutions/Changes Needed

. Review course readings, discussions, outside research, your experience.

· Select the Best Solution

. Consider strong supporting evidence, pros, and cons. Is this solution realistic?

Drafting the Case

Once you have gathered the necessary information, a draft of your analysis should include these general sections, but these may differ depending on your assignment directions or your specific case study:

OUTLINE:

1. Introduction

. Identify the key problems and issues in the case study.

. Formulate and include a thesis statement, summarizing the outcome of your analysis in 1–2 sentences.

· Background

. Set the scene: background information, relevant facts, and the most important issues.

. Demonstrate that you have researched the problems in this case study.

· Evaluation of the Case

. Outline the various pieces of the case study that you are focusing on.

. What are the ethical considerations?

. What type of law suit

. Evaluate these pieces by discussing what is working and what is not working.

. State why these parts of the case study are or are not working well.

· Proposed Solution/Changes

. Provide specific and realistic solution(s) or changes needed.

. Explain why this solution was chosen.

. Support this solution with solid evidence, such as:

. Concepts from class (text readings, discussions, lectures)

. Outside research

. Personal experience (anecdotes)

· Recommendations

· Determine and discuss specific strategies for accomplishing the proposed solution.

· If applicable, recommend further action to resolve some of the issues.

· What should be done and who should do it?

Finalizing the Case

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Formatting

Title Page

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Outline

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