Communication and Dangerous Medical Errors
Robert M. Blumm, MA, PA, DFAAPA, PA-C Emeritus
Communication is as old as the human race and has always played a part in our lives: from early writing on the walls of caves in pictures, to smoke signals, the printing press, Morse Code, the welcoming of Alexander Bell's telephone and, of course, all of the enhancements that we have today, including that annoying cell phone with its robocalls. The purpose of communication is to share a message and to get a response. The key to communication is not mere hearing, but the focused act of listening, responding, and returning information. How often do we go to a store, give an order, only to have the clerk say, “What did you want?” They have not listened to what you ordered.
This is unacceptable in a medical practice. Just yesterday, as I began to write this article, I was informed of a medical error which caused a patient a greater morbidity risk because the message that was given was not relayed and the patient trusted the nurse who gave the response. We all know Mrs Jones; Mrs Jones called the gastroenterologist three days ago with the complaint of minimal left lower quadrant pain, severe bloating, gas, was afebrile and had unusual bowel movements. Mrs. Jones called her doctor when she realized that she was not healing spontaneously and needed the attention of a specialist rather than running to an Emergency Room. The nurse said the doctor was booked, but that she would double her up sometime that day or the next day and to wait for a call. The call did not come that day or the next. When the patient was finally seen as an emergency, she was beyond Flagyl and Cipro as she now had a perforated diverticulum. If the patient had been seen as she had been promised, the need for emergency surgical intervention might well have been averted.
This is only one of the hundreds of errors that can occur when employees in our offices drop the ball or when we do not have protocols in place. Every time that a PA or an NP orders blood labs, urine, radiological studies, special consultations or has a patient that has been discharged from the hospital, they should be notified by the provider or designated office person as to the results and what they may mean. Telling a patient that their WBC is 16,000 is not the same as saying that it is abnormally high and indicates an infection. When a patient reports a problem or calls to say their blood glucose is 50 or 350, these are examples of hypo and hyperglycemia and they will need to speak to a provider for directions and follow-up. All responses need to be placed in a log with the signature of the person making the call and what they told the patient. Hospital discharge patients require the same procedure to assure them that you are concerned and that they have had their questions addressed. These are written procedures and protocols and your health care system probably has forms for this for their own follow up. What if your office workers are not diligent to maintain this type of record? You, as the provider or owner of your practice are 100% responsible and, therefore, you need to have the proper liability insurance. You will also need to discharge that employee from your practice setting.
What is the best type of insurance to have for these potential problems as well as the many others that you may encounter as you practice medicine or nursing? My suggestion would be an occurrence policy, and not just any occurrence policy or one from your healthcare system, but a personal liability insurance policy that specifically names you as the covered and owner of the policy. What company would I choose? A company with a reputation for honesty, paying their claims, securing excellent attorney’s and having the ability to pay claims without bankruptcy. I would choose a company called CM&F, Personal Liability Insurance experts with a 70 year history of excellence and an A++ (Superior) rating by A.M. Best. Why this company? Because it is proven and has cared for nurses, PAs and NPs throughout its history and is a committed family-owned business.
I'm a new grad PA with a recent job offer in my desired specialty and location but offers only to pay for claims based malpractice without tail. I would be practicing in a tier 3 location and specialty (meaning I need the most expensive form of malpractice). I looked into purchasing my own occurrence based malpractice and it is wildly expensive (it would be almost 10% of my salary) and the physician I would be working for refused to help me pay for it. I am practicing in a state that only allows someone to sue practitioners within 3 years after the supposed incident or 1 year after the incident was discovered.
I am wondering your thoughts on this situation - would you bite the bullet and pay for your own occurrence based plan? or would you let the physician pay for the claims based insurance, knowing you would have to pick up the tail if you left?
Lastly, if I were to pay for a tail after leaving, how many years would you suggest I buy the tail for?
Thank you all!
