Tucker Poling, JD
General Counsel and VP of Claims

“What we’ve got here is failure to communicate…”

Cool Hand Luke, 1967

Over the course of my career – whether as a litigator representing healthcare providers, in my former role as Executive Director of the Kansas State Board of Healing Arts, or in my current role as Vice President at KAMMCO – I’ve found communication and documentation problems to be the most common contributing factors in malpractice claims against healthcare providers. More accurately, “factor” rather than “factors”; because documentation is just a modality of communication.

Although some facts have been modified to avoid disclosing sensitive information, the following scenario draws upon the core facts and issues from a lawsuit against two physicians. This case study highlights how communication and documentation issues can contribute to allegations of malpractice.

Case Study

Facts:

• A patient in their 70s presented to the emergency department (ED) with complaints of nausea, vomiting, and generalized abdominal pain. The ED physician assessed the patient and ordered blood work, a chest x-ray, IV fluids, and antiemetic medications.

• The physical examination of the patient’s abdomen was negative, with absence of distension or tenderness. The patient reported feeling better after IV fluid and medication, but his lab work and clinical presentation led the ED Physician to admit the patient to the hospital. Specifically, the patient had elevated lactic acid, leukocytosis with elevation in BUN and creatinine to bilirubin, in addition to low sodium, elevated proBNP, and mildly elevated lipase.

• The ED Physician paged the hospitalist (co-defendant), who accepted admission.

• The hospitalist was considering ischemic bowel disease on his differential diagnosis and asked the ED Physician to order a CT of the abdomen, which the ED Physician entered prior to the patient being transferred to the floor.

• The CT report came back around the time the ED Physician was entering bridge orders for the patient. The CT scan was interpreted as “Findings consistent with small bowel obstruction. No evidence for hollow viscus rupture.”

• Notably, the ED Physician included a bridge order to advance diet as tolerated. The ED Physician did not believe he reviewed the CT results prior to entering the bridge orders, but he testified it was possible it would not have changed his orders.

• There was no documentation noting any plan for communicating or following up on the CT results. It was not clear whether the admitting hospitalist was notified of the CT results. If anything was communicated between the ED physician and the admitting hospitalist regarding the bridging orders or the CT results, it was not documented.

• Another hospitalist covering the midnight to 6 a.m. shift received notification of a critical lactic acid of 5.4 at 1:35 a.m. the following morning, but no new orders were entered at that time.

• The nursing assessments indicated 5 mL of oral intake at 4:05 a.m. and then 500 mL of oral intake at 6:22 a.m.

• The patient was found pulseless and not breathing prior to the admitting hospitalist making rounds at 9:30 a.m. A large amount of emesis was visible on the patient’s bed and right side of his head.

• The patient was transferred to ICU and placed on a ventilator. Upon assessment, the patient was noted to have a distended abdomen. Once an NG tube was placed, four liters of dark brown fluid were collected. The patient was removed from the ventilator at 4:57 p.m. and pronounced dead.

Claim Assessment

• The communication and documentation gaps in the handoff between physicians and departments, as well as the ED Physician’s bridging order to “advance diet as tolerated” in conjunction with the transfer from the ED to an inpatient admission were difficult aspects of this case from a liability standpoint.

• The hospitalist who accepted the patient testified in his deposition that he believed the ED physician would place the orders, and any changes to those orders would be the responsibility of the ED Physician, including any response to the CT results. The admitting hospitalist testified he did not have a physician-patient relationship until the patient was moved to the floor. Thus, orders prior to that time were not his responsibility.

• The ED physician testified that he had markedly different assumptions about which provider would follow up on the CT results.

• Neither physician communicated or documented any of their respective assumptions about the next steps in the patient’s care. The physicians’ conflicting opinions and perspectives about who was responsible for receiving, reviewing, and taking action based on the CT results made this a challenging case to defend for both defendants.

Risk Management Tips

• When working with a care team, communicate as clearly as possible about next steps in the plan of care and who is doing what and when. Document the plan. Ambiguous responsibility may increase the risk of follow-up failure.

• Risk is often reduced when test results are 1) communicated to the patient, the attending physician, and any other relevant physician involved in the patient’s care, and 2) all those communications are conspicuously documented.

• The ordering physician is often viewed as bearing the responsibility for reviewing resulting reports and communicating the information without delay.

• Risk is often reduced when admitting physicians take immediate or early responsibility for patient care.

• When an attending physician asks an emergency physician to write admission orders, transition orders may be a reasonable alternative to minimize the risk of a lapse in care if permitted. However, if transition orders are used, time-limiting the orders (when appropriate) may reduce risk. Communication between the attending physician and emergency physician regarding transition orders should be maintained and documented.

• Risk may be reduced by following up on all test results or outstanding test results prior to entering transition orders and documenting such follow-up.

• One way of promoting effective communication is by incorporating mechanisms such as information exchange protocols and closed-loop communication. This style of communication fosters the ability to ensure that the entire team has shared goals, expectations, awareness, and plan execution.

Ambiguous communication and lack of documentation likely lead to more malpractice allegations than any other factors. Healthcare providers who focus on communication and documentation in their clinical practice significantly reduce their risk of being the target of a lawsuit.