When Things Go Wrong
Whitaker advises hospitalists to keep the lines of communication open. “Especially after something unexpected has happened,” she says. “So many times I think the human tendency is to just withdraw, or you feel terrible and you don’t know what to say, or you’re afraid you’re going to get emotional while you’re talking with the family.”
This is normal human response in these circumstances, but if you act on the impulse to withdraw and avoid the patient and family, or hold back, which may eventually lead to a filed claim from a family that feels abandoned.
“Until now the number of lawsuits has been really steady and the amount that we were paying in lawsuits was increasing,” says Whitaker. “However, we’re trying to work with the families earlier on so if we make a mistake and we realize that we made a mistake then we admit that. And we try to do what we can to make it right for that patient and their family.”
This often means reaching a fair and reasonable settlement, says Whitaker, “and [examining fair and reasonable means reviewing] the communication at the time the event occurred. Did we acknowledge that we made a mistake? Did we let them know we’d be willing to work with them? And did we let them know we [have since] made these changes … so they’ll … be reassured [that] hopefully it won’t happen again?”
Who’s in Charge?
Linda Greenwald, RN, MS, editor of risk management publications at ProMutual Insurance Group in Boston, wrote in the company’s newsletter, Perspectives on Clinical Risk Management, that in prior times, the question, “Who’s in charge?” was rhetorical.10 These days any number of generalists or specialists might claim that role. And therein lies the rub: Greenwald says that in many cases involving hospitalists the lines of responsibility are unclear and one or more systems may fail. If so, Greenwald writes, the result may be a malpractice claim alleging:
- Failure to diagnose when each of two physicians assumes the other has responsibility for follow-up;
- Negligence in treatment when one physician fails to monitor on an outpatient basis the medication first prescribed by another physician when the patient was an inpatient; and/or
- Negligent care when a patient misinterprets the information one physician asks him or her to relay to another physician.10
Halpern concurs that the modern mix of professionals working as a team on hospital care can be a major challenge.
“In olden days, when a primary care physician referred to a surgeon, and the surgeon performed surgery, and the surgeon took responsibility for postoperative care, and occasionally brought in a consultant, the lines were relatively clear,” says Halpern. “When a hospitalist is injected into the mix, unless the hospital has really clear procedures and unless everybody is comfortable with the system and everybody is talking to each other and agreeing on the lines of demarcation, you’re creating a soup that plaintiff lawyers would be happy to stir.”
The more murky the communication, the greater the liability. “And when you have murky lines of communication, murky lines of responsibility, and a medical catastrophe,” says Halpern, “human nature compounds the problem by frequently causing a finger-pointing contest, where each component of the patient care team circles its own wagons [and] points in a different direction. And that is the absolute worst thing that can happen when trying to deal with a patient injury claim.”
Summary
The hospitalist’s primary risk for malpractice claims may be inadequate or absent patient follow-up resulting from a lack of communication. The best means of protection from claims is for hospitalists to incorporate a comprehensive risk management program into their practice.