lesson learned from failing to follow up

8/19/2019 Lesson learned from failing to follow up

http://slidepdf.com/reader/full/lesson-learned-from-failing-to-follow-up 1/4

O B G M A N A G E M E N T • F e b r u a r y 2 0 0 7 29w w w. obgmanagement . c o m

FOCUS ON

FAST TRACK

PROFESSIONAL LIABILITY

P hysicians are multitaskers. Everyday, we balance the demands ofpatient care, the burden of regu-

latory mandates, and the needs of ourfamilies—and try to get adequate restand recreation in the process!

As pressures upon us increase, wehave begun to build teams and systemsthat ensure the kind of care our patientsdemand. We may not be able to deliverpersonal continuity to every patient,

but a team can approximate that con-tinuity—after it meets several key chal-lenges. Foremost: developing systemsof communication that are consistent,reliable, accurate, and accessible to anymember of the team.

There is another locus in the contin-uum of care that is often neglected: post-event follow-up for medical, psychoso-cial, or legal purposes. The following caseillustrates this point.

CASE A lawsuit is leddespite comprehensive care

C.S., a 34-year-old G4P3, at 35weeks’ gestation with suspected prema-ture rupture of membranes, was referredto the tertiary-care center where I prac-tice. She had reported a gush of uid,and the referring physician had observednitrazine-positive uid at the introitus.

On initial speculum examination at the

tertiary-care center, no uid was observed

coming from the cervix, and vaginal secre-tions were nitrazine-negative. The cervixwas long, posterior, and patulous. Ultra-sonographic examination of the uterusdemonstrated a normal fetus of appropriatesize for the reported gestational age and amaximum pocket of amniotic uid greaterthan 10 cm in depth. The fetus was active,and the nonstress test was reactive. Thepatient’s urine was alkaline; a specimensent for culture was found to be negative.

Despite the reassuring clinical as-sessment, this mature multipara’s de-scription of events was credible. She wasoffered the option of overnight observa-tion or amniocentesis with instillation ofindigo carmine. Because her husbandand 3 children would have had to stay intheir car overnight if she remained in thehospital, the patient chose instillation.

Amniocentesis was performed un-der sonographic guidance, with a returnof clear uid. The uid was sent to thelab for fetal lung maturity testing, whichwas negative. Ten cubic centimeters ofindigo carmine dye were instilled, anda tampon was inserted. After 2 hoursof ambulation, there was no dye on thetampon, and another nonstress test wasreactive. The patient was discharged.

The next day, the patient reported toher family physician complaining of severeuterine pain, fever, and a loss of fetalmovement. When fetal heart activity could

not be detected by Doppler ultrasound, she

Lessons learned from failingto follow upGood intentions don’t compensate for faultysystems of tracking patients’ needs

Stephen S. Entman, MDProfessor of Obstetrics andGynecology, Vanderbilt UniversitySchool of Medicine, Nashville, Tenn

The author reports no nancialrelationships relevant to this article.

In a team setting,communicationsystems must beconsistent, reliable,accurate, andaccessible to anymember



30 O B G M A N A G E M E N T • F e b r u a r y 2 0 0 7

AST TRACK

FOCUS ONPROFESSIONAL LIABILITY C O N T I N U E D

was again referred to the tertiary-care cen-ter. There she was noted to be in extremepain, with a temperature of 104°F, and bulg-ing forewaters. There was copious uid andno fetal heart motion on ultrasonography.

Amniotomy elicited a gush of clear,blue, odorless uid. The cervix dilatedcompletely, and the fetal head was expelledto the chin. Examination revealed a nuchaland shoulder cord tightly wrapped andtethering descent. The vaginal wall wasretracted, and the cord was visualized anddivided. A stillborn male was immediatelyexpelled, and the placenta followed rapidly.Bleeding remained within normal limits.

Although there was no explanation for

the fever, the patient was treated with anti-biotics during her postpartum hospital stay.She recovered quickly. Cultures from mother,baby, and placenta detected no organisms.The patient was discharged on day 4.

Ten months later, the patient leda lawsuit alleging a failure to diagnoseamnionitis at the time of the rst visit.

What prompted the lawsuit?

Clearly, this patient had a tragic loss. Justas clearly, there were multiple incongrui-ties between her clinical presentation andthe outcome. The patient and the careteam were both aware of these truths.

