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January 2012 (see below for Dentistry: Diagnosing Diabetes article)
Psychiatrists & Psychologists:
Failure to Diagnose
Printable Version
When is a medical condition masquerading as a behavioral health issue? Or conversely, how does one discern when mental health symptoms are obscured by a presentation of physical ailments?
The challenge is something akin to the question of which came first: the chicken or the egg?
At issue for psychiatrists and psychologists is a sometimes-perplexing evaluative (diagnostic) process as to whether a medical condition is at the root of behavioral health symptoms or vice versa. Such was the focus of a recent Wall Street Journal article by Melinda Beck published in the healthcare journal section (August 9, 2011).
In her article “Confusing Medical Ailments with Mental Illness” Beck raises public awareness of one challenge that is neither new nor revolutionary to psychiatrists and psychologists: the possibility that a latent or evolving physical (medical) condition may mask itself in the form of a mental disorder or diagnosis.
For mental health professionals, Beck’s article may be regarded as a subtle reminder of the importance and benefit in understanding each patient’s medical history – a useful clinical component, when applied methodically – to properly contextualize a patient’s symptoms, develop an effective treatment plan and, in the process, thwart any potential allegations of “failure to diagnose” or “missed diagnosis.” This medical “inventory taking” is particularly important when treating those patients who do not routinely see a primary care physician (PCP) to monitor the status of their physical health.
Beck pens an informative piece for the lay reader providing specific examples of medical conditions that often manifest themselves obscurely in behavioral health symptomatology. Her article is well-substantiated, citing recent published findings, such as Dr. Barbara Schildkrout’s book Unmasking Psychological Symptoms and an article in the Journal of Clinical Psychology Practice by neuropsychologist Dr. Jerrold Pollak, et. al. It is in this latter context that Beck’s article reminds us of the delicate juxtaposition of a patient’s medical and mental well-being.
Some of the examples Beck cites from Schildkrout and Pollak:
· A 40s-something male suddenly exhibits fits of anger and depression. The diagnosis may be one of midlife crisis, or the latent (Pollak uses the word “sleeper”) effects of head trauma sustained 20 years ago during his college years as an athlete.
· Another middle-aged male has increasingly frequent outbursts of anger. A treatment plan to address anger-management issues may be appropriate, but a CT scan of the brain identifies temporal-lobe seizure activity.
· A new mother is diagnosed with postpartum depression, but testing suggests the underlying culprit is a postpartum thyroid imbalance that is treated effectively with medication.
Beck explains, “In some cases, a psychological problem is just the first sign of a serious medical issue.” She then cites a statement from Gary Kennedy, director of geriatric psychiatry at Montefiore Medical Center in Bronx, NY: “Depression predicts heart disease and heart disease predicts depression.”
Titled “warning signs” in Beck’s article, below are some considerations when suspicion points its finger, suggesting that the root of a mental problem may be medical:
· Sudden change in mood or personality
· History of head trauma
· Depression occurring for the first time after the age of 55
· Recent travel or exposure to infections
· Any rash, swelling, drooping eyelid, facial tic, etc.
· Standard medication and/or therapy fails to effect a positive change
It’s a reasonable assumption that amid the readership of this WSJ article will be attorneys representing patients. It’s not a stretch to assume, then, that well-researched articles such as this will be filed in a plaintiff attorney’s arsenal when evaluating the merits of a “failure to diagnose” or a “missed diagnosis” claim against a mental health professional.
What you can do to provide your patients the highest quality of care while protecting yourself professionally:
· Be vigilant and current in your documentation of your patients’ complaints and symptoms.
· Routinely conduct intakes and periodic reviews of your patients’ medical histories (with attention to prior head trauma, changes in medications prescribed by other healthcare providers and so forth).
· Develop a treatment plan that accounts for deliberation of potential medical/health conditions and the rationale to include or dismiss any medical conditions in your diagnostic evaluation (and revise when necessary and appropriate if treatment is ineffective or new patient information comes to light).
· Recommend to and follow up with your patients any tests (MRI, CT scan, blood work, as examples) that will help rule out potentially contributory medical factors, and be sure your medical record documentation is current and factual, including results of recommended tests or referrals.
