Hospitalist Liability

Question: A three-person hospitalist team contracts with a local hospital to provide in-house coverage for all medical admissions. Dr. A, who admitted a febrile female patient 3 days earlier, failed to check her urine culture and sensitivity. Dr. B was on duty the night the patient developed septic shock. He promptly transferred her to the ICU, drew blood cultures, and started her on a third-generation cephalosporin. He failed to check on the sensitivity results for the next 2 days, and did not prioritize this item when signing off to Dr. C, who then assumed care for the patient. The patient died shortly thereafter, and her blood cultures grew out MRSA, resistant to the cephalosporin. In a lawsuit alleging negligence, which of the following is best?

A. Dr. A is liable, as his failure to check on the urine specimen in the first place was the proximate cause of the patient’s eventual demise.

B. Dr. B is liable, as he should have checked on or alerted Dr. C to the blood cultures.

C. Dr. C has an independent duty to review the lab studies. But for this failure, the patient would not have succumbed to the infection, so Dr. C is liable.

D. All three hospitalists are jointly and severally liable.

E. If an autopsy showed death resulted from an unsuspected myocardial infarct, then there will be no liability.

Answer: D. Liability will likely attach to all three hospitalists, as the conduct of each arguably fell below the standard of care. Choice E is incorrect as there may still be liability for missing an MI, and the plaintiff will likely argue that the inadequately treated infection precipitated or aggravated the cardiac complication. This hypothetical is meant to underscore the critical need for various caregivers in a hospital setting to fully communicate.

The hospitalist movement began about 2 decades ago amidst rumblings that it would represent a "dangerous" trend, with disruption of the doctor-patient relationship when the patient needs his/her regular doctor most. Notwithstanding these early reservations, the specialty has now become widely accepted, and its membership has tripled in the last decade to reach almost 35,000. Hospitalists increase the work efficiency of primary care physicians, who can now devote all their attention to the office or clinic, free of the time-consuming interruptions of attending to an acutely ill patient in the hospital.

Hospitalists also have been shown to reduce the hospital length of stay by about half a day, although there was no significant cost savings (N. Engl. J. Med. 2007;357:2589-2600).

Large-scale studies on the quality of hospitalist care are still pending, but smaller studies demonstrate that it has improved patient outcomes.

The two most important challenges facing hospitalists are to form a meaningful doctor-patient relationship in an acute situation and to ensure good communication. The first challenge makes it easier for a patient to sue (a "stranger" doctor), and the second creates liability traps as medical errors tend to occur when communication among providers and others are suboptimal.

The scope of a hospitalist’s duty should therefore be carefully spelled out in advance, and include where each physician’s duty begins and ends. There must be no doubt from the outset as to who is responsible for what. The coordination and communication between the emergency department and the hospitalist is a key area. A hospitalist is generally responsible for directly supervising and coordinating a patient’s care, and may not be expected to function at the level of another specialist. For example, in Domby v Moritz, D050165 (Cal 2008), a hospitalist was not found liable in the death of a cardiac patient, the court holding that he had a narrower scope of duty than the standard of care expected of the cardiologist who was comanaging the case. However, depending on the facts, not all such cases will necessarily be decided in the hospitalist’s favor.

The overarching risk management strategy is clear and effective communication at all levels, especially during the handoff from one caregiver to another. A missed or delayed diagnosis remains the main malpractice allegation, but handoff communication problems are among the most common root causes of hospital errors, and can extend beyond hospital care.

In one study, more than a third of follow-up evaluations were not completed because the discharge summary was incomplete or unavailable. In another study of 696 discharged patients from two academic centers, only 25% of the discharge summaries mentioned any pending test results, and a mere 13% listed the nature of those tests (J. Gen. Intern. Med. 2009;24:1002-6).

The duty of the hospitalist does not end when a patient leaves the hospital, and all patients should be specifically advised regarding the importance of follow-up appointments with their primary care physicians. Inadequate communication with the primary care doctor regarding the patient’s hospital course and follow-up plans can create liability for the hospitalist should something go wrong post discharge.

Malpractice carriers and others have developed various mnemonics to assist the hospitalist. A handy one is the five P’s for Patient, Plan, Purpose, Problems, and Precautions. Another more elaborate mnemonic is PASS the BATON, which stands for Patient (identification), Assessment (e.g., complaints, diagnosis), Situation (e.g., response to treatment, code status), Safety (e.g., lab results, falls), Background (e.g., relevant past history), Actions (what’s done and what’s needed), Timing (urgency and priority), Ownership (who is responsible) and Next (plans to come).

This column, Law & Medicine, appears regularly in Internal Medicine News. Dr. Tan is emeritus professor at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk" (2006). For additional information, readers may contact the author at [email protected].

