Documenting Bad Outcomes

[NinerNiner999]

With the recent award of $26M against an EM physician and a pediatric resident, a few questions have come to mind. First, please do not hijack this thread into a political debate - this is not my intention.

While reviewing the outline of this case (but not seeing any details), It sounds like small bowel ischemia may have been the missed diagnosis leading to the judgment. It also sounds like the patient was an adolescent, making typical small bowel obstruction and/or ischemia very low on a differential list. As others on this forum have alluded to, the outcome of the case (which resulted in 89 subsequent bowel repairs and an angry patient's family), may or may not have been the result of poor prompt surgical consultation, may or may not have been the result of poor clinical decision making, and may or may not (given the atypical presentation of non-emergency abdominal pain) have presented as a run of the mill gastroenteritis.

That being said, and despite the continuous education of residents to thoroughly document every patient encounter, just how often do malpractice judgements rest solely on the results of a "bad outcome" and to what extent do they consider clinical practice guidelines?

What defense other than thorough documentation and record storage do we as EP's have against bad outcomes that occur years after a patient visit (as in this example)?

Does documentation cut it in the court room or are each of us merely sitting ducks against in this current legal climate despite our most thorough efforts to leave documentation of our encounters?

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[southerndoc]

Hindsight is always 20/20, so no matter how thoroughly you document at the time of your patient encounter, there will always be something that you could have documented but didn't. It's easier for someone to pick at your documentation two years after it was completed than it is for you to document everything in just a few minutes.

Having said that, I don't think it really matters how thorough you are at documenting things. If a bad outcome occurs, there will always be someone to take the blame in an attorney's eyes.

 

[Sessamoid]

Hindsight is always 20/20, so no matter how thoroughly you document at the time of your patient encounter, there will always be something that you could have documented but didn't. It's easier for someone to pick at your documentation two years after it was completed than it is for you to document everything in just a few minutes.

Having said that, I don't think it really matters how thorough you are at documenting things. If a bad outcome occurs, there will always be someone to take the blame in an attorney's eyes.

True, but if you document well and it's really not your fault, you want that person to be found "at fault" to be somebody else. I'd also comment that patients and their families tend not to sue doctors they like and feel cared about them, regardless of outcome or malpractice. Doctors they don't like or are indifferent to get sued far more often in cases of poor outcome, also regardless of any true malpractice. If you screwed up, don't be afraid to apologize. An interesting recent study found that owning up to your mistakes and showing true remorse made it less likely that you would be sued.

In sum,

1) Show your patients that you care. Talk to them, and talk to their families when things go badly.
2) Document and time everything.
3) Apologize for mistakes made, sincerely.

 

[Annette]

I'd be a little cautious about the apology. I had some difficulties when a patient with a nasty diabetic foot came in. She had been told by the ED that she had a cold or some other somesuch when she went in with a fever. I have a feeling she didn't even mention her foot because the ED documented "extremities: no clubbing, no cyanosis, no edema." The patient was refusing amputation for a gangrenous foot because she had been told her foot was fine. Psych was consulted for capacity. They WROTE in the consult that we should apologize to the patient that someone lied to her. Well, I have no way to know that that was the case. Risk management had an absolute fit about the consult. The patient relations manager was wonderful about the whole thing in helping me deal with the patient and the family (a very difficult patient and family). She said I could certainly apologize for the patient being in the situation that she was in (i.e., "I'm sorry that you need this surgery"), but that I definately should not apologize for anyone else's care of her.

I haven't gotten a letter. Yet. Despite doing all I could to help this lady out, I was "fired" by her. Sometimes there is nothing you can do.

 

[anonymousEM]

do be sure to document who you talked to and the time on consults...particularly when you have to call multiple times or you get the "i'm capped call hosptialist, no not our pt, no call someone else, blah blah runaround"

 

[NinerNiner999]

Ok, but assuming documentation is well kept and orderly, and, in reference to one of my original questions, your clinical belief (being the results of good practice, through workup, and no obvious diagnosis) is the diagnosis of a non-emergent condition, how much can your adherence to commonly accepted clinical guidelines protect you from being liable for a bad outcome? In simple terms, is doing your job correctly good enough to protect you from a zebra that hasn't been born yet?

 

[Sessamoid]

Ok, but assuming documentation is well kept and orderly, and, in reference to one of my original questions, your clinical belief (being the results of good practice, through workup, and no obvious diagnosis) is the diagnosis of a non-emergent condition, how much can your adherence to commonly accepted clinical guidelines protect you from being liable for a bad outcome? In simple terms, is doing your job correctly good enough to protect you from a zebra that hasn't been born yet?

Short answer: no. Nothing's to prevent somebody from suing your for a poor outcome whether or not it's your fault. There's nothing that guarantees that a jury of people with a 6th grade education won't find you at fault whether or not you did anything wrong. The best you can do is try to minimize the risk as much as is reasonably possible.