Pushback from healthcare providers focuses on the element of time spent with each patient. Many argue, perhaps rightly so, that there isn’t sufficient time to thoroughly evaluate and document a patient’s condition and treatment. More than a few adverse outcomes of claims against mental health professionals are the direct result of inadequate documentation and the argument “I didn’t have enough time.” Such admissions damage the defensibility of a claim as “lack of time” is no excuse in providing quality healthcare.
Copyright 2012 Princeton Insurance Company
January 2012
Dentistry: Diagnosing Diabetes
Printable Version
A recent report titled “Identification of unrecognized diabetes and pre-diabetes in a dental setting” published in the Journal of Dental Research (July, 2011) finds that patients with certain dental conditions may be at greater risk for the disease.
For patients, a sooner-rather-than-later diagnosis of a diabetic condition provides a preemptive strike in managing their illness and mitigating the potential for serious disease-related complications (such as heart disease, stroke and other vascular conditions).
For dentists, a patient’s overall medical history should be considered when evaluating dental conditions. The likelihood of desired dental outcomes increases when the disease is treated with the help of the patient’s primary care physician.
Dr. Evanthia Lalla, lead author of the report and an associate professor at Columbia, states “relatively simple lifestyles changes in pre-diabetic individuals can prevent progression to frank diabetes, so identifying this group of individuals is also important. Our findings provide a simple approach that can be easily used in all dental-care settings.”
Lamster, dean of Columbia University’s College of Dental Medicine, and his team of researchers followed 600 patients treated at the Northern Manhattan dental clinic from 2009-2010. Included in this study were white adults (≥40 years old) and Hispanic and non-white adults (≥ 30 years old). Of these adults, approximately 88% had at least one risk factor for diabetes (family history of the disease, were overweight with a BMI or body mass index ≥25, or had high cholesterol and/or hypertension). These individuals received a periodontal exam and a hemoglobin A1c test during the same visit. They later returned for a fasting plasma glucose test and the latter test results were then compared with the results of the identification protocols.
The outcome of this study demonstrates that using an “algorithm” based on two dental factors that included the number of missing teeth and the percentage of deep periodontal pockets was effective in identifying heretofore undiagnosed pre-diabetes or diabetes in this patent population. Results of the A1c test given during the dental visit further demonstrated the accuracy of this algorithm.
Other studies with similar findings include a survey by the National Center for Health Statistics (an arm of the Centers for Disease Control and Prevention) which tracked 2,923 adults from 2003-2004. According to the author of that report, Sheila Strauss, “… the dental visit could be a useful opportunity to conduct an initial diabetes screening – an important first step in identifying those patients who need follow-up testing to diagnose the disease.”
An associate professor of nursing at New York University, Strauss notes that “93 percent of subjects who had periodontal disease were considered to be at high risk for diabetes and should be screened for diabetes. This compares to 63 percent of those without periodontal disease.”
“Dentists are in a unique position to serve as the unsung hero in early diagnosis. Most patients have the opportunity to visit dentists twice a year, whereas visits to the doctor are less frequent and many people visit a doctor only when they have an immediate medical issue,” notes Dr. Ron Inge, Vice President and Dental Director for Washington Dental Service and Executive Director of the Institute for Oral Health. “With this in mind … dentists [need] to pay closer attention to diabetes and general health warning signs and recognize the close correlation dental health has to overall well being.”
What does all of this mean for the dentist? It is not unreasonable to anticipate that as studies such as those referenced support dentists’ ability – and therefore, responsibility – to consider a disease such as diabetes when treating their patients, there may be an additional exposure to a claim of dental negligence. This could be particularly relevant if an undiagnosed diabetic patient sustains permanent or life-threatening complications from the condition going untreated. Following are some risk management strategies a dentist can implement to limit his/her exposure to a negligence claim.
Give proper attention to your patients’ non-dental health issues. This can be achieved with a routine review of intake and updated medical histories (with attention to family history, obesity, hypertension and high cholesterol). Make sure documentation in the dental record reflects your review of these issues and when indicated, document your discussion with the patient and your recommendation for follow-up with a primary care physician.
1. Identify patients in your practice who may be at risk:
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Those with 4 or more missing teeth, a condition that may be due to higher levels of glucose inhibiting the ability of white blood cells to fight off infection and promote bacterial growth. Higher blood sugar levels decrease the amount of saliva often resulting in dry mouth, which contributes to tooth decay and, if left untreated, leads to the loss of one or more teeth. Other conditions include mouth ulcers and fungal infections.