Question: A three-person hospitalist team contracts with a local hospital to provide in-house coverage for all medical admissions. Dr. A, who admitted a febrile female patient 3 days earlier, failed to check her urine culture and sensitivity. Dr. B was on duty the night the patient developed septic shock. He promptly transferred her to the ICU, drew blood cultures, and started her on a third-generation cephalosporin. He failed to check on the sensitivity results for the next 2 days, and did not prioritize this item when signing off to Dr. C, who then assumed care for the patient. The patient died shortly thereafter, and her blood cultures grew out MRSA, resistant to the cephalosporin. In a lawsuit alleging negligence, which of the following is best?

A. Dr. A is liable, as his failure to check on the urine specimen in the first place was the proximate cause of the patient’s eventual demise.

B. Dr. B is liable, as he should have checked on or alerted Dr. C to the blood cultures.

C. Dr. C has an independent duty to review the lab studies. But for this failure, the patient would not have succumbed to the infection, so Dr. C is liable.

D. All three hospitalists are jointly and severally liable.

E. If an autopsy showed death resulted from an unsuspected myocardial infarct, then there will be no liability.

Answer: D. Liability will likely attach to all three hospitalists, as the conduct of each arguably fell below the standard of care. Choice E is incorrect as there may still be liability for missing an MI, and the plaintiff will likely argue that the inadequately treated infection precipitated or aggravated the cardiac complication. This hypothetical is meant to underscore the critical need for various caregivers in a hospital setting to fully communicate.

The hospitalist movement began about 2 decades ago amidst rumblings that it would represent a "dangerous" trend, with disruption of the doctor-patient relationship when the patient needs his/her regular doctor most. Notwithstanding these early reservations, the specialty has now become widely accepted, and its membership has tripled in the last decade to reach almost 35,000. Hospitalists increase the work efficiency of primary care physicians, who can now devote all their attention to the office or clinic, free of the time-consuming interruptions of attending to an acutely ill patient in the hospital.

Hospitalists also have been shown to reduce the hospital length of stay by about half a day, although there was no significant cost savings (N. Engl. J. Med. 2007;357:2589-2600).

Large-scale studies on the quality of hospitalist care are still pending, but smaller studies demonstrate that it has improved patient outcomes.

The two most important challenges facing hospitalists are to form a meaningful doctor-patient relationship in an acute situation and to ensure good communication. The first challenge makes it easier for a patient to sue (a "stranger" doctor), and the second creates liability traps as medical errors tend to occur when communication among providers and others are suboptimal.

The scope of a hospitalist’s duty should therefore be carefully spelled out in advance, and include where each physician’s duty begins and ends. There must be no doubt from the outset as to who is responsible for what. The coordination and communication between the emergency department and the hospitalist is a key area. A hospitalist is generally responsible for directly supervising and coordinating a patient’s care, and may not be expected to function at the level of another specialist. For example, in Domby v Moritz, D050165 (Cal 2008), a hospitalist was not found liable in the death of a cardiac patient, the court holding that he had a narrower scope of duty than the standard of care expected of the cardiologist who was comanaging the case. However, depending on the facts, not all such cases will necessarily be decided in the hospitalist’s favor.

The overarching risk management strategy is clear and effective communication at all levels, especially during the handoff from one caregiver to another. A missed or delayed diagnosis remains the main malpractice allegation, but handoff communication problems are among the most common root causes of hospital errors, and can extend beyond hospital care.

In one study, more than a third of follow-up evaluations were not completed because the discharge summary was incomplete or unavailable. In another study of 696 discharged patients from two academic centers, only 25% of the discharge summaries mentioned any pending test results, and a mere 13% listed the nature of those tests (J. Gen. Intern. Med. 2009;24:1002-6).

The duty of the hospitalist does not end when a patient leaves the hospital, and all patients should be specifically advised regarding the importance of follow-up appointments with their primary care physicians. Inadequate communication with the primary care doctor regarding the patient’s hospital course and follow-up plans can create liability for the hospitalist should something go wrong post discharge.

Malpractice carriers and others have developed various mnemonics to assist the hospitalist. A handy one is the five P’s for Patient, Plan, Purpose, Problems, and Precautions. Another more elaborate mnemonic is PASS the BATON, which stands for Patient (identification), Assessment (e.g., complaints, diagnosis), Situation (e.g., response to treatment, code status), Safety (e.g., lab results, falls), Background (e.g., relevant past history), Actions (what’s done and what’s needed), Timing (urgency and priority), Ownership (who is responsible) and Next (plans to come).

This column, Law & Medicine, appears regularly in Internal Medicine News. Dr. Tan is emeritus professor at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk" (2006). For additional information, readers may contact the author at [email protected].

