#7.
Inappropriate prescribing

Most trauma professionals worry about over-prescribing
pain medication. But under-prescribing can create problems as well.
Uncontrolled pain is a huge patient dissatisfier, and can lead to unwelcome
complications as well (think pneumonia after rib fractures). Always do the math
and make sure you are sending the right drug in the right amount home with your
patient. If the patient’s needs are outside the usual range, work with their primary
provider or a pain clinic to help optimize their care.

#8. Improper
care during an emergency

This situation can occur in the emergency
department when the emergency physician calls a specialist to assist with
management. If the specialist insists on the emergency physician providing care
because they do not want to come to the hospital, the specialist opens themselves up to major problems if any actual or perceived problem occurs
afterwards. The emergency physician should be sure to convey their concerns
very clearly, tell the specialist that the conversation will be documented
carefully, and then do so. Specialists, make sure you understand the emergency
physician’s concerns and clearly explain why you think you don’t need to see
the patient in person. And if there is any doubt, always go see the patient.

#9.
Failure to get informed consent

In emergency situations, this is generally not
an issue. Attempts should be made to communicate with the patient or their
surrogate to explain what needs to happen. However, life or limb saving
procedures must not be delayed if informed consent cannot be obtained. Be sure
to fill out a consent as soon as practical, and document any attempts that were
made to obtain it. In urgent or elective situations, always discuss the
procedure completely, and provide realistic information on expected outcomes
and possible complications. Make sure all is documented well on the consent or
in the EHR. And realize that if you utilize your surrogates to get the consent
(midlevel providers, residents), you are increasing the likelihood that some of
the information has not been conveyed as you would like.

#10.
Letting noncompliant patients take charge 

Some patients are noncompliant by nature, some are
noncompliant because they are not competent (intoxicated, head injured). You
must use your judgment to discern the difference between the two. Always try to
act in the best interest of your patient. Document your decisions thoroughly,
and don’t hesitate to involve your legal / psych / social work teams.

#3. You are responsible for the conduct of your staff

If the people who work for you treat patients
poorly, you may be responsible. It is important that your staff have bedside
manner at least as good as yours.

#4. Avoiding
your patients

Some of your patients may need to contact you,
either while in the hospital or while at home. Don’t appear to be inaccessible.
This is an extension of your bedside manner. Return phone calls or messages
promptly, or have one of your staff do so. Make time to meet with patient
families while in the hospital. Remember, you
deal with trauma all the time; this is probably the first time they have and it
is extremely stressful.

#5. Ordering
a test without checking the result

I presume that if you order a test, you are
interested in the result. And hopefully it will make some difference in patient
care. If not, don’t order it. But if you
do order a test, always check the
result. If a critical result is found, don’t assume that “someone” will
tell you about it. You are
responsible for checking it and dealing with any subsequent orders or followup
that is needed.

#6. “What
we have here is a failure to communicate” – part 2

Most of the time, our patients have primary care
providers somewhere. Make it a point to identify them and keep them in the
loop. Provide, at a minimum, a copy of the discharge summary from the hospital
or emergency department. If new therapies of any kind are started, make sure
they are aware. And if an “incidentaloma” is found (a new medical condition
found on lab tests or imaging studies), followup with the primary care provider
to make sure that they are aware of it so they can take over responsibility for
further diagnosis or treatment.

See part 3 of this series tomorrow!

Many
trauma professionals believe that they can only be sued if they make a medical
error and some harm occurs. Unfortunately, this is not entirely true. Yes,
this is one obvious way to spark a suit or claim.

Unfortunately, it goes beyond that. Your patient
may sue you if they even believe that
they were harmed in some way, or think that something untoward happened while
you were providing care. Here are the top 10 reasons for getting sued and my
thoughts on each (in no particular order).

#1. “What
we have here is a failure to communicate”

Your interpersonal skills are at least as
important as your clinical skills! You may be a clinical prodigy, but if you
are an asshole at the bedside, your patients will never appreciate your skills. You must be able to listen and
empathize with your patient. Sit down, look at them eye to eye. Listen
attentively. Don’t appear to be in a rush to get out of the room. You’d be
surprised at how much more valuable information you will get and the
relationship you create.

#2. “Work
not documented is work not done” (This is my quote and it’s one of my favorites.)

Accurate, complete, timely, and legible
documentation is a must!
The legibility problem is fading with the widespread use of electronic health
records (EHR, although this is creating new problems). Documentation, or lack
thereof, will not get you sued by itself. However, if you are involved in a suit or claim
and your care is scrutinized, poor or missing documentation will make it
impossible to plausibly contend that you did what you say you did. 

It’s
critical that you document every encounter thoroughly enough to be able to
reconstruct what you were thinking and what you did. And providing a date
and time is absolutely critical. This is especially important when the EHR
timestamps everything you enter. Frequently, you will be documenting something somewhat
after the fact. Always make sure that it’s not too far after the fact. Document as promptly as you can, and
include the time that you were actually providing the service. 

And
never go back and try to “correct” your documentation, especially if the chart
is being requested for inclusion in a suit or claim. If you believe there is an error, create an addendum and explain why the correction
is necessary. If a suit or claim has been started, do not touch or open the
chart without advice from your legal counsel.

Stay tuned for Part 2 tomorrow!