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Those with deep periodontal pockets, a condition once again potentially attributable to higher glucose levels promoting bacterial growth that increases the risk for periodontitis and gingivitis.
2. Give proper attention to your patients’ non-dental health issues. This can be achieved with a routine review of intake and updated medical histories (with attention to family history, obesity, hypertension and high cholesterol). Make sure documentation in the dental record reflects your review of these issues and when indicated, document your discussion with the patient and your recommendation for follow-up with a primary care physician.
3. Follow-up with the patient regarding recommendations for referrals and consultations is important, and these efforts should be documented as well, including outcome (“patient saw primary care physician” or “patient failed to follow through on referral”).
4. Develop a treatment plan that accounts for deliberation of potential medical/health conditions and the rationale to include or dismiss any medical conditions in your diagnostic evaluation (and revise when necessary and appropriate if treatment outcome is not one that is anticipated).
Not only are the above strategies useful in limiting liability exposure, but provide a “value-added” component that will increase patient satisfaction with the services you provide.
Copyright 2012 Princeton Insurance Company
December 2011
Risk Alert
Hot Liquids: Avoiding Patient Injury
Printable Version
Burns or scalds attributable to hot beverages pose a serious concern for any organization providing food service to consumers. This concern is particularly worrisome for healthcare facilities treating already physically compromised patients.
A well-publicized 1992 incident involved Stella Liebeck, an Albuquerque, NM woman who received burns from a cup of coffee purchased at a McDonald’s restaurant. Public perception following the subsequent lawsuit largely held that this multi-million dollar jury award ($160,000 for compensatory damages and $2.7 million for punitive damages) was nothing more than a frivolous claim. Challenging public sentiment was an HBO documentary “Hot Coffee” (2011) examining the facts surrounding the case with a focus on the mental anguish, physical trauma (3rd degree burns) and two years of treatment (including skin grafting to her thighs and groin area) experienced by the victim following the incident. We believe such incidents in a healthcare setting may attract greater media attention, result in greater personal harm and higher claim settlements, not to mention severely damaging the reputation of the facility and its staff.
Even the most well-intentioned, compassionate, patient-focused healthcare giver attempting to satisfy a simple patient request for a heated beverage can become party to an incident that endangers a patient’s well-being.
Avoiding catastrophe
What are the systems failures that turn an act of kindness into crisis?
Risk management and patient safety efforts with regard to hot liquids should focus on staff adherence to policies and procedures related to the proper and approved use of facility equipment (such as any device used to heat liquids), appropriate response to patient needs/requests for a hot beverage, and patient monitoring following delivery of a heated beverage. Your facility may be like many others with established operational hours for dietary services. If so, accommodation for those “after-hours” patient requests for hot beverages needs to be considered to ensure that all staff respond to such requests uniformly, as approved by management.
Let’s review factors that may contribute to an incident involving a burn or scald from hot liquids.
Microwave ovens
A recent informal poll of acute, assisted living and long-term care facilities found a range of responses to the question: “Does your facility allow the use of microwave ovens?” Some facilities do not permit such equipment on nursing floors and in patient care areas. Others permit microwave ovens on patient floors for staff use only. Still others permit the use of microwave ovens on patient floors, but do not restrict their use exclusively to the personal needs of staff (such as heating food during a shift break).
It is the last scenario above that harbors the greatest potential for harm to a patient.
If the use of microwave ovens is permitted in a facility, understand that each microwave oven is unique in terms of energy used, time needed to heat something to a desired temperature, the age of the equipment, amount of use and so forth.
All staff using microwave ovens must appreciate the potential for liquids to exceed boiling points (known as superheating) without any recognizable appearance of a rolling boil.
A phenomenon known as “nucleation” typically occurs when a liquid being heated allows bubbles to form, gas to escape, the “boiling” to occur, and thus be visible. However, in microwave conditions, nucleation may not occur. If trapped gases cannot escape, a higher probability exists that the liquid being heated will explode when the container is moved or something such as a tea bag, coffee crystals or powdered drinks is added. Factors facilitating nucleation are impurities in the liquid being heated or some type of defect (irregularity) in the surface coating of the container itself.
