Errors

[maybemedicine]

I am a new grad PA practicing for about 4 months. I work in occ med/urgent care. Without getting into specifics. A patient had and intraarticular finger fracture. I treated/ splinted conservatively and referred the patient stat to a hand specialist on the date of injury, who did not get seen until 2 months after her date of injury, due to WC insurance. The patient was unable to have surgery due to the timing of being seen by the surgeon. The patient will have permanent and stationary deficits and need future medical care for possible joint fusion. The patient is currently undergoing PT. Not only did I do a disservice to the patient as far as ensuring timely care, but the referral department did as well. How do I manage this going further? Obviously try to regain as close to normal function prior to the patients injury. I am learning from this experience when referring, especially with intraarticular fractures. I feel like this is my first error in patient care that has affected the patients condition and has directly impacted the patients quality of life and functionality. How should I proceed? Any recommendations? Not looking for validation nor looking for critique (no more than I am already giving myself). Need suggestions on how to proceed further in my attitude and semi guilt with this case. Thank you in advance. 

[MediMike]

??? I'm failing to see where you went wrong here. Not attempting to validate but if you provided a timely referral to an appropriate specialist with the proper documentation I'm unsure as to the issue.

[maybemedicine]

Unfortunately, not timely enough as the patient was unable to have surgery for the fracture, as 2 months have passed and the fracture healed with malunion.

[wilso2ar]

I see what you mean as far as not following up to make sure the patient had been seen soon enough.  I don't know how one would be expected to follow up on every referral that is made to make sure that it happens.  Ideas that come to mind are.  making follow ups with that patient in a week or a few days. Then you would see the patient, read your note and ask where he/she is in the referral process.  Then you could document the urgency of the referral as well as the insurance denial of the referral. That puts it back on them. 

Something I always do in a urgent referral is make sure the patient understands the urgency as well as put it in the consult ie: intraarticular fracture, concerned with permanent deformity, please see ASAP. Make sure to document this. If the patient understands the urgency that puts some ownership on them. 

[LT_Oneal_PAC]

You said you put in a stat referral? I don’t really see the problem either. Only thing I can say is I call the office directly, or sometimes the on call, and have them tell me exactly when the patient can show up and put it in the discharge paperwork. If I can’t do that, then I also tell them to follow up with the PCP this week to help coordinate referral if needed.

[maybemedicine]

I appreciate the suggestions, I will definitely use these going forward. Thank you all so much!

[briansk]

Trying to figure out why the delay happened.

Did the hand surgeon not take WC insurance?

Did insurance not authorize the referral?

Did your facility not push the referral and accept the first available appointment?

Did the patient delay care not realizing the potential complications (or ignoring advice)?

Each of these is an issue in and of itself. 

It seems that you recognized the issue and urgency and the "system" failed you. 

[Cideous]

If your referral dept dropped the ball on making the referral then I could see some liability.  I've also read of many instances where a patient was referred to a specialist, didn't go, had a bad outcome and the referring provider was sued for not following up and making sure the patient went to the specialist.  It's one of those wtf aspects of practicing medicine.  

Also, if you are seeing dozens of injuries a day, good luck following up on all of them and their referrals.

One thing I did in not just WC but Urgent Care, was make a separate patient log on my secure work computer.  I literally named it, "Patients I am worried about".  I would list them by last name, DOS, diagnoses and where I referred them along with their phone number.  Then every few days I would look at it and follow up on them.  It helped...a lot!

[maybemedicine]

100% this Briansk!! Actually a multi factorial relation: delay in specialist appt availability, insurance authorization issues, and the patient not realizing the potential complications.

Now a separate question, how often can I look forward to the system failing me and patients? This isn’t a good feeling knowing I did practice appropriately and still did not get the outcome expected due to other factors outside of my control. 

[maybemedicine]

Cideous, I’m a few months in. I’m starting to realize I need to do this. It’s unfortunate, that despite the appropriate referrals and status that such a thing may happen. Not a great way to look at each patient as a potential liability case. Thank you! I actually will start this list today. Very much appreciated! 

