(word processor parameters LM=8, RM=78, TM=2, BM=2) Taken from KeelyNet BBS (214) 324-3501 Sponsored by Vangard Sciences PO BOX 1031 Mesquite, TX 75150 July 8, 1990 MEDICAL MALPRACTICE PREVENTION March 1990 Pages 6-7 text file courtesy of Double Helix at 212-865-7043 Medical Lessons To Be Learned The single greatest factor in the generation of medical malprac- tice cases is a breakdown in communications. Even in those cases in which the medical care given is optimal and the appropriate tests are ordered, dangers loom in the realm of communication. This unfortunate case demonstrates a situation that an error in diagnosis was made, but it might not have led to litigation had it not been compounded by additional breakdowns in the critical exchange of information. Several common pitfalls are encountered in this case that are readily avoidable by using basic risk-management techniques. 1. The first error made in this case arose in the actions taken when there was confusion regarding interpretation of the x-rays. Fractures of the femoral neck began to be seen at the age of 45 and increase in frequency with age. Osteoporosis, with it's weakening effects on the structural integrity of the bone, is largely responsible for because mild to moderate trauma, may occur in falls, may result in neck and intertrochanteric fractures in older patients. When examining x-rays of the hip, both the superior and inferior aspects of the cortex of the femoral neck should form a smooth concave form as they flair to join the head of the femur, best seen on internal rotation. Disruption of the cortex in this junctional area may be the only manifestation of an impacted fracture, the medial cortex is disrupted and the lateral aspect of the head/neck junction is sharply angulated. An incomplete fracture will reveal cortical irregularity at the head/neck junction laterally. With both types of impactions, increased density with disruption of the trabecular pattern may be evident. These signs may be subtle and overlooked unless there is a high index of suspicion. It is a common practice in community hospitals for an emergency room physician to be called upon to read x-rays on night shifts, during weekends, or on holidays when there is no radiologist or other specialist on duty. While there may reluctance by the ER doctor to consult with the appropriate specialist (in this case, the radiologist or the orthopedist) during these "off hours," communication is imperative, especially when the Page 1 potential need for hospitalization of the patient hinges upon the appropriate interpretation of the study involved. In this case the residents were misled by the absence of the typical findings of a hip fracture, that is, shortening and external rotation of the leg. With a non-displaced fracture, physical findings may be least or absent, and the only symptoms seen may be pain and difficulty in bearing weight. A high index of suspicion was in order in this case, and when coupled with a questionable interpretation of the x-ray, communication with a specialist was clearly indicated. 2. The procedures by which discrepancies in x-ray readings (or any lab tests) are handled should be very explicit and adhered to scrupulously. Explicit mechanisms to detect differences in ER diagnosis and official interpretations of test results must be carefully worked out in advance and adhered to. When the cardiologist reviews EKGs taken in the ER from the day before, for example, they should have a means of corroborating the consistency of his reading with that of the emergency physician, and when there is a significant difference, immediate action should be taken. These procedures should be monitored during the inter-departmental meetings. In this case, the radiologist's assumption that "a patient with a fractured hip would be admitted to the hospital" and that no further communication was required proved disastrous for all parties involved. 3. The review of test results should never be performed by any member of the staff other than a physician. The discrepancies involved between "wet" ER and official x-ray readings may escape detection by a non-physician, as in this case, and result in disaster. 4. It is good practice for any physician, especially an ER physician who often only gets "one-shot" at a patient, to select a small number of his more significant charts from the previous day and make "call-backs" to see how his patients are doing and to monitor compliance. In practice, this only takes a small amount of time and pays big dividends in terms of ensuring both good results and pleased patients who are invariably impressed by their doctors concern for their well being. This "communication enhancement" technique should be practiced routinely, and in this case might have ensured that the patient got to the proper specialist in a timely fashion. 5. When performing follow-up care of a patient who has been treated in an ER or other facility, it is imperative to check all test results obtained elsewhere and not to rely on the patient's understanding of his diagnosis. Obtaining all x-ray readings, EKGs, and any other tests is of vital importance. 6. Beware of the patient whose native language presents the possibility of misinterpretation of explanations and instruc- tions. Zealous efforts should be made either to make sure that communications are understood, or to find another person (friend, interpreter, family member, follow-up physician) who will ensure that the patient gets appropriate care. Page 2 In summary, one of the essentials of a successful medical interaction is good communication. Without it, when a mistake has occurred, and even when exemplary care has been rendered, a provider's best efforts may be doomed to failure. -Case submitted by: Jan K. Lipes, MD Doylestown, Pennsylvania -------------------------------------------------------------------- If you have comments or other information relating to such topics as this paper covers, please upload to KeelyNet or send to the Vangard Sciences address as listed on the first page. Thank you for your consideration, interest and support. Jerry W. Decker.........Ron Barker...........Chuck Henderson Vangard Sciences/KeelyNet -------------------------------------------------------------------- If we can be of service, you may contact Jerry at (214) 324-8741 or Ron at (214) 484-3189 -------------------------------------------------------------------- Page 3