Alternative sources for hot liquids
There are alternatives to microwave ovens, some of which may be cost-effective when considering the replacement of ovens with equipment that affords greater safety. Following are choices made by facilities to provide hot beverages without compromising the threshold of safety for patients and staff:
· Hot water delivered from dietary services stored in thermoses at the nurses’ station.
· Water coolers equipped with a hot water tap that is maintained at an established temperature to avoid burns or scalds.
· Some type of unit similar to a coffee urn that heats water and keeps it hot at a regulated temperature.
Serving hot liquids
What about cups to serve the hot liquid beverage? Are the cups or beverage containers supplied to patients contributing to the potential for a spill that may result in patient scalding or burning? Styrofoam cups usually are tapered, where there is greater area at the top of the cup, which slims down in a “V” formation to a smaller area at the bottom. Such a design harbors the potential for a spill: the cup, when filled with liquid, has more mass and, therefore, more weight at the top, making it somewhat imbalanced and unstable for patients to handle safely. Using a cup design that is uniformly contoured from top to bottom will help decrease the likelihood (risk) of a cup filled with a hot liquid from tipping over.
When microwave ovens are a must
If using microwave ovens is unavoidable for heating beverages (be that for staff or patient service), users should be knowledgeable of the following:
· Use only containers suitable for microwaving.
- Place a non-metallic object in the liquid to be heated (such as a wooden spoon or stirrer).
- Use a “beverage” setting to heat the liquid if the microwave oven has such an option. Caution: using such a setting is no guarantee that the liquid will not be overheated.
- Absent a “beverage” setting, do not heat the liquid on “high.” Instead, use a lower power setting for a longer period of time to permit the nucleation process to occur and avoid superheating.
- Once heated, leave the container in the microwave undisturbed for 1 minute per cup of liquid being heated.
- Remove the container from the microwave oven slowly (covered, if possible).
- When serving the heated water with an accompanying tea bag or powdered beverage, if at all possible, stay with the patient until the flavoring agent has been introduced to the liquid to be certain there is no problem with the beverage temperature before patient consumption.
Not all microwave ovens are created equal. Even if those microwave ovens used in the facility are of the same make and model, each should be tested individually by qualified technicians to determine the length of time it takes for a given volume of liquid to reach a pre-determined temperature at a specific power (such as 50%). Posting this unit-specific information somewhere visible on each microwave oven will provide safety information for users of the equipment. This test may have to be done routinely – such as annually – as microwave ovens age and depending on the amount of use.
Is there a safe temperature for hot liquid consumption?
A question frequently asked: “what is the ‘optimum’ temperature of a heated liquid that is both safe and maximizes flavor?”
In the Liebeck v. MacDonald’s litigation, it was discovered that the food franchise required coffee to be maintained at a temperature between 180° and 190°. Expert testimony during trial demonstrated that a burn sustained from a spilled liquid at that temperature would cause 3rd degree burns in 12-15 seconds.
Temperatures recommended by a variety of national and international organizations concerned with injuries from scalding or burning attributable to hot liquids ranges from 104°F to 136°F, or slightly higher, but not to exceed 140°. However, our research findings suggest that most experts recommend a hot liquid temperature not to exceed 125° F (51.66 C). Any higher temperature poses a serious risk of bad burns, particularly to children and the elderly with more delicate skin tissues.
What this information means to a facility caring for patients or residents
Develop a facility-wide policy for responding to patient requests for hot liquids that addresses those risk and safety elements outlined above, if such a policy does not exist already in your facility. When a policy has been adopted, educate all members of staff with regard to the approved procedure(s) and require strict adherence by all employees to the policy.
When an emerging topic becomes particularly prominent in our day-to-day interactions with healthcare providers, our physician risk consultants will issue a Risk Alert in order to spread awareness of the issue. In this Risk Alert, our staff discusses ways to avoid patient injury when dealing with hot liquids in the ambulatory setting. To read additional Reducing Risk Documents including Risk Alerts, visit our publications page on PrincetonInsurance.com here.