2018, The Unwritten Chapter
Robert M. Blumm, MA, PA, PA-C Emeritus, DFAAPA
The year 2017 was an amazing chapter in our lives with many changes in leadership, politics, healthcare, the advancement of both the NP and PA professions, tremendously increased knowledge in medical education, the loss of at least twenty-five international personalities and, for a number of us, a year of unprecedented medical litigations due to medical errors, the traps of an EMR, informed consents and failure to diagnose. We have gained much in the ability to enter new fields of interest and to become pioneers in specialties, but all of this has a cost. We always will pay a price to gain a prize.
We are now writing the first few pages of a new chapter with the hopes of improving our personal skills, our professional achievements, our outcomes with our patients and our overall success in life and in the marketplace. “The new year stands before us, like a chapter in a book, waiting to be written. We can help write that story by setting goals.” Melody Beattie
In order to set goals, it is essential to know the facts and change the outcomes or the injury created by a faulty outcome. CM&F insures 12,000 NPs and PAs and serves them with diligence, respect, and instant access. With OPA becoming the buzz word for PAs in this new year, it is my hope that PAs with an eye toward future independent practice will become aware of the absolute need to have a personal liability insurance policy as offered by CM&F as the endorsed group for the AAPA. This could have an extremely favorable impact on premiums for PAs.
There are so many positive aspects of independent practice for NPs, but payouts for malpractice claims filed against NPs are on the rise, according to a new report. The average payout was $240,471 according to studies from CNA Insurance which covers NP malpractice insurance. The highest area of claims is neonatal, which at only 1% of the claims was $630,411. Obstetrics, another high-risk area, had indemnities that averaged $417,500. The lowest of the three was emergency medicine with indemnities averaging $277,812. Though those three specialties accounted for the costliest claims, the vast majority of closed claims were related to four other specialties: adult primary care, family practice, behavioral health, and gerontology. It is surprising, as well as a hidden trap, that most of these were related to a failure to order a medical test or obtain an address that test result.* As I mentioned earlier, knowledge of the facts can dramatically change the outcome; the meticulous attention of the provider is essential.
So my fellow colleagues, how will we write the 2018 chapter of our history? We can all hope for a greater future with less misadventure, fewer litigations, and healthier patients. But we must engage with the conscious reminder that we are caregivers and we are, therefore, vulnerable. Why carry that vulnerability on our own shoulders when the fear, anxiety, and burden can be shouldered by personal liability insurance? How empowering is the knowledge that we are protected from potential errors by specialists who are experienced fighters in this field of litigation? What do you believe? What price are you willing to pay to obtain security and peace? “Beliefs have the power to create and the power to destroy. Human beings have the awesome ability to take any experience of their lives and create a meaning that dis-empowers them or one that can literally save their lives.” Tony Robbins. Let us join hands together and make the latter choice.
* Source- CNA and Nurses Services Organization (2017, October). CNA and NSO Nurse Practitioner Claim Report (4th Edition): A Guide to Identifying and Addressing Professional Liability Exposures, page 12. Retrieved from https://www.nso.com/Learning/Artifacts/Claim-Reports/Nurse-Practitioner-Claim-Report-4th-Edition-A-Guide-to-Identifying-and-Addressing-Professional-Liability-Exposures. --
Robert M. Blumm, MA, PA, PA-C Emeritus, DFAAPA Surgical PA, National Conference Speaker, Author, Suture Workshop Director, Former AAPA Liaison to American College of Surgeons, Past President four National Associations, Editorial Board Clinician1.com, Advisory Board POCN., AFPPANP Treasurer
A Perplexing Presentation of Influenza
Robert M. Blumm, MA, PA, PA-C Emeritus, DFAAPA
Last month, I was teaching a six-hour suturing workshop for FHEA and had an insightful conversation with one of my associates, Dr Theresa Campo, DNP. Theresa is a well-trained NP and author of two textbooks; she serves as an educator and an emergency department nurse practitioner. While performing her duties in the ER, she encountered a strange presentation on a pediatric patient that required further testing and transfer to a pediatric facility. When working for a hospital emergency room, we are serving under a medical director of the ER. That director can determine if our treatment is correct or whether we really need to triage the patient to another service. In this case, Theresa’s experience and intuition told her that there could be multiple zebras running through the child’s presentation; yet the physician was reluctant to approve the referral. Because of her experience, Dr. Campo realized that she was still the provider and culpable for her decisions. Transferring the patient to provide a safe transition on a difficult diagnosis was strongly indicated. This is a situation that many NPs and PAs will encounter and the correct action is to follow your gut unless the director wants to take over the entire case and disregard your input. Today, an experienced NP or PA in this arena is as capable of making the decision for treatment as the physician and is legally responsible for their actions.