[Cideous]

15 minutes ago, Flcapa2020 said:

Cideous, I’m a few months in. I’m starting to realize I need to do this. It’s unfortunate, that despite the appropriate referrals and status that such a thing may happen. Not a great way to look at each patient as a potential liability case. Thank you! I actually will start this list today. Very much appreciated! 

You must look at every case this way, especially in WC.  I've done a ton of occmed and you have to really assume every note will be looked at by a lawyer. Good luck and I'm sure the list will help.  It did me.

[EMEDPA]

2 hours ago, Cideous said:

 

One thing I did in not just WC but Urgent Care, was make a separate patient log on my secure work computer.  I literally named it, "Patients I am worried about".  I would list them by last name, DOS, diagnoses and where I referred them along with their phone number.  Then every few days I would look at it and follow up on them.  It helped...a lot!

I keep pt stickers for folks I am worried about from the ER. 

[GetMeOuttaThisMess]

42 minutes ago, EMEDPA said:

I keep pt stickers for folks I am worried about from the ER. 

I did this as well, in addition to the room number and CC/significant D/C dx.  I’d keep these records for two years (SOL in Tx. typically).

Edited March 2, 2021 by GetMeOuttaThisMess

[AbeTheBabe]

Did you check and see when your benefits department sent the referral to insurance? This sounds like an acute injury and the patient probably didn't have a lawyer, meaning they can talk to the adjustor. For stat referrals you can ask the patient or your MA to call the adjustor and help move things along.

[CAAdmission]

3 hours ago, Flcapa2020 said:

how often can I look forward to the system failing me and patients? 

Shockingly often. Sometimes it will seem like more often than not. 

[rev ronin]

10 hours ago, CJAadmission said:

Shockingly often. Sometimes it will seem like more often than not. 

Moreso for worker's comp.  It seems like every effort is made to screw up actual healing based on an adversarial process that's not supposed to require lawyers, and Procrustean rules that simply don't make sense.

[ohiovolffemtp]

Again, like everyone else said: your care at the time of injury was appropriate.  Splinting and stat referral was exactly right - would have done the same out of the ED.  There's nothing more you could or should have done.  Follow-up is a shared responsibility of the patient (it is their body), your organization, and follow-up provider.  I recommend not following up personally with patients - that's a role for social work, MA's, admin, etc who have that as part of their job.

[MediMike]

Ok, all of the above replies have settled some of MY unease. I couldn't believe that you have more of a responsibility, be it legal or ethical to ENSURE follow up with a specialist outside of providing the timely referral.

Once you have done that it seems to be out of your hands? Never having worked outpatient it's a different world to me.

[Mayamom]

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Posted 16 hours ago

  20 hours ago, Flcapa2020 said:

how often can I look forward to the system failing me and patients? 

Shockingly often. Sometimes it will seem like more often than not

 

This.  Unless you work for a well run office this had always been an ongoing issue in my experience.   The other lesson learned is besure you document in your notes the importance of follow up to the patient.   Probably best to include a timeframe.  As other have said you practiced good medicine but the system can be problomatic.

[LT_Oneal_PAC]

7 hours ago, ohiovolffemtp said:

Again, like everyone else said: your care at the time of injury was appropriate.  Splinting and stat referral was exactly right - would have done the same out of the ED.  There's nothing more you could or should have done.  Follow-up is a shared responsibility of the patient (it is their body), your organization, and follow-up provider.  I recommend not following up personally with patients - that's a role for social work, MA's, admin, etc who have that as part of their job.

Agree, but the only point I will add is follow up also helps you learn a lot. I learned so much about what works and doesn’t in FM where I could follow up. EM you follow a lot of evidence, but it can feel very abstract until you talk to the patient telling you what helped and didn’t. Not saying following up with everyone, just a thought. People just love you for it too.

[ohiovolffemtp]

I agree on the value of following patient's courses of treatment.  I often follow the charts of patients I've admitted.

I've just had bad experiences following up directly with patients - they've not respected boundaries and tried to turn me into their PCP.