September 2011
Printable Version
In the first part, which you can read below, we discussed the background of the issue relating to Propofol and who should administer it – gastroenterologists (non-anesthesiologists) or strictly anesthesiologists. The warning label debate, involving the ACG and the ASA, took an interesting turn when the FDA got involved and spoke out in support of keeping the label. Per their standards, individuals administering moderate or deep sedation and anesthesia must have the appropriate credentials to manage patients at whatever level of sedation or anesthesia is achieved. They assert that those practitioners must be qualified to rescue patients from general anesthesia and be competent to manage an unstable cardiovascular system as well as a compromised airway and inadequate oxygenation and ventilation and that a sufficient number of qualified personnel must be present during the procedure to provide moderate or deep sedation.
CMS responds
Seemingly, this is what prompted the Centers for Medicare & Medicaid Services (CMS), in their Condition of Participation (42 CFR 482.52(a) to limit the administration of deep sedation to “qualified anesthesia professionals” in Medicare settings (i.e. hospitals and Medicare-approved ambulatory centers). CMS further requires that any professional who administers and monitors deep sedation must be dedicated to that task only. Therefore, the non-anesthesiologist sedation practitioner who administers and monitors deep sedation must be different from the individual performing the diagnostic or therapeutic procedure.
Who should administer?
A task force comprised of one representative each from the four gastroenterology/hepatology societies convened in 2008 for the purpose of generating an evidence-based analysis of published literature, consisting of outcomes of 29 studies and more than 460,000 cases, most of which involved nurse-administered Propofol sedation. In 2009, information was updated to include an additional 200,000 cases – the outcome being the release of a four-society position statement reiterating their position, as supported by what they believe to be “overwhelming evidence” of the safety and efficacy of GD-P (a loading dose administered by gastroenterologist with titration and monitoring by nurses, under the direction and supervision of the gastroenterologist performing the procedure).
Regardless of the evidence-based recommendations set forth by gastroenterologists in the four- society statement, the CMS appears to support a different view. Concurrent with the publication of the four-society statement, the CMS sent revised hospital anesthesia interpretive guidelines to state survey agency directors clarifying the agency’s stance on who should be allowed to deliver Propofol: the essence of which is that Propofol administration for deep sedation should only be performed or directed by an anesthesiologist. The CMS guidelines apply only to Medicare patients and Medicare settings. It does not, however, apply yet to physician offices or to non-Medicare patients –this could have a tremendous ripple effect, as other payors often follow the lead of CMS.
Following the December 2009 release of the updated interpretive guidelines for hospital anesthesia services, medical societies and organizations called for clarifications regarding the distinction between analgesia and anesthesia, suggesting that some of the examples cited in the guidelines didn’t fall clearly on one side or the other of the anesthesia/analgesia spectrum. Following complaints that the CMS policy was unworkable, the CMS released revised guidelines on January 24, 2011.
Conflicting, contradicting and overlapping guidelines
Hospitals are now directed to rely on “nationally recognized” guidelines to decide where various drugs fall within the anesthesia continuum and develop their own internal policies concerning what is anesthesia versus analgesia; which leaves open the option of using different guidelines in different clinical departments within one facility. CMS acknowledges that nationally recognized guidelines may not always fully agree with each other. For example, a hospital could use the American College of Emergency Physicians (ACEP) guidelines in their ED and follow those of the 4-specialty gastroenterology organizations position for their GI lab. The revisions also provide greater flexibility regarding pre and post-anesthesia evaluations while other problematic references were dropped entirely.
The guidelines retain the six broad categories of anesthesia and analgesia, but acknowledge that this spectrum of described levels of sedation for a particular medication may vary on the basis of such factors as dosage, route and timing of administration. Thus, it’s possible for the same drug to be used for general anesthesia in the operating room and for sedation in the emergency department or procedure room, as is the case with Propofol. The CMS stressed that “for some medications there is no bright line that distinguishes when their pharmacological properties bring about physiologic transition from the analgesic to the anesthetic effects”.
Under the current guidelines, hospital policies should address whether specific clinical situations involve anesthesia versus analgesia, and specify the qualifications for each category of practitioner who administers analgesia and their supervision requirements.
In Part III, we address the current state of affairs surrounding the administration of Propofol and conclude with ways to minimize risk for GD-P.
