Disclosure

1. Disclosure • Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services related to the content of this CME activity. • My content will not include discussion / reference of any commercial products or services. • I do not intend to discuss an unapproved investigative use of commercial products / devices.

2. Preventing Malpractice Lawsuits in Pediatrics / Pediatric Emergency Medicine STEVEN M. SELBST, M.D. A.I. duPont Hospital for Children Wilmington, DE Jefferson Medical College Philadelphia, PA

3. Closed Claims- Average Indemnity 1985-2006 • Neurology $302,181 1st • Neurosurg $300, 843 2nd • Ob-Gyn $267,711 3rd • Pediatrics $261,231 4th • Intern Med $182,297 11th • Emerg Med $158,401 15th • Gen Surg $158,237 17th • Ortho Surg $148,053 19th • Fam Med $139,966 21st Source: Physician Insurers Assoc of America, 2006

4. Malpractice Lawsuits • 1/3 AAP members named • ED = high risk • 85% suits involve “off-hours” • Most settle out of court • 10% reach jury

5. High Risk Cases Pediatric Emergency Medicine  Meningitis  Appendicitis  Fractures  Testicular Torsion Selbst SM, Friedman MJ, Singh SB Ped Emerg Care, 21:165-169, 2005.

6. High Risk Cases Pediatric Emergency Medicine • Wound complications • Medication errors • Myocarditis • Dehydration

7. Why people sue  Bad outcome  Negligent care  Poor communication

8. Why people sue  Monetary needs  Anger/revenge  Guilt/displaced blame  “Save next patient”  Relatives  Greed

9. Lawsuits and The ED Why Us? Long waiting times Impersonal registration Brief contact with physician Rapport not established Physician strain

10. The Legal ProcessIs it Malpractice? • Bad outcome or bad practice? • Was there a: • Duty to treat • Breach of duty • Injury related to this • Role of an expert

11. Standard of Care What a reasonable practitioner, in that specialty, under those circumstances, would do

12. Risk Management Strategies 1. Practice good medicine 2. Communicate well (patients, staff, consultants) 3. Document the good care

13. Practice Good Medicine • Act reasonably • Consider mother’s concerns • Observe if worrisome history, exam • Focus on persistent vomiting, lethargy • Arrange follow-up • Look for improvement

14. Practice Good Medicine • Follow policies and protocols • Often sought by attorneys • Make sure they are reasonable • Defend deviation from guidelines • Supervise trainees • Lack of supervision-- medical errors Singh H, et al. Arch Intern Med 2007;167:2030

15. Case Illustration

16. 13 Year Old Male cc: Abdominal pain Allergy - none Medications - acetaminophen Exposure - none PMH - none

17. History (Nurse) RLQ pain since last AM Nausea, vomiting Walks with obvious pain NPO, no BM 2 days Fever to 102 Resp easy, awake, guarding abdomen Ambulates, off stretcher, no difficulty

18. History (Physician) Began yesterday when woke Throwing up, nausea Pain mostly RLQ Better with movement Past history of pain with urination Urine clear, no blood

19. Vital Signs Temperature 103.9 Pulse 98 Respirations 24 Weight 44.6 kg Blood pressure 122/82

20. Physical Exam HEENT Benign Lungs CTA Heart RRR Abdomen Positive BS, tender R and LLQ Mild-moderate involuntary guarding No rebound, no mass Rectal Vault empty, no stool

21. Abdominal X-Ray Small calcified mass - pelvis Possible appendicolith vs renal stone Official reading: “Appendicolith cannot be ruled out”

