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Diagnoses are liability problem No. 1
Sketchy comanagement leads to big trouble
by Robin Diamond, JD, RN
Susan Shepard, MSN, RN




Published in the January 2011 issue of Today's Hospitalist

WHY DO HOSPITALISTS GET SUED? We analyzed more than 350 consecutive closed claims made between 2000 and 2007 against internists and hospitalists and came up with this striking figure: 58% of the allegations made in these claims were related to diagnosis.

The allegations ran the gamut from a delay in ordering a necessary diagnostic test to a failure to establish a differential diagnosis or to assess clinical information. Here’s a case that illustrates the type of claim we see.

CASE: A 45-YEAR-OLD PATIENT admitted to the neurosurgery service was unresponsive, hypotensive and bradycardic.
Drift toward failure occurs when safety goals take a back seat to production.

A CT scan and MRI revealed a large intracerebral hematoma and an arteriovenous malformation (AVM).

By the second day, the patient had stabilized, with medical and nursing notes describing her as alert and oriented. As a result, surgery was scheduled to take place within a week.

The comanagement arrangement between the hospital staff neurosurgeons and the contracted hospitalists was not clearly defined for either specialty, other than that the hospitalists would care for patients’ medical conditions. Also, the unit had recently implemented a nursing protocol and checklist that called for nurses to do neuro checks—to gauge a patient’s level of consciousness, speech and reaction to light—every hour.

On the fourth day, the patient began complaining of headache and nausea. The nurse contacted the neurosurgeon, who told her to call the hospitalist. When the hospitalist arrived, she could not find the nursing flow sheet that documented the patient’s vital signs or neuro checks.

The patient told the hospitalist that she no longer had a headache but wanted an order in case the headache returned. The patient did not, however, mention the complaints she’d made to the nurse about blurry vision and dizziness. The hospitalist ordered an analgesic and for the neuro checks to continue.

Within five hours, the patient’s pupils were fixed and dilated. (Documentation later showed that a nurse “did neuro checks” twice during those five hours, with a Glasgow Coma Scale score of 15.) The patient was rushed to surgery, where the hematoma and AVM were removed, but the patient never regained consciousness and died four days later.

The cause of death was brainstem herniation. Neither the neurosurgeon nor the hospitalist diagnosed the unstable hematoma that caused the herniation.

What went wrong
A lot went wrong with the care of this patient. For one, the nurses weren’t doing what their new protocol required, so they didn’t detect the patient’s deteriorating condition.

Then there was this problem: When the hospitalist arrived, she couldn’t find the nurses’ documentation to see if checks revealed any change. The hospitalist should have followed up on that missing documentation by talking to the nurse.

But probably the biggest error made was between the neurosurgeon and the hospitalist: Neither of them was clear about who was in charge of the patient.

The neurosurgeon believed that the hospitalist was handling the patient’s pre-surgery care, so he wasn’t monitoring the neuro checks. The hospitalist, meanwhile, believed the neurosurgeon was tracking those checks, so she didn’t address them.

Unfortunately, many hospitals never lay out specific ground rules for comanagement arrangements. Why? In some hospitals, specialists aren’t used to working with hospitalists, and administrators don’t make it clear what hospitalists’ role will be in caring for patients for other specialties. And hospitalists themselves may not have a good understanding of that role because it can vary among specialties and facilities.

The human factor
The fact that the nursing protocol wasn’t being followed may have been the result of fatigue, overwork or “drift toward failure.” Drift toward failure occurs when production goals (having to do more and more) take precedence over safety goals (performing all the required assessments).

When assessments are missed but nothing bad happens, we assume that ignoring checks doesn’t result in a bad outcome. That assumption makes it increasingly acceptable to skip assessments.

And in terms of comanagement, the entire model is a new concept—and it is being used to describe everything from a written to an informal verbal arrangement that may vary from physician to physician or from one unit to the next.

Tips to avoid missed or delayed diagnoses
  • Everyone should be able to identify the physician— hospitalist or specialist—in charge of the patient’s care. Comanagement arrangements need to be spelled out in a written protocol that clearly states who is considered the primary physician and the consultant—and under what circumstances. Hospitals also need to specify at which points specialists will take over the patient’s care and how handoffs between the two services must occur.

  • Handoffs should include a verbal report, documentation in the record and communication with the nursing staff. Physicians need that verbal communication to determine their own individual responsibilities.

  • During handoffs, use a standardized communication process such as SBAR (situation, background, assessment, recommendation). Find out if your hospital has such a handoff policy, which in this case would have at least forced the two physicians to communicate.

  • Make sure that all clinicians caring for a patient review the history and physicals, daily physician notes and nursing assessments. The physician in charge of the patient is responsible for reviewing the medical record and for ensuring that appropriate orders are written and carried out.

  • Take action when orders aren’t implemented. At least one of these physicians should have known that neuro checks were not being done and should have discussed that with nursing management.

  • Finally, transfer a patient to another physician if a specialist isn’t communicating with you or the staff, or is not capable of providing treatment. If you have a comanagement agreement with specialists who don’t respond when you call, rethink that arrangement.

    Traditionally, we analyze claims to retrospectively determine how frequent or severe a group of claims is, and how those claims were affected by the defendant physician (or other provider) or hospital. In this case, our analysis identified processes or failures within a health care system that led to great harm.

    As this case makes clear, missed or delayed diagnoses are often the result of multiple failures, including the lack of coordination of care, ineffective communication, and missing or inadequate patient assessment.

    Robin Diamond, JD, RN, is senior vice president of The Doctors Company, a national medical malpractice insurer based in Napa, Calif. Susan Shepard, MSN, RN, is director of patient safety education for The Doctors Company.

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