August 2011
Printable Version
Considered by the FDA to be intended for general anesthesia or Monitored Anesthesia Care (MAC) sedation, Propofol’s black box warning on the product labeling states that the drug should be administered “only by persons trained in the administration of general anesthesia and not involved in the performance of the surgical/diagnostic procedure.”
Controversy
Research reveals that there is a decade-long history of controversy surrounding the use of Propofol in GI endoscopy; not because of disagreement within the medical community as to the drug’s efficacy for this purpose, but rather to differing viewpoints between gastroenterologists and anesthesiologists over who should administer Propofol and under what conditions.
Gastroenterologists favor the use of Propofol as a fast-acting, non-analgesic sedative with amnesic effects when administered at sub-hypnotic doses for endoscopy, targeted to produce moderate sedation. It allows patients to wake up, recover, and return to baseline activities and diet sooner than some other sedation agents; and because it reduces the need for opioids, its use results in less post-procedure nausea and vomiting. They contend that non-anesthesiologists can safely administer the sedation, either alone or in combination with a small dose of narcotic, a benzodiazepine, or both.
Anesthesiologists argue that the benefits of using Propofol are outweighed by the risks associated with its administration by non-anesthesiologists. Cited as the reason for this concern is the unpredictable and profound effects of the drug, in that dosing and titration are variable based on a patient’s tolerance to the drug, which can lead to profound and rapidly occurring changes from moderate sedation to deep sedation and even general anesthesia. Furthermore, patients can go from breathing normally to full respiratory arrest in seconds, even at low doses, without warning from typical assessment parameters. Unlike other sedation agents, there is no reversal agent, which means that adverse effects have to be treated and monitored until the drug is metabolized. Anesthesiologists therefore assert that the administration of Propofol should be handled as MAC, or deep sedation – the purview of which remains under the domain of anesthesiologists.
The FDA also did not find the ACG’s argument compelling enough, concluding that the warning label is appropriate in light of the risks associated with the sedative. They based their decision on three factors:
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their belief that, while some colonoscopies can be performed with moderate sedation, most patients require deep sedation, at least transitionally, during the course of an endoscopic examination, which would make administration by a non-anesthesiologist outside of their scope of practice
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the risk that a deeply sedated patient may slip into general anesthesia due to the drug’s narrow therapeutic window
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that practitioners administering Propofol need to be appropriately trained in the management and rescue of patients at all levels of anesthesia.
The FDA also notes that the warning is consistent with the findings and policies of The Joint Commission, the American Association for Accreditation of Ambulatory Surgery Facilities, the Accreditation Association for Ambulatory Health Care, Inc., and the American Society of Anesthesiologists. Per their standards, individuals administering moderate or deep sedation and anesthesia must be qualified and have the appropriate credentials to manage patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally. Accordingly, those practitioners must be qualified to rescue patients from general anesthesia and be competent to manage an unstable cardiovascular system as well as a compromised airway and inadequate oxygenation and ventilation. A sufficient number of qualified personnel (in addition to the licensed independent practitioner performing the procedure) must be present during the procedure to provide moderate or deep sedation.
We want to know – who administers Propofol in your facility? Send us an email – we’ll discuss the feedback we receive in an upcoming article.
Stay tuned for Part II where we discuss how CMS responded and the various overlapping and conflicting guidelines that have been released.
Copyright 2011, Princeton Insurance Company
July 2011
Communication Breakdown among ED Providers
Printable Version
Communication breakdown – especially among practitioners – is one of the major contributors of claims arising in the Emergency Department (ED).
Urgent situations and critical decision-making in the often chaotic environment of an ED bring together strangers: for the patient – clinicians and rotating staff members due to shift changes and surroundings; for the clinician – unknown patients, fragmented medical histories and unfamiliar family members.
Unlike other clinician-patient relationships, those forged in the ED are done so with the complicating challenges of time, acuity, complexity and hastily compiled medical information. In this environment, you are expected to review the information gathered, make a diagnosis and develop a treatment plan. Because of the acute nature of many of the significant health-related issues with which patients present to the ED, a patient‘s status can change rapidly, requiring more frequent and necessary communication between care givers.
Perhaps nowhere else in the medical community is communication more vital than for the physicians practicing medicine in this demanding and unforgiving environment.
