Summary
Objectives
The telephone can facilitate medical care but also result in adverse outcomes leading to telephone-related malpractice suits. Analyzing claims might identify errors amenable to prevention. The objective of the study was to describe medical errors involving the telephone in patient–clinician encounters that significantly impacted medical care and medico-legal outcomes.
Design
The design of the study was a descriptive, retrospective case review of telephone-related closed malpractice claims that included depositions, expert witness testimony, medical records, allegations, injuries, and outcomes.
Patients/Participants
Forty defendants from 32 cases coded specifically as telephone related by a major provider of malpractice insurance. Leading specialists sued: Internists, pediatricians, and obstetricians.
Measurements and Main Results
Cases were reviewed by a physician experienced in telephone medicine and independently checked by a risk management nurse specialist and discussed by 2 additional risk management analysts before arriving at full agreement. Twenty-four (60%) cases were settled or awarded to the plaintiff. The most common allegation was failed diagnosis (68%), most common injury was death (44%), and most common setting was general medicine ambulatory practice. Leading errors were documentation (88%) and faulty triage (84%). The average indemnity was $518,932, with a total indemnity of $12,454,375.
Conclusions
Telephone-related claims were costly; injuries were catastrophic. Poor documentation and faulty triage were major factors influencing care and legal outcome. Telephone errors may represent the tip of the iceberg in patient safety in ambulatory practice; however, these preliminary results need to be confirmed in a larger sample of cases.
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Acknowledgment
Dr. Katz received financial support as a consultant to ProMutual Group for this study.
Financial Disclosure
The only documentation in the medical record was a sketchy note prefaced with a question mark—“? did tell pt. to come to office. failed to follow up,” which did not appear to be written in real time. The lack of clear documentation and the suspicious note strongly supported the plaintiff’s allegation that the physician made the recommendation that no visit was needed for an examination based on the reported normal mammogram.
Conflict of Interest
Conflict of interest disclosure is indicated in the following:
Dr. Harvey Katz was a consultant to the ProMutual Group, and Dawn Kaltsounis, Liz Halloran, RN, and Maureen Mondor are employees of the ProMutual Group.
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APPENDIX: THREE CASE STUDIES
APPENDIX: THREE CASE STUDIES
Case 1: Specialty, Internal Medicine
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Allegation: Failure to diagnose breast cancer resulting in reduced chance of survival
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Issue(s): Poor, possibly “touched up” documentation; faulty triage decision, patient never seen; call back problem
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Outcome: Settled, closed with payment because of high degree of liability and weak case: $1,045,000 indemnity
This 41-year-old woman discovered a lump during her self breast examination. Family history was positive for breast cancer. She telephoned her primary care physician to request a mammogram, which he ordered. The patient alleged she requested an appointment but was told an examination was not necessary because the mammogram was normal, an allegation that was denied by the physician. Six months later, the patient noted that the mass was larger and called her physician again, but the call was allegedly never returned. She consulted and was examined by another physician followed by an excisional biopsy. The diagnosis was extensive intraductal carcinoma. She underwent a radical mastectomy and currently remains cancer-free.
Comment
The only documentation in the medical record was a sketchy note prefaced with a question mark—“? did tell pt. to come to office. failed to follow up,” which did not appear to be written in real time. The lack of clear documentation and the suspicious note strongly supported the plaintiff’s allegation that the physician made the recommendation that no visit was needed for an examination based on the reported normal mammogram.
Recommendation
Never change or touch up a medical record entry. All parties agreed that a patient with this problem should have been examined, and the examination clearly documented in the medical record. A universal guideline is that if a patient asks to be seen, they should be seen. Further, an in-person examination should be required for any new, potentially high-risk problem. If a patient declines, this should be well documented in the medical record.
Case 2: Specialty, Obstetrics and Gynecology
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Allegation: Delay in diagnosis of preterm labor because of failure to respond to complaint of decreased fetal movement reported by telephone
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Injury: Neurologic damage to newborn infant born prematurely (29 weeks) with subsequent cerebral palsy and spastic diplegia
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Issue(s): Failure to respond to multiple calls
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Outcome: Closed with payment, Corporation of Physicians settled for $575,000 indemnity
A 22-year-old woman was treated successfully for infertility by her obstetrician. In her 5th month of pregnancy, she noticed decreased fetal movement and reported this to the physician’s receptionist whose note documented the patient’s call. The message was referred to the nurse midwife in the practice. She attempted to return the call, but no one was home. The patient alleged that she had called several other times but her calls were not returned. She phoned the following day to report spots of blood and mucous after urinating and was scheduled for an immediate appointment. Examination revealed that her cervix was dilated 4 cm, and she was admitted to the hospital for tocolytic treatment. Contractions continued. A low transverse c-section was performed because of a double flootling breach presentation. The infant was delivered at 29 weeks and subsequently diagnosed with cerebral palsy and spastic diplegia.
Comment
Multiple calls for the same problem are often not recognized as an alert to the urgency of a problem. Often, multiple staffs are receiving calls unaware of prior calls because they are not documented or communicated within the office. In this instance, the message was dropped.
Recommendation
Recognize multiple calls for the same problem as a risk factor and need for an office visit. When no one is home and the message may indicate a serious problem, close the loop by repeat calls and documenting the attempts.
Case 3: Specialty, Pediatrics
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Allegation: Failure to diagnose meningitis resulting in death
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Issue(s): Inadequate history taking; no documentation, unresponsive to multiple calls
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Outcome: Closed with payment, $225,000 indemnity
A mother phoned the pediatrician at 5:23 pm having tried several times unsuccessfully during the day. Dr. G. acknowledged problems with the answering service and testified that the mother told him that her son, a 6-year-old boy with Downs syndrome, had fever, chills, vomiting, and a rash that looked to her like chickenpox. Dr. G. did not ask any questions about the rash or illness. Dr. G. prescribed symptomatic treatment and advised to bring her son to the emergency department if he became worse. His condition deteriorated. An ambulance was called when his mother found him “stone cold and rigid” at 2:30 am. The child was noted to have an extensive petechial rash. He was pronounced dead upon arrival of fulminant meningococcemia.
Comment
This tragic case begs the question, who is doing the triage? An experienced pediatrician was alleged to be negligent in taking a complete history and making the triage decision to treat over the phone rather than see the patient based on the mother’s diagnosis. The pediatrician acknowledged that he should have asked more questions. Because there was no documentation of the phone call, there was no way to verify the physician’s testimony or objectively contradict the patient’s version of events. As in most undocumented calls, it comes down as a “he says, she says” situation for the jury to decide. This was compounded by an answering service problem.
Recommendation
An evaluation of telephone-reported symptoms requires the same focused and relevant history taking as in an office visit. Documentation, complete history taking, and monitoring the answering service closely are all needed for quality improvement. Patients should not be doing their own triage.
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Katz, H.P., Kaltsounis, D., Halloran, L. et al. Patient Safety and Telephone Medicine. J GEN INTERN MED 23, 517–522 (2008). https://doi.org/10.1007/s11606-007-0491-y
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DOI: https://doi.org/10.1007/s11606-007-0491-y