As the graph below illustrates, medication errors was a common theme in SVMIC paid nephrology claims over the past 5 years. Additionally, failure to diagnose was a primary allegation asserted in the claims. Most typically, the diagnostic errors were not the result of a lack of knowledge or diagnostic ability on the part of the physician, but rather, as the graph below illustrates, were a product of poor documentation, communication breakdowns and poorly designed or ineffective systems.
MEDICATION ISSUES: Wrong dose and contraindicated medications were the main issues noted in the reviewed claims. A classic example of a wrong dose event is illustrated in the case of a physician who intended to order 2 mEq potassium chloride to peritoneal dialysis fluid, but mistakenly wrote 20 mEq. The patient arrested and died. To compound the problem, the physician went back after the event, crossed out the “20” and replaced it with a “2”. Contraindicated medications were a problem in a case where the physician failed to discontinue Heparin in the face of Heparin-induced thrombocytopenia, and in another case where there was a failure to discontinue Lovenox in a patient scheduled for an invasive biopsy on the kidney. In both cases, the patients suffered bleeding complications and died.
COMMUNICATION ISSUES: Effective communication is essential in establishing trust, building good patient rapport and helping to achieve treatment compliance. It is important to communicate information and instructions to patients in terms understandable to non-medically trained individuals. The majority of the cases involving physician to patient communication breakdowns involved the physician failing to provide clear information related to the risks or instructions associated with medications.
There were also communication breakdowns between providers in the reviewed cases. An example involved a patient hospitalized for angina and a subacute MI with congestive heart failure. Treatment included Lovenox and Digoxin. During the hospitalization, the patient was determined to have chronic renal insufficiency requiring acute hemodialysis. The Nephrologist failed to adjust the Lovenox dose, assuming the cardiologist would do so. The patient developed a thoracic hematoma and died.
DOCUMENTATION ISSUES: The importance of maintaining a well-documented medical record, from both a patient care and a risk management standpoint, cannot be overstated. As the graph above illustrates, documentation issues were a factor in 38% of claims paid in Nephrology. The majority of these cases involved inadequate documentation. Most often, there was a failure to document completely the patient and/or family history, details of the physical exam, rationale for the diagnosis and treatment plan, patient education, and conversations with the patient and family regarding treatment recommendations.
SYSTEMS ISSUES: The failure to track and act on test results was a common problem in the cases involving systems issues. One case involved a hospitalized patient who was administered IV morphine following the onset of severe flank pain six hours post-renal biopsy. The on-call nephrologist ordered a CT scan and labs. The CT scan revealed a large perirenal hematoma. The on-call doctor did not receive notification of the CT scan results, nor went to the hospital to evaluate the patient. The next morning, the patient’s hematocrit dropped significantly. The physician then reviewed the results of the CT scan and noted the hematoma. Transfusions and other measures were unsuccessful and the patient died. The failure of the on-call physician to follow up on the results of the tests he ordered and his delay in going in to evaluate a patient in clear distress caused problems for the defense that led to a settlement of the case.
Shelly Weatherly is Vice President, Risk Education and Evaluation Services for SVMIC. Ms. Weatherly graduated from the University of Tennessee School of Law, is a member of the Nashville and Tennessee Bar Associations, and has been with SVMIC for 26 years. Prior to joining SVMIC, Ms. Weatherly served as Law Clerk on the Tennessee Court of Appeals for the Honorable William C. Koch, as well as on the U.S. District Court for the Middle District of Tennessee under the Honorable Charles Neese. Ms. Weatherly leads SVMIC's Risk Education and Evaluation Services. Prior to 2015, she developed and administered the company's Risk Evaluation Services and earlier served as a Claims Attorney. She is a frequent speaker on risk management, liability assessment, and professional liability topics at medical professional association meetings, medical schools and residency programs, and industry seminars.
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