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

Clinical Sequence

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

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.