Description

A 33-year-old male experienced complications, infection, and hospitalization following treatment at an urgent care center for an accidental knife wound to his hand.

Key Lessons

The vast majority of medical malpractice cases involve some degree of suboptimal communication and/or documentation.
Multiple patient complaints within a short period of time should trigger further inquiry of possible explanations.
All providers should identify themselves by name and discipline

Clinical Sequence

A 33-year-old restaurant worker presented at an urgent care center with a deep hand laceration. He was triaged by a physician’s assistant (PA), sent to the surgery department, and treated by a nurse practitioner (NP). The NP irrigated, sutured, and dressed the wound. The patient was given oral instructions on wound care and the signs and symptoms of infection.

The next day, the patient called the center with complaints of extreme pain. The treating NP prescribed Tylenol with Codeine. Five hours later, the patient called the NP again stating that the pain medication had been ineffective and that he was now having chills. The NP advised him to take an anti-inflammatory agent. Later that same day, the patient called the center again reporting a fever. He was seen that evening by the PA who had done his initial triage.

The PA examined the patient’s hand and found the wound to be reddened, swollen, and hot. A lymphangitis (red streaking) was also noted which extended just distally to the antecubital fossa, indicating that the lymphatic system was also involved in the infection process. The patient was febrile (100) even after several doses of ibuprofen. The PA diagnosed abscess formation, lymphangitis, and significant cellulitis.

After consulting with the covering surgeon, the PA removed six of the nine sutures and observed spontaneous evacuation of purulent material, including old non-clotted blood. The wound was cultured, irrigated with saline and peroxide, and dressed. The lymphangitis and cellulitis were delineated.

The patient was given intravenous antibiotics and discharged home on oral dicloxacillin. A follow-up appointment was made for the next morning. He was instructed to keep the limb elevated and go to the ED if fever or chills developed. Subsequently, the CBC revealed a WBC of 17,000, and the culture was positive for streptococcal and staphylococcus organisms.

The following morning, the patient presented at the center with severe pain with passive motion of the digits and increased edema. He was admitted to the hospital where he underwent three irrigation and debridement procedures and received IV antibiotics. He was discharged home with occupational therapy and IV antibiotics. He was left with scarring and some loss of function of his left hand.

Claim Sequence

The patient filed a claim against the covering physician, the PA, and the NP claiming improper supervision, improper care, and unqualified personnel providing care.

Disposition

Following an unsuccessful Tribunal finding, the claim was settled in the low range (<$100,000).

Analysis

This case illustrates many of the elements that can lead to a malpractice claim: multiple providers involved with the care, several phone calls about pain, an unhappy patient who was confused about who was caring for him, and limited documentation about what he was told.
The vast majority of medical malpractice cases involve some degree of suboptimal communication and/or documentation. Perseverance of the basics: assessing a patient’s understanding of what’s going on, aligning the patient’s expectations with yours, and maintaining a medical record that augments subsequent care, goes a long way toward avoiding errors and mitigating adverse outcomes.
The patient argued that the possibility of infection was not promptly addressed despite his multiple calls complaining of pain.
Multiple patient complaints within a short period of time should trigger further inquiry of possible explanations; e.g., complaints of severe pain within 24 hours of a deep laceration should prompt caregivers to rule out infection. Not only document that calls were received, but that appropriate questions were asked. Establish the threshold where examining the patient is the most prudent course of treatment. Although the additional visit may be inconvenient for both the clinician and the patient, serious complications can often be identified more quickly or avoided altogether. Offers to see patients regarding their complaints that are refused should also be documented. Information that is not in the medical record is often more troublesome than what is actually recorded.
At issue in this case was the degree of pain that the patient complained of and how that misunderstanding ultimately affected his care.
For thorough documentation and continuity of care, ask patients to rate their pain on a scale of 1 to 10. This helps provide a frame of reference, specific to that patient, for evaluating the pain over time.
Although the surgeon did not see the patient, the supervising physician at the center briefly examined the patient’s wound. The patient, believing he was never seen by a physician, stated in his letter of complaint that, “another man came in and assisted a bit, but I didn’t know who he was.”
All providers should identify themselves by name and discipline. When NPs and PAs are the primary caregivers treating a patient, physician involvement should be explained and discussed.
The patient argued that the PA and NP were improperly supervised.
The treating NP was qualified to treat this type of wound. The following day, when the patient’s infection became apparent, the PA consulted with the supervising surgeon and followed his suggestions. The PA also had the in-house physician look at the wound; he concurred with the treatment plan and deferred to the covering surgeon. Experts who reviewed the case for the defense stated that, had a physician seen the patient sooner, the patient’s treatment would not have changed.
The plaintiff alleged that the standard of care was breached when the NP failed to prescribe an antibiotic when the wound was sutured.
Discussing with the patient the reasons not to prescribe antibiotics (possible reactions, infections can still occur) would have informed his that a treatment plan had been formulated rather than that an omission had occurred.