By John Palmer
A new report from medical liability insurer Coverys indicates that the emergency department (ED) is the fourth most common healthcare delivery location in which malpractice claims are triggered, and that alleged malpractice in the ED is responsible for at least a third of deaths resulting from those claims.
This is due mostly to the fact that the ED is the first point of contact for 138 million hospital patients in the U.S. In addition, the stressful nature of the ED, as well as a lack of patient background information and rapidly changing conditions, can challenge staff and lead to breakdowns in the healthcare delivery process.
The study, titled Emergency Department Risks: Through the Lens of Liability Claims, was released in late June. It is the latest in a series of reports that explores the increased risk and liability brought on by several patient safety issues in healthcare, and offers suggestions on how to improve.
This is the fourth report in the company’s “Dose of Insight” series, which has previously explored medication errors, diagnostic accuracy, and obstetrics. The report was coauthored by Coverys employees Tara Gibson, CPCU, RPLU, ARe, vice president of risk management; Ann Burke, RN, CPHRM, CPPS, director of risk management; Solveig Dittmann, RN, BA, BSN, CPHRM, senior risk specialist; and Maryann Small, MBA, director of data governance and business analytics. It is available for download from the Coverys website.
“Care and treatment in the ED have the potential to impact a patient’s entire medical journey. The ED experience is analogous to the first domino in a chain of falling dominos,” the report authors wrote. “The decisions and actions of healthcare providers and other staff impact whether a patient seeks specialty care or follows up with a primary care provider.”
The study was based on an analysis of 1,362 ED-related closed medical professional liability claims at Coverys across a five-year period from 2014 to 2018. Among the major findings were the fact that diagnosis failure claims account for 56% of ED claims; in addition, 13% of all medical professional liability claims involve care that occurred in the ED, preceded only by care provided in inpatient units (17% of such claims), physicians’ offices (25%), and surgery (26%).
“The steps that will be taken by the patient long after the patient is transitioned to another department in the hospital, transferred to another facility, or discharged from the ED are impacted by the visit to the ED,” said Gibson in a statement. “Paying close attention to specific risks in the ED can and will enhance patient care and safety overall.”
The report found that a majority of claims filed against ED care involved a failure or delay in making a diagnosis—the blame for which largely was placed on a lack of appropriate information about patient or family history, as well as inappropriate ordering of diagnostic tests. Of the 1,362 cases followed, 56% of the allegations were related to the patient’s diagnosis, followed by the patient’s medical treatment (20%), an issue related to patient medication (9%), or something related to a surgery/procedure (4%).
Also, the top conditions that triggered a claim were cardiac/vascular conditions (23%) and infections (18%), followed by neurologic conditions (8%), medication-related issues (7%), fractures and dislocations (7%), GI-related issues (6%), and finally psychiatric issues or suicides (6%).
The report also found that more than a third (36%) of malpractice claims stemming from ED care resulted in death, followed by significant permanent injury (15%), temporary minor and temporary major injury (12% each), and emotional injuries (4%).
Clinical judgment, specifically issues in patient assessment, therapy selection, and obtaining consultations, was cited as a factor in 44% of ED-related claims, the report found. This was followed by claims citing clinical systems issues (10%), documentation or issues with electronic health records (10%), communication errors (8%), and medication-related errors (7%).
“Claims data should serve as signals for greater vigilance for all who contribute to the complex patient care ecosystem in the ED,” said Small in a press release. “By learning from historic data and identifying the areas most prone to error, we can proactively reduce errors, improve patient safety, and decrease emergency department risk.”
The report also broke down its findings into six crucial vulnerabilities in the U.S. emergency care system. The findings are as follows:
> “Clinical judgment can be impaired for a variety of reasons, not the least of which is that the diagnostic journey can be a solitary, rushed, and high-pressure affair.
> A narrow diagnostic focus can contribute to misdiagnosis.
> There are effective tools to assist with diagnostics and communication. Using these tools can be effective, but training and practice are critical.
> Communication breakdowns among providers at all levels, including front desk staff, can be minimized if you treat communication and collaboration as a combination of art and science.
> Practitioners and staff in radiology and other diagnostic departments (such as laboratory) too often function in silos, opting for electronic notes when a timely phone call or hallway conversation could significantly improve patient outcomes.
> Epidemics of drug abuse, heart disease, diabetes, obesity, and chronic pain have left EDs vulnerable to risks related to medications like antibiotics, opioids, and anti-coagulants, the top three types of medications involved in malpractice claims.”
How do we fix the problem?
According to the Coverys report, a hospital ED contains many complex factors that must be executed near flawlessly, lest patients experience a communication breakdown or other problem that could cause a visit to end in disaster—and ultimately a legal claim.
“In the ED, we succeed and we fail as teams—teams whose members must, in working together, provide expertise and care that eclipses the impact that one provider alone could deliver,” the report stated.
The factors cited are nothing new to healthcare professionals, but their inclusion in the report highlights that they must be addressed to make healthcare safer and less litigious. Some of the factors include the following:
> High pressure. The ED has a high-pressure atmosphere, and its pace of activity can quickly go from calm to chaotic. If the staff of the ED aren’t well drilled and prepared for the different scenarios that can happen—leading to breakdowns in diagnostic, organizational, and communication skills—the situation can suddenly become a disaster.
> High stress. ED staff are under a lot of stress, and they don’t know what’s going to hit them on an hourly or daily basis. They must be able to transition from a relatively calm environment one moment to a high-stakes situation the next, and can experience emotional fatigue due to caring for the acutely ill, as well as physical fatigue from working long hours and late nights.
> High acuity. ER staff must stay clear and levelheaded in any situation, especially when traumatic events such as heart attacks, seizures, and patient violence take place.
> Low information. Patients come into the ED at all hours of the day and night, often with no notice and little information to give to the staff helping them, such as medical histories or other background information (especially if a patient arrives alone or unconscious).
Perhaps one of the best features of the report is a section identifying process vulnerabilities at four steps of emergency care: arrival/transport, triage, waiting room, and treatment room. Each step identified contains a description of potential vulnerabilities, a case study, and a list of suggested improvements. Among the suggestions are the following:
> Arrival/transport. Strengthen your relationships with EMS providers that transport to your facility. Develop a protocol to determine when the ED must go on “divert” status to slow down the patient flow.
> Triage. Have one or more RNs designated as triage nurses, who have completed the required training and competency evaluation from nursing leadership to function in this role.
> Waiting room. Keep patients informed about wait times and when they can expect to be seen. Consider moving disruptive patients to another area of the ED, and adding a special room or area in the ED for patients with psychiatric issues. Provide masks and hand sanitizers.
> Treatment room. “The H&P [history and physical] in the emergency department must be focused and complaint-driven.”
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.