Research has demonstrated that phy-sicians who interact in a positive mannerwith their patients are less likely to besued than those who fail to communicatewarmth and caring. Patients of physicianswho have a history of multiple lawsuitsmay consider them knowledgeable andcompetent—but they also are likely todescribe them as unavailable, abrupt, anddisinterested. Patients often characterizetheir experiences with such physicians asnegative even when the clinical outcomeis good. This negativity often prevails evenwhen the of ce staff is skilled in commu-nication, education, and support. 1,2

The team performed wellIn the case of C.S., the physicians, by na-

ture and by intent, were attentive to the

human needs of this grieving family. Hereis what we did well:

• The same residents provided carethrough both labor and delivery andduring postpartum care• The attending physician (me) waspresent through all clinical milestones• All members of the team openlyexpressed their sorrow to the family• I visited with the patient daily—pro-viding honest answers to the family’squestions and acknowledging gaps inthe medical team’s understanding ofwhat had happened• A follow-up plan was established toprovide autopsy results to the family

At discharge, the family expressed appre-ciation for the team’s efforts and caring.

So what went wrong? Why did the fam-ily—and the members of the care team—have to suffer the ordeal of litigation?

Critical lapse uncoveredNote the last bulleted item, above. This wasthe critical lapse: I did not call the family torelay the results of the autopsy. Why not?I knew better, after all, and prided myself

on my commitment to all dimensions ofthe care I provided. As with most lapses inmedical care, failure was multifactorial—part system design, part human failing.

At the tertiary-care institution inquestion, maternal transport high-riskpregnancies are managed with a groupof attending obstetricians on a week-by-week rotational schedule. This providescontinuity of care through the calendarweek but, by its very nature, relieves theattending of the previous week from clini-cal responsibilities. By happenstance, themonthly rotation of residents coincidedwith this patient’s hospitalization. Thus, nomember of her care team had continuingdirect responsibility for the OB service.

To complicate matters, I left town af-ter the delivery for a conference, with va-cation tacked on afterwards. When I re-turned to the of ce 10 days later, my headwas refreshed but my memory had beenpurged, and I failed to follow through on

my promise to contact the family.

Establish a plano ensure continuity

of care even whenkey team membersare unavailable

C O N T I N U E D




AST TRACK

FOCUS ONPROFESSIONAL LIABILITY

About 3 months after the delivery,I overheard a secretary trying to calma frustrated patient on the telephone.When I heard the secretary say, “I’m sor-

ry, ma’am, but we just don’t have the au-

topsy results, maybe you should call pa-thology,” I realized which patient it wasand took over the conversation. Abjectlyapologetic, I promised to get the infor-

mation for her within hours. The patient

Averting disaster: 4 ways to ensure adequate follow-up

Build a solid foundation. We allknow communication is important, butmany of us fail to take the extra steps nec-essary to standardize communication sothat the entire care team is apprised of thegoals for a given patient—as well as exactlyhow much progress has been made towardthose goals. Various systems have beendesigned to accomplish this aim, many ofthem derived from the aviation industry.

A small investment in time can reap big

rewards. A few examples:• “Time-out” —A pause before an in-

vasive procedure to con rm that you havethe correct patient and will be performingthe appropriate procedure.

• “Snapshot” —An overview of caseswithin a de ned time period, includingidenti cation of the team’s priorities. Forexample: “This morning we have 3 patientsscheduled for surgery, beginning withMrs. ‘A,’ whose hysterectomy for a largemyomatous uterus will likely be time-con-

suming.”• “Turn-over” —A synopsis of cases atthe time they are handed over to anotherteam member or a different team. Theinformation provided should include out-standing tasks and tests.

• “De-brief” —Time set aside aftera case to discuss what happened, whatcould have been handled differently, andwhat the next steps are. These sessionsprovide immediate feedback to the teamand in uence the care of future patients.

Don’t leave warmth and caring to your staff. The evidence is in: Physicianswho interact in a positive manner with theirpatients are less likely to be sued thanthose who fail to communicate warmth and

concern. Given the competing demands onour time, it is all too easy to rush throughpatient visits or other aspects of care with-out attending to the human component.Take a few minutes to greet each patientby name, inquire about her family and anyconcerns she may have about her condi-tion, and listen attentively to her response.Then document any important details thatarise during this discussion, so the rest ofyour team knows about them, too.

Offer and follow through on anevidence-based explanation of events.