Question: A three-person hospitalist team contracts with a local hospital to provide in-house coverage for all medical admissions. Dr. A, who admitted a febrile female patient 3 days earlier, failed to check her urine culture and sensitivity. Dr. B was on duty the night the patient developed septic shock. He promptly transferred her to the ICU, drew blood cultures, and started her on a third-generation cephalosporin. He failed to check on the sensitivity results for the next 2 days, and did not prioritize this item when signing off to Dr. C, who then assumed care for the patient. The patient died shortly thereafter, and her blood cultures grew out MRSA, resistant to the cephalosporin. In a lawsuit alleging negligence, which of the following is best?

A. Dr. A is liable, as his failure to check on the urine specimen in the first place was the proximate cause of the patient’s eventual demise.

B. Dr. B is liable, as he should have checked on or alerted Dr. C to the blood cultures.

C. Dr. C has an independent duty to review the lab studies. But for this failure, the patient would not have succumbed to the infection, so Dr. C is liable.

D. All three hospitalists are jointly and severally liable.

E. If an autopsy showed death resulted from an unsuspected myocardial infarct, then there will be no liability.

Answer: D. Liability will likely attach to all three hospitalists, as the conduct of each arguably fell below the standard of care. Choice E is incorrect as there may still be liability for missing an MI, and the plaintiff will likely argue that the inadequately treated infection precipitated or aggravated the cardiac complication. This hypothetical is meant to underscore the critical need for various caregivers in a hospital setting to fully communicate.

The hospitalist movement began about 2 decades ago amidst rumblings that it would represent a "dangerous" trend, with disruption of the doctor-patient relationship when the patient needs his/her regular doctor most. Notwithstanding these early reservations, the specialty has now become widely accepted, and its membership has tripled in the last decade to reach almost 35,000. Hospitalists increase the work efficiency of primary care physicians, who can now devote all their attention to the office or clinic, free of the time-consuming interruptions of attending to an acutely ill patient in the hospital.

Hospitalists also have been shown to reduce the hospital length of stay by about half a day, although there was no significant cost savings (N. Engl. J. Med. 2007;357:2589-2600).

Large-scale studies on the quality of hospitalist care are still pending, but smaller studies demonstrate that it has improved patient outcomes.

The two most important challenges facing hospitalists are to form a meaningful doctor-patient relationship in an acute situation and to ensure good communication. The first challenge makes it easier for a patient to sue (a "stranger" doctor), and the second creates liability traps as medical errors tend to occur when communication among providers and others are suboptimal.

The scope of a hospitalist’s duty should therefore be carefully spelled out in advance, and include where each physician’s duty begins and ends. There must be no doubt from the outset as to who is responsible for what. The coordination and communication between the emergency department and the hospitalist is a key area. A hospitalist is generally responsible for directly supervising and coordinating a patient’s care, and may not be expected to function at the level of another specialist. For example, in Domby v Moritz, D050165 (Cal 2008), a hospitalist was not found liable in the death of a cardiac patient, the court holding that he had a narrower scope of duty than the standard of care expected of the cardiologist who was comanaging the case. However, depending on the facts, not all such cases will necessarily be decided in the hospitalist’s favor.

The overarching risk management strategy is clear and effective communication at all levels, especially during the handoff from one caregiver to another. A missed or delayed diagnosis remains the main malpractice allegation, but handoff communication problems are among the most common root causes of hospital errors, and can extend beyond hospital care.

In one study, more than a third of follow-up evaluations were not completed because the discharge summary was incomplete or unavailable. In another study of 696 discharged patients from two academic centers, only 25% of the discharge summaries mentioned any pending test results, and a mere 13% listed the nature of those tests (J. Gen. Intern. Med. 2009;24:1002-6).

The duty of the hospitalist does not end when a patient leaves the hospital, and all patients should be specifically advised regarding the importance of follow-up appointments with their primary care physicians. Inadequate communication with the primary care doctor regarding the patient’s hospital course and follow-up plans can create liability for the hospitalist should something go wrong post discharge.

Malpractice carriers and others have developed various mnemonics to assist the hospitalist. A handy one is the five P’s for Patient, Plan, Purpose, Problems, and Precautions. Another more elaborate mnemonic is PASS the BATON, which stands for Patient (identification), Assessment (e.g., complaints, diagnosis), Situation (e.g., response to treatment, code status), Safety (e.g., lab results, falls), Background (e.g., relevant past history), Actions (what’s done and what’s needed), Timing (urgency and priority), Ownership (who is responsible) and Next (plans to come).

This column, Law & Medicine, appears regularly in Internal Medicine News. Dr. Tan is emeritus professor at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk" (2006). For additional information, readers may contact the author at [email protected].