Exploring ways to promote effective communication and the relationships forged in the ED, a comprehensive white paper entitled Optimizing Physician-Nurse Communication in the Emergency Department: Strategies for Minimizing Diagnosis-Related Errors has recently been released by CRICO/RMF Strategies.
Three Princeton Insurance-insured ED physicians served as members of the team who collaborated on the development of the paper, which revealed that communication problems and information gaps between physicians and nurses were a primary driver of diagnostic failure in the ED.
According to medical malpractice data from CRICO/RMF Strategies’ Comparative Benchmark System (CBS) database, which includes Princeton Insurance data, emergency medicine is among the top five specialties with the highest malpractice claims, and diagnostic failure is the number one cause of medical liability in this area.
To download the full report, click here.
To read a press release on the development of the report, click here.
Also, be sure to read our current From the Resource Line article addressing bridge orders (aka transition orders) here. It outlines the differences between an “order to admit,” “admission order” and “bridge orders” and offers helpful guidelines for implementing a transition order policy.
An article appearing in the Health & Wellness section of the Wall Street Journal on May 10, 2011 also discusses the need for better communication among providers in the ED setting, while highlighting conditions, mistakenly given diagnoses and the circumstances often leading to the wrong diagnoses. View it here.
Strangers in Crisis Course Available
Princeton Insurance can help you learn to avoid the most common pitfalls that lead to communication breakdown, and ultimately, claims that often arise in the ED. We offer Strangers in Crisis courses designed for this setting. Visit our CME page here, call us at 1-866-Rx-4RISK or send us an email if you would like to schedule a class or learn more.
Copyright 2011, Princeton Insurance Company
June 2011
Don't forget to prepare your "snowbird" and "sunbird" patients
Printable Version
The number of people age 65 or older will grow to 70 million by 2030 according to the Gerontological Society of America, and more and more physicians will be involved with treating seasonal patients. Today’s seniors are more mobile and generally speaking begin to migrate south starting in early November or after the holidays, returning in late April or May for the reverse migration back to the north. This cycle is repeated every year in increasing numbers as baby boomers are able to manage two households and live with increasing mobility.
Typically, most “snowbirds” and “sunbirds” are senior citizens on Medicare. They have lived in the northern part of the country like New Jersey, New York, and the New England states and still maintain their homes in the north in order to be close to their children and grandchildren, but when the cold weather sets in, they travel to the southern states to enjoy the warmer weather. By continually repeating this cycle, they have their move down to a simple routine and therefore tend to consider their time in the sun as a vacation, perhaps forgetting that their health status can change or that they may need access to care when they are in the secondary residence. Some seniors go unprepared – leaving without checking with their treating physician(s) or failing to line-up a physician at their new location in advance of needing one in an emergency. Therefore, it is important for you to prepare your patients for their seasonal shift.
It is a good idea to advise patients to have a check-up before the planned seasonal move. This may include obtaining refills for medications or helping them choose a local physician who can provide ongoing treatment for a chronic illness. In addition, it is important to either make copies of medical records for patients to take with them, or to provide them with a summary of their current condition and treatment plan. This facilitates easy transfer of information and can help avoid problems with medical record security compliance when patients transport the information on their own. Transfer of information among treating physicians is the key to avoiding difficulties or conflicts in care, especially as the season changes again and patients move back north. Physicians may send patients home with a summary of care for the past several months, and now the pattern of care shifts, and it is imperative that all treating physicians keep the lines of communication open.
To summarize, below are helpful tips in treating migrating patients who either returning home or beginning their travel:
- Remind patients to contact you on their return and ascertain any changes in health status or treatment while at their seasonal destination
- Post notices in your office reminding patients to notify you if they are traveling and to see you in advance for a visit to review their current treatment plan, continued care and prescription needs
- Provide copies of necessary medical records or a summary of care that patients can carry with them
- Assist in locating a primary care physician or specialist at their seasonal residence or destination
- Provide refills for medications
- Communicate with the patient and other physicians as needed
Alert your patients of the need to make healthcare arrangements before “migrating”
Click here to download our sample flyer for you to print and post in your office (cut-out).
Remember: the level of your involvement with your snowbird and sunbird patients may change with the seasons, but your commitment to continuity of care lasts all year round.
Copyright 2011, Princeton Insurance Company
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