Risk Management

Lessons Learned from the IHS and Tribal Health Care - Medical Malpractice Tort Claim Experience

Medical risk management practices examine alleged incidents of medical malpractice to assess what factors may have led to the adverse event, to help determine how the system can be improved to prevent recurrences of the problems identified, and how the care that is provided can be made more defensible in the medico-legal arena. The risk management issues related to each incident of alleged medical malpractice are recorded into the IHS-RMP database as free text notes in a memo field. There was no facile way to electronically query the database to compile a list of common risk management issues. However, what follows (in no specific order) are short explanations of 24 commonly encountered risk management concerns, in accordance with the experience of this article’s authors (SWH and EYH), who have collectively been involved with these activities for over 24 years.

1. Know and conscientiously practice the standard of care for your discipline. This goes without saying, but it is worth emphasizing. It is difficult to defend care that is outdated or does not conform to accepted standards of practice. Ensure that you are properly credentialed and privileged to provide the services required.
2. All new health care practitioners (including all temporary hires) should receive orientation with respect to the recognition and treatment of locally prevalent disease entities, such as hanta virus and plague in the southwest and tick-bome diseases in Oklahoma.
3. Acknowledge and respond appropriately to abnormal vital signs identified during the screening or monitoring of patients. If an adverse outcome does occur, significantly abnormal vital signs on a nurse's screening profile that do not receive any documented recognition by the patient’s provider create major challenges for the defense of a claim. Especially in the acute care setting, it is extremely important to both acknowledge and then reassess any abnormal vital signs before discharging a patient from your care, including documentation of what was done to address them.
4. Similarly, the chief complaint, as identified by the triage health professional during the screening process, must be acknowledged and fully addressed by the examining practitioner, including a review of systems appropriate for all the symptoms expressed by the patient.
5. Acknowledge and respond appropriately to all abnormal laboratory values and imaging studies. In the acute care setting, all abnormal studies must be commented on, and your facility must have a workable process that enables all practitioners to be notified of abnormal lab results that are generated after a patient leaves the facility. Initial and date laboratory   slips,  medical imaging  reports, electrocardiograms, etc., when they are reviewed. The system must also accommodate notification of the patient to return for reevaluation of abnormal studies when necessary.
6. Avoid focused diagnoses in the setting of an acute illness or new patient complaint, but rather consider and document a differential approach to the management of the patient’s signs and symptoms. When a particular disease entity is being considered (such as cardiac origin of chest pain), the patient must then be appropriately screened for that diagnosis.
7. Chart comprehensively and legibly, whether it be a handwritten paper record or a typed electronic health record (EHR). Legible signatures are also critical; print or rubber stamp your name below all written signatures. As the EHR becomes more commonplace (at least in the outpatient clinic setting) illegibility will become less of an issue, but accurate and complete documentation may still be a challenge for providers who are poor keyboarders.
8. All entries should be timed, including inpatient and outpatient notes and orders. Always indicate the time when medications are administered.
9. All encounters should have follow-up plans that are clearly documented in the medical record, and (when appropriate) discharge instructions provided to patients; this holds true for all clinic visits and hospital discharges. Carefully document patient education efforts, and who received the information (patient, parent, guarding, etc).
10. Chart as soon after the care event as possible. Entries must be reasonably contemporaneous with the care that was given, including operative and procedure notes. If necessary, a late entry must always be identified as such, dated and timed accordingly.
11. Never attempt to alter a medical record after an episode of care. When a correction needs to be made to the medical record, use acceptable practices to make those changes.
12. Fetal monitor and cardiac monitor tracings should be carefully dated and timed, and note on the strips all interactions performed during the monitoring process (e.g., when medications were given, or when a procedure was performed).
13. Obtain proper written, informed consent prior to any non-emergency invasive procedure. Every facility should have a formal written policy regarding informed consent, indicating those procedures that require written consent.
14. Before any invasive procedure is initiated, follow prescribed "'time-out" protocols to ensure that the correct procedure is being performed on the correct patient and that the correct side (left versus right) has been clearly identified.
15. Be cognizant of the known complications for all the procedures you perform.  It is not necessarily negligence when a known complication occurs, but the failure to recognize and treat complications in a timely manner when they do occur may often be considered below the standard of practice.
16. Treat all injuries related to possible glass and/or wood fragments (i.e., foreign bodies) with due diligence. Document a thorough exam and cleansing of the wound and always consider appropriate medical imaging.
17. The appropriate choice of medical imaging is also important when evaluating bone and joint injuries (plain films, CT, MRI). Non-improvement in the patient’s symptoms should prompt additional imaging and/or timely consultation.
18. Reference past medical records or attempts to locate past medical information that is not available. Regularly seek written summaries of all outside care relevant to the patient’s ongoing medical problems, including past specialty consultations, procedures, and surgeries.
19. Document in the chart all consultations and/or advice obtained by phone or other means from in-house or outside colleagues and specialists.
20. Advice to patients given over the phone should be documented in the chart, including the date and time the information was given.
21. Medication prescribing and dispensing errors are an increasingly common target for tort claims. Each facility should have an active patient safety program to monitor and minimize the incidence of medication errors. Individuals who prescribe, dispense, and administer medications should work as a team to ensure drug allergies and drug interactions are carefully appraised before any medicinal is given to a patient. Use of the EHR will be of great benefit in this regard.
22. A child who will not bear weight or who has hip or knee pain without antecedent trauma should receive careful consideration for the possibility of occult infection, Osgood-Schlatter disease, or slipped capital femoral epiphysis.
23. Younger males with genitourinary complaints: if a urinary tract infection is diagnosed, further testing may be indicated for an underlying cause; if testicular torsion is part of the differential diagnosis, it must be ruled in or out emergently.
24. Ensure that your facility has an active inpatient and outpatient fall-prevention program for all patients, but especially frail elders. Never leave an incapacitated adult or minor child in a clinic room unattended.

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