The patient in question presented with cough, fever, and rash that started two days prior. She had one episode of vomiting one day prior to her ER visit and none since. She incidentally presented with a subconjuctival hemorrhage in the medial aspect of her left eye, possibly caused by violent coughing. The patient also had epistaxis of the left naris that lasted for one hour and stopped with direct pressure after fifteen minutes. The patient developed a petichial rash of her chest as well as her right and left upper extremities during examination. She tested positive for Flu A, CBC was normal, coagulation profile was normal; but she had blood in her urine with few RBCs on microscopy. While she was in the ED, the rash spread on both upper extremities to her hands, the upper back, and down the midline to the abdomen. Just prior to transfer to their other campus for peds admission, she developed urticaria. This is a formidable presentation and other differential diagnoses are required to form the correct treatment plan. As you can see, this is not an everyday flu presentation. This case demonstrates why Theresa was required to follow her instincts and make the proper transfer.
I have discovered that many new clinicians become intimidated by the “oversight” of some physicians. They have a tendency to blindly follow their instructions, forgetting that they are the responsible party if there is a poor outcome. Those clinicians with less experience can often make poor decisions due to lack of experience and failure to diagnose based on conflicting presentations. They fail to demonstrate that they are secure in their diagnosis and fail to realize that, despite working under a facilities' malpractice insurance, they are still a responsible target in a litigation and are at the mercy of the hospital's carrier. It is for this reason that every new PA or NP needs to discover that the most efficacious policy for their practice is a personal liability insurance policy that protects them as the individual clinician and protects their assets and their reputation. A new clinician can pay a fraction of the cost of a policy during the first year of practice. The new clinician will soon discover what it means to have a parachute when it becomes necessary. CM&F has been insuring nurses, PAs and NPs for the past 70 years and has an A++(Superior) by A.M. Best rating and protects their insured. Call them today to add the safety net that is necessary in the practice of caring for patients.
Hello all, I'm in a bit of a pickle.
New grad here. I just left a small clinic after four months because it wasn't a great environment in general (I won't get into details, but they were incredibly disorganized and the clinic was poorly run. Had I not had financial obligations, I would have left after about a month). While I was there, I was covered under the clinic's malpractice policy and didn't have a policy of my own. The clinic claimed I would be fine without the individual policy, but I'm trusting what the clinic said less and less. I believe their policy is claims made.
Here are my questions:
1. I don't have any suits filed against me. Can I get a retroactive individual policy? Can I go elsewhere or do I need to get it from the clinic's company?
2. How do I ensure that I continue to be covered if the clinic's policy is canceled? That's what I'm most nervous about. I have no idea if the clinic will remain open and I don't want to risk not having coverage. Is there any way I can find out if the coverage gets canceled?
3. What kind of information regarding the policy do I need to get from my former employer? Do I need a company and policy number on hand?
In retrospect, I probably should have done my research a bit better at first, but being a new grad I trusted my clinic and everyone who worked there as they're way more experienced than I am. However, after working there for a few months they seem to not always know what they're talking about.
Is it a bad idea to stay under my clinic's policy if I have a similar situation in the future?