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Asking for It: Malpractice Risks Linked to ED Consults

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Asking for It: Malpractice Risks Linked to ED Consults

By Jock Hoffman, CRICO

Related to: Communication, Diagnosis, Documentation, Emergency Medicine, Primary Care, Other Specialties, Surgery

Patients uncertain about their diagnosis are encouraged to get a second opinion…and so are physicians. But if you see patients in the Emergency Department (ED) and ask for a consult—or provide it—are you increasing your malpractice risk?

The threshold for consults in the ED is relatively low: in many settings, more than 20 percent of ED patients will receive some kind of third-party consultation (many will receive multiple consults). But in a survey related to a recent CRICO/RMF-funded project, one-third of ED physicians and one-fourth of consultants reported having a patient involved in an ED consultation who experienced an adverse event or near miss.

Undoubtedly, physicians requesting and providing consults hope to optimize the diagnostic process. But too often the process fails and the patient is exposed to the risk of miscommunication, either about the reason for the consult or about its findings. When those communication breakdowns contribute to an adverse outcome, they can also trigger an allegation of malpractice.

In the 41 malpractice cases filed against CRICO-insured defendants since 2004 that alleged a misdiagnosis in the ED, 17 percent cite errors in the consultation process. In addition to the patient injuries and emotional impact on the caregivers, those cases reflect more than $2.4 million in potential losses. Both Emergency Medicine physicians and the specialists they call upon for consultation are vulnerable.

To address that vulnerability, CRICO/RMF launched (in 2008) an effort to tackle consultation issues at seven Harvard-affiliated hospitals. Not surprisingly, the project revealed several common gaps in communication between those ordering the consults and the specialists providing them. For example, a review of ED patient records found that critical time points, such as when the request was made and the response time, were rarely documented, and a significant percentage of records lacked:

  • the reason for consultation,
  • evidence of real-time closed loop communication at the consultation’s completion, or
  • documentation of an attending consultant’s involvement.

By more precisely pinpointing the weaknesses in ED-specialty consults, the Harvard project also served to identify three key practices that can help physicians strengthen their consultation processes:

  1. Insist upon clearly defined, two-way communication at the beginning and at the end of a consultation.

  2. Record the time of consult initiation and completion, and establish standards for response timeliness.

  3. Maintain appropriate supervision of trainees who serve as ED consultants.

Of course, the most effective ED communication standards are those developed locally to account for the unique issues of different consultant services. Not every hospital has a clear written policy for consultations. Some lack standards for ED-based consultations and some have standards that are unenforced. But clear standards, particularly around the principles of two-way communication, timeliness, and supervision are essential. Otherwise, you’re just asking for it.

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November 2, 2009
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