September 21, 2016
A report examining nearly 1,200 malpractice suits closed by The Doctors Company revealed a number of interesting patterns and trends of note to internists.
But maybe most useful, said Howard Marcus, MD, is a collection of case studies highlighting how some of the leading causes of malpractice suits play out in practice.
“The best way to get started it to use (these case studies) within your own practice and talk about what happened, and why this went wrong,” he said. “Once you understand that better, how can you avoid it?”
Pancreatitis? Or …
A 53-year-old male presented to the hospital with complaints of acute chest, epigastric, and back pain with nausea. No pain radiated to the arm or jaw. He gave a history of hypertension, diabetes mellitus, and being a smoker. A brother had died from an MI.
An EKG showed no evidence of ischemia and no significant ST segment changes. Lab test results included lipase of 1,455 U/L (normal range <95 U/L), CK of 78 U/L (total CK normal range for males <235 U/L), and elevated triglycerides of 388 mg/dL (normal range <250 mg/dL). He was admitted to the hospital by an internist and diagnosed with acute pancreatitis, probably due to alcohol abuse. The troponin was mildly elevated at 0.08 ng/mL (normal range <0.03 ng/mL).
The day after admission, the patient complained of pain in the lower chest. His epigastric pain was decreased, and the following day he had no epigastric pain and was eating well. There was chest pain only on palpation, so the internist believed that it was not cardiac in origin. He was discharged with instructions to follow up with the internist in 2 to 3 days, but the patient did not schedule an appointment.
Two weeks later, the patient presented to the ER with complaints of substernal chest pain radiating to his neck and jaw. The EKG indicated that he had suffered an MI.
An emergent cardiac catheterization revealed 100% occlusion of the right coronary artery and 95% occlusion of the left anterior descending artery. An angioplasty was successful.
A claim was filed alleging that the internist failed to diagnose and treat an impending MI. Physician reviewers opined that, even though the pain was atypical for angina and troponin levels were borderline, the patient’s risk factors should have prompted a cardiac workup.
Lost to Follow-up
A 42-year-old female nonsmoker presented to her internist for a cough that was nonresponsive to antibiotics and albuterol treatments. A chest x-ray was ordered and showed a 4.2 cm mass. The radiologist stated that a neoplasm could not be ruled out, and a CT scan was recommended. The internist sent a letter to the patient advising her to make an appointment for the CT scan.
The patient did not return to this physician, and the physician made no subsequent attempts to communicate with her. She saw another internist, but her medical records and chest x-ray report were never sent to the new physician. Eighteen months later, she was diagnosed with stage III lung cancer.
Although patients have responsibility for managing their own healthcare, physicians are expected to make reasonable attempts to communicate when there is a suspected health concern.
In this case, the physician sent a letter advising further studies. It is not clear whether the physician communicated the urgency of performing the studies or if he alerted the patient that failing to investigate the lung mass was potentially life threatening. More than one attempt to contact the patient should have been made. Without tracking mechanisms, opportunities to provide medical treatment are easily lost and forgotten.
A 54-year-old male presented to his internist with complaints of shortness of breath and right leg pain. A Doppler exam revealed a deep venous thrombosis. The patient was admitted to the hospital the next day with an order for IV heparin. A CT angiogram of the chest revealed a pulmonary embolus. The internist discontinued the heparin and ordered ASA, Lovenox, and Coumadin.
Four days after discharge, the prothrombin time (PT) was 37.7 seconds (normal range 11–13 seconds), and the international normalized ratio (INR) was 3.5 (therapeutic range 2.0–3.0). Medications were adjusted. Two days later, the PT was 40.4 seconds, and the INR was 3.8. The physician wrote on the lab report to decrease Coumadin, adding that the patient was aware of the anticoagulation risks.
Five days later, the patient presented to the ER with complaints of severe abdominal pain, distended abdomen, and low blood pressure. A CT of the abdomen revealed a large hematoma in the right lower quadrant pressing on the femoral artery. It was surgically drained, but he subsequently developed foot drop and ultimately lost function in the right leg because of pressure by the hematoma on the femoral nerve.
Physician reviewers stated that too many anticoagulants had been ordered and that all anticoagulants should have been discontinued until the INR was in therapeutic range. Poor communication between the laboratory and internist and the internist and patient contributed to the patient’s injury.
A Failure to Communicate
A 20-year-old morbidly obese male presented to the ER with difficulty breathing and lethargy. He had a recent history of strep throat and was taking antibiotics. Upon admission, his blood pressure was 155/97, heart rate 145, WBC 17,000, and blood glucose 450 mg/dl. He was started on insulin and admitted to the ICU with a diagnosis of diabetic ketoacidosis.
Shortly thereafter, the patient became comatose. A brain CT scan, blood cultures, and neurology consult were ordered. The impression was toxic metabolic encephalopathy, probable sepsis, diabetic ketoacidosis, and rule out meningitis. A lumbar puncture (LP) was attempted, but the patient arrested and CPR was unsuccessful. An autopsy determined that the cause of death was diabetic ketoacidosis.
Physician reviewers were critical that both the dosage of insulin and the IV rate of administration were too low to reduce the ketoacidosis. Concerns were raised about poor nursing communication regarding critical laboratory results and changes in the patient’s condition. Some questioned whether the patient aspirated when he was turned on his side for the LP.
by Ryan Basen and Matt Wynn
Staff Writer, MedPage Today