22. CBC WBC 9.76 Segs 83 Hgb 14.7 Bands 14 Hct 41.6 Lymph 2 Plts 233 Baso 1

23. UA Sg < 1.005 PH 6.0 Protein, glucose Negative Bili, blood Negative Nitrates Negative Ketones Trace

24. Impression Probable renal lithiasis Plan Repeat UA Acetaminophen IV NS

25. Re-evaluation PO taken well Less pain Mild abdominal tenderness Impression: renal colic vs AGE

26. Discharge Instructions Encourage oral fluids Strain urine, save any stones Ibuprofen

27. Your Thoughts?

28. Case Illustration

29. Triage at 2000 16 yr old girl • T- 39.2 • P- 112 Trouble breathing • RR- 40 45 minutes • BP- 112/90 PMH asthma Alert, dyspnea Numbness hands & feet Lungs clear

30. Physician Hx at 2020 C/O left shoulder, LLQ pain Began while driving Numbness, tingling fingers Difficulty breathing resolved Now C/O pain everywhere Saw psychologist in past

31. Exam • Alert, anxious, appears upset Skin- warm, dry • • Neck- supple • Heart/ lungs- normal • Abd- soft, LUQ tender • Extrems- 2 + pulses, FROM

32. Course 2130 • Feels fine- “wants to go” • “Histrionic patient” • Abd soft • Joints FROM, no swelling • CXR negative • Assessment- Viral syndrome • Plan- recheck 3-4 days

33. Your Thoughts?

34. Communicate Well

35. Case Illustration  16 year old “feeling terrible”  3 ED visits in 5 days  Dx flu, atypical pneumonia, stress  Mother wants admission  Mother escorted out of ED  Admitted elsewhere with pneumonia

36. Failure to Communicate 70 % of lawsuitsinvolve communication style, clinician attitude • Inadequately explained diagnosis, treatment • Failed to understand patient/family perspective • Discounted, devalued patient/family views • Patient felt rushed Beckman HB. Arch Int Med 154:1365-1370, 1994

37. Failure to Communicate Families who sue are dissatisfied with patient-doctor communication. • 13% doctor would not listen • 32% doctor does not talk openly • 48% doctor attempted to mislead • 70% doctor did not warn about outcome Hickson GB, et al. JAMA 267:1359-1363,1992.

38. Failure to Communicate Unsolicited patient complaints about physicians are significantly related to lawsuits. Hickson GB, et al. JAMA 287: 2951-2957, 2002.

39. Communication Skills  Patient satisfaction is key  Consider professional training, role playing  Patient advocate helps  Triage and registration important

40. Communications Skills ED Physician • Unhurried appearance • Dress, posture, manners •  Demonstrate compassion •  Apologize for wait time •  Listen well •  Speak clearly, simply •  Hide your own anger

41. Communication Skills • Tell family what to expect • Keep family informed • Don’t demean others • Avoid joking, stray comments • Calm angry families

42. Discharge Instructions • When to see PCP • When to return immediately • Review written instructions • Obtain signature

43. Medical Record • Your best defense or • Plaintiff’s best witness

44. Recommendations for Documentation Carefully Document • History of illness / injury • Physical exam & vital signs • Time of exam, orders, procedures • Patient change or improvement • “Tell the chart”

45. Recommendations for Documentation Carefully Document • Conversations with consultants • Reports of procedures, tests • Diagnostic impression, thought process • Discharge instructions • Disposition

46. Recommendations For Documentation  Show a concerned, professional note  Avoid inflammatory remarks  Carefully note correct body part  Document injuries with diagrams

47. Additional Recommendations for the Medical Record Do Not:  Black out or erase  Engage in “battles” on paper  Use insensitive terms  Use unnecessary terms  Alter the chart later

48. Advantages of Telephone Management • Many for the patient • Some for office practitioner • None for ED physician

49. Liability Case – Telephone Mother called: 13-month-old baby, 3 day hx of chickenpox. Now fever, bruising. Office staff did not bring in for visit. Child died from group A strepsepsis following varicella. Office has no record of phone call. • Settled for $400,000

50. Liability case – Telephone Mother called: spoke with nurse in office on Saturday. Teenage son had scrotal pain. Nurse said doctor would call back. No one called back until Monday. Testicle lost from torsion,subsequent ischemia and necrosis. The plaintiffwas awarded $150,000.