Annals of EM Malpractice Editorial

Mark Graber Mark.Graber at IMPROVEDIAGNOSIS.ORG
Mon Mar 5 14:55:57 UTC 2018


Tom – my sympathies go out to all the ED providers out there.  I’m sure we’d agree that, compared to other diagnostic settings, the challenges in the ED are enormous, reflecting the complexity and uncertainty involved, the chaotic environment, the workload pressure, etc etc.

That is what prompted my concern with the Venkat article that looked only at very superficial, easily measured parameters.  They concluded that: ….

“Total number of years in practice and visit volume were the only identified factors associated with being named, suggesting that exposure to higher patient volumes and longer practice experience are the primary contributors to malpractice risk.”

I’m saying that there are MANY MANY other MAJOR factors that contribute to safety and malpractice risk in the ED, of the sort that you mention:  the dysfunctional EMR, the lack of support from team members, the distractions, etc.  In the future, we need studies that look at these harder-to-measure, but actionable factors.

Mark


From: Tom Benzoni <benzonit at gmail.com>
Date: Monday, March 5, 2018 at 7:49 AM
To: Listserv ImproveDx <IMPROVEDX at list.improvediagnosis.org>, Mark Graber <Mark.Graber at Improvediagnosis.org>
Subject: Re: [IMPROVEDX] Annals of EM Malpractice Editorial

Dr. Graber:
May be a fine point, but I don't think I worry about preventing malpractice suits in the ED; that would be easy: raise the burden of proof.
There is no relationship (but random and/or communication skills) between error and malpractice suits in the ED. I think your article noted bears this out.
That said, communication and expectation management is crucial.
So is style, which is a subset of communication.

To mitigate error is another pursuit entirely.
We need but cannot have a "sterile cockpit" mentality, among other concepts.
When I most need the time, I have the least cognitive reserve and vice versa.

A few hours ago, I have a patient with severe sepsis.
B/P by oscillometry  (MAP) 60 - 70 mmHg.
4 l NS later, no change.
Hgb = 5.9
Lactate = 5.6 (nl < 2.)

While entering orders for sepsis, we are given an order set that has no relationship to clinical flow and thought patterns, but it does capture structured data so the purchaser can get a rebate.
While ordering blood, there were no less than 40 mouse clicks. The Hgb did not automatically populate, so I had to manually search for Sepsis with Anemia to be allowed to order blood.
I am using very high end software for which this very large center paid a fortune.
Meanwhile, I had at least 10 interruptions from nursing staff; do not bother telling me I can ask staff to leave me alone. That is not acceptable even to me.

tom

On Thu, Feb 15, 2018 at 12:48 PM, Mark Graber <Mark.Graber at improvediagnosis.org<mailto:Mark.Graber at improvediagnosis.org>> wrote:
Thanks for posting this article Keel and welcome to our discussions.

I’ll take issue with the implication in the editorial and the Venkat article<http://dx.doi.org/10.1016/j.annemergmed.2017.06.023> that there is nothing that can be done to prevent malpractice suits in the ED.  I have no argument with the findings that no practice characteristics have been identified to date, but would argue that the interventions we believe could improve diagnosis have not been evaluated in the ED setting so far.  These include: Better patient engagement, better teamwork, better follow-up, and more use of clinical decision-support.

We will have trouble eliminating the ‘crapshoot’ element, but to the extent that we could improve the diagnostic process, there’s hope that at least some fraction of claims could be avoided.

   Mark

Mark L Graber MD FACP
President, SIDM
Senior Fellow, RTI International
Professor Emeritus, Stony Brook University
[cid:image001.png at 01D3A64A.8FBC9D50]



From: Keel Coleman <keelcoleman at GMAIL.COM<mailto:keelcoleman at GMAIL.COM>>
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Keel Coleman <keelcoleman at GMAIL.COM<mailto:keelcoleman at GMAIL.COM>>
Date: Thursday, February 15, 2018 at 8:43 AM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Annals of EM Malpractice Editorial

Long time reader, first time poster.
Attached find an editorial from Annals of Emergency Medicine regarding a study of malpractice claims.

The editorial reviews the current literature looking for three things:
1. Are their practice patterns or decisions by EM providers that are associated with increased likelihood of being named in a suit?
 Answer: No. None that we can find.

2. Are there identifiers for EM providers that are associate with likelihood of being named in a suit?
Answer: Yes. Time in practice (number of years), and number of pts seen.

3. What other avenues might we study to further understand patterns of malpractice litigation?
Answer: Look at your local patient-plaintiff attorney relationships.

Given these answers, what can be done to first protect patients from the wages of defensive medicine, and deranged decision making driven by the fear of of litigation?

Second, what can be done to support physicians who will certainly find themselves in the crosshairs of litigation despite doing 'the right thing' every day?

Third, as the study of indemnity claims moves to focus on local variability of malpractice environments, how do we maintain objectivity and best practices when a care space becomes adversarial by virtue of its location?

Thank you.
Keel Coleman DO, MBA, FACEP




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