At times of tragedy, pay attention to theneeds of grieving patients—and their fami-lies. This begins with an acknowledgment ofthe shock and sorrow they are experiencingand includes reassurance that the reasonsfor the adverse event will be explored andreported. This should not be an empty prom-ise. It is important that the physician offers as

full an explanation of an event as possible—as soon as all the facts are in—and that thisexplanation is voluntary, not something thepatient has to ask for repeatedly.

Implement an effective trackingsystem. The case of C.S. (page 29) illus-trates the need for a more comprehensivetracking system. In that case, my failureto relay the need for autopsy results toother team members, and my subsequentabsence from the scene, allowed a criticaldetail to slip through the cracks.

Because patient les tend to be forgot-ten once they are stored away, a tickle leor similar system is a simple way to keeptrack of tests and communications thathave not yet been performed.

1.

2.

3.

4.Physicianswho interact in apositive mannerwith their patientsare less likely to besued than those whofail to communicate

warmth and concern

C O N T I N U E D

C O N T I N U E D




AST TRACK

FOCUS ONPROFESSIONAL LIABILITY C O N T I N U E D

was reserved but accepted my offer.The autopsy revealed a polymorpho-

nuclear leukocyte in ltration through-out the body, but no organisms could beidenti ed by culture or on histologic ex-amination. The nal pathologist’s reportprovided no de nitive explanation of thesequence of events that led to fetal death.When I explained this to the patient dur-ing a telephone call, her demeanor turnedicy and she hung up. Several months later,the lawsuit was served.

To trialThe jury deliberated for 18 minutes aftera 5-day trial, and returned a verdict for

the defense. As one of the physician-de-fendants was leaving the courtroom, heoverheard the patient’s husband comfort-ing her about the verdict. Her responseresonated: “That’s OK. All I wanted wasto know the real reason Bobby died.”

This was a painful way to relearn animportant lesson. Although OB patientsand their families le suit for any num-ber of reasons, 20% state that one driv-ing force is the need for information, and

24% believe a cover-up occurred.3

Further, although a defense verdictwas returned, legal fees and lost timeamounted to roughly $250,000 in costs—a substantial loss that a timely telephonecall could have prevented.

Loss of trust can be exponentialAll the warmth the care team shared withthis patient and her family during herhospitalization became irrelevant afterthe lapse in follow-up. The team let thispatient down by failing to implement asystem to track her human needs as wellas her acute clinical issues. One individu-al’s limitations of memory led to severalyears of anguish for a grieving family.

We have learned the importance ofkeeping track of Pap smear results, quadscreens, mammograms, and other teststhat have direct, acute impact on patientcare, but many of ces lack a system fortracking the ful llment of other needs.

Such a system need not be complex.

In this case, a tickler le would havesuf ced—ie, a calendar or accordion

le that contains individual remindersof tasks that need to be performed andthe date they are required, such as theneed to obtain results or to touch baseabout personal issues. (The remindershould also include patient contact in-formation, to eliminate the need to lookit up again.) If the results are delayed,the reminder can be re led or repostedfor the following week.

“Out of sight, out of mind”Some of us have a photo of each pa-tient taped to the inside front cover of

her chart—along with her nickname,children’s names, life-cycle events, andkey personal information. These piecesare a prompt that allows us to human-ize the relationship during of ce visits.That approach works well for the pa-tient, and for us: We use the chart tomake notes about the need for clinicaland, perhaps, personal follow-up. Butthere is one fatal aw: The chart hasno value once it is put back in the le

rack, where we won’t see it when weneed to act.As we confront the complexity and

demands of practice in the 21st century,we cannot rely on our intrinsic goodcharacter, good will, and good intentions.And we certainly cannot depend on ourmemory or trust that the documents thatwill direct us to our next step will land onour desk when we need them. We owe itto ourselves, our partners, and, most im-portant, our patients to take the time todevelop systems for the “miscellaneous”tasks that remind us when it is time to dothe right thing. ■

References

1. Hickson GB, Clayton EW, Entman SS, et al. Obste-tricians’ prior malpractice experience and patients’satisfaction with care. JAMA. 1994;272:1583–1587.

2. Entman SS, Glass CA, Hickson GB, et al. The relation-ship between malpractice claims history and subse-quent obstetrical care. JAMA. 1994;272:1588–1591.

3. Hickson GB, Clayton EW, Githens PB, et al.Factors that prompted families to le medicalmalpractice claims following perinatal injuries. JAMA.1992;267:1359–1363.

20% of OB patientswho le suit do soprimarily to obtainnformation, and

24% because theyfeel a cover-uphas occurred

lesson learned from failing to follow up

Documents