Lindor, Rachel A.

Introduction: Medical documentation issues play a role in 10-20% of medical malpractice lawsuits. Inaccurate, incomplete, or generic records undermine a physician’s defense and make a plaintiff’s lawyer more likely to take on a case. Despite the frequency of documentation errors in malpractice suits, physicians receive very little education or feedback on their documentation. Our objective in this case series was to evaluate malpractice cases related to documentation to help improve physicians’ documentation and minimize their liability risks. Methods: We used Thomson Reuters Westlaw legal database to identify malpractice cases related to documentation. Common issues related to documentation and themes in the cases were identified and highlighted. Results: We classified cases into the following categories: incomplete documentation; inaccurate text; transcription errors; judgmental language; and alteration of documentation. By evaluating real cases, physicians can better understand common errors of other practitioners and avoid these in their own practice. Conclusion: Emergency physicians can reduce their liability risks by relying less on forms and templates and making a habit of documenting discussions with the patients, recording others’ involvement in patient care (chaperones, consultants, trainees, etc.), addressing others’ notes (triage staff, nurses, residents, etc.), paying attention to accuracy of transcribed or dictated information, avoiding judgmental language, and refraining from altering patient charts.

Introduction: This series reviews three cases of back pain where a highly morbid diagnosis was missed by an emergency physician and subsequently successfully litigated. Case Report: We review the clinical entities of spinal epidural abscess and cauda equina syndrome, challenging diagnoses that can be easily missed and lead to patient harm if not treated promptly. Here we offer suggestions for recognizing these conditions quickly, performing an adequate history and exam, and using documentation to support decision-making. Conclusion: When confronted with an unfortunate medical outcome, maintaining honesty is of paramount importance in medical-legal environments.

Lawsuits involving medical trainees are underappreciated and poorly documented, including within cardiology-related fields. The purpose of this review was to characterize clinical characteristics and legal outcomes of cardiology- and cardiac surgery-related lawsuits involving trainees. Westlaw, an online legal research database containing legal records from around the United States, was retrospectively reviewed for malpractice cases involving medical students, residents, or fellows through November 2020. Cases included both cardiac and cardiac surgery cases. A total of 28 cases were identified, with 16 involving female patients (57%). In the 17 cases in which patient age was included, the median age was 51 years. A total of 22 (79%) cases resulted in death or permanent disability. The most common alleged errors included procedural issues (n = 14, 50%) and failure to diagnose (n = 7, 25%). A total of 14 cases (50%) ended in favor of the physicians, 9 (32%) ended in a settlement or verdict against the physician, and 5 cases had an unknown outcome. Of the 8 cases in which the settlement or verdict amount was reported, the median payment was $1,291,992 with a range of $220,507–$30,000,000. This review of cardiac and cardiac surgery malpractice cases involving a trainee suggests trainee involvement in procedures and diagnosis may confer relatively high liability risks for both trainees and their supervisors.

Introduction: Most emergency medicine (EM) applicants use the internet as a source of information when evaluating residency programs. Previous studies have analyzed the components of residency program websites; however, there is a paucity of information regarding EM program websites. The purpose of our study was to analyze information on EM residency program websites. Methods: In April–May 2020, we evaluated 249 United States EM residency program websites for presence or absence of 38 items relevant to EM applicants. Descriptive statistics were performed, including means and standard deviations. Results: Of the 249 EM websites evaluated, the websites contained a mean of 20 of 38 items (53%). Only 16 programs (6%) contained at least three-quarters of the items of interest, and no programs contained all 38 items. The general categories with the least amount of items were social media use (9%), research (46%), and lifestyle (49%), compared to the other general categories such as application process (58%), resident information (63%), general program information (67%), and facility information (69%). The items provided by programs most often included program description (98%), blocks and rotations (91%), and faculty listing (88%). The items provided least often included housing/neighborhood information (17%) and social media links (19%). Conclusion: Our comprehensive review of EM residency websites in the US revealed the absence of many variables on most programs’ websites. Use of this information to enhance accessibility of desired information stands to benefit both applicants and programs in the increasingly competitive specialty of EM.

EXECUTIVE SUMMARY We sought to determine emergency medicine physicians’ accuracy in designating patients’ disposition status as “inpatient” or “observation” at the time of hospital admission in the context of Medicare’s Two-Midnight rule and to identify characteristics that may improve the providers’ predictions. We conducted a 90-day observational study of emergency department (ED) admissions involving adults aged 65 years and older and assessed the accuracy of physicians’ disposition decisions. Logistic regression models were fit to explore associations and predictors of disposition. A total of 2,257 patients 65 and older were admitted through the ED. The overall error rate in physician designation of observation or inpatient was 36%. Diagnoses most strongly associated with stays lasting less than two midnights included diverticulitis, syncope, and nonspecific chest pain. Diagnoses most strongly associated with stays lasting two or more midnights included orthopedic fractures, biliary tract disease, and back pain. ED physicians inaccurately predicted patient length of stay in more than one third of all patients. Under the Two-Midnight rule, these inaccurate predictions place hospitals at risk of underpayment and patients at risk of significant financial liability. Further work is needed to increase providers’ awareness of the financial repercussions of their admission designations and to identify interventions that can improve prediction accuracy.

AbstractBackgroundLittle is known about the optimal use of shared decision making (SDM) to guide palliative and end‐of‐life decisions in the emergency department (ED).ObjectiveThe objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end‐of‐life care decisions in the ED.MethodsParticipants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient‐advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time‐staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in‐person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement.ConclusionKey research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long‐term goals of care, and what policies influence palliative and end‐of‐life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.

AbstractThe idea of shared decision making (SDM) is gaining traction within emergency medicine, although concerns about potential legal consequences of its use may be slowing its adoption. We describe the similarities and differences between informed consent (IC) requirements and SDM, highlighting their different purposes, scope, and implementation. We also illustrate several areas in which SDM may affect clinicians’ liability risks and suggest that while SDM is likely to reduce net liability risks, it may increase providers’ liability risks in certain situations or with select patients. Overall, engaging in SDM should be understood as clearly distinct from the process of obtaining IC and could reduce clinicians’ risk of liability when applied carefully and thoughtfully.

AbstractObjectivesThe objectives were to describe lawsuits against providers for failing to order head computed tomography (CT) in cases of head trauma and to determine the potential effects of available clinical decision rules (CDRs) on each lawsuit.MethodsThe authors collected jury verdicts, settlements, and court opinions regarding alleged malpractice for failure to order head CT in the setting of head trauma from 1972 through February 2014 from an online legal research tool (WestlawNext). Data were abstracted onto a standardized data form. The performance of five CDRs was evaluated.ResultsSixty relevant cases were identified (52 adult, eight children). Of 48 cases with known outcomes, providers were found negligent in 10 cases (six adult, four pediatric), settled in 11 cases (nine adult, two pediatric), and were found not liable in 27 cases. In all 10 cases in which providers were found negligent, every applicable CDR studied would have indicated the need for head CT. In all eight cases involving children, the applicable CDR would have suggested the need for head CT or observation.ConclusionsA review of legal cases reported in a major online legal research system revealed 60 lawsuits in which providers were sued for failing to order head CTs in cases of head trauma. In all cases in which providers were found negligent, CT imaging or observation would have been indicated by every applicable CDR.