Medicolegal Issues

In July 2009, a 59-year-old California woman was diagnosed with atrial fibrillation and congestive heart failure. She was seen by the on-call cardiologist, who prescribed warfarin but discontinued it after a few days.

The patient then underwent heart surgery and was placed on warfarin again to prevent potential clotting associated with a mechanical heart valve. While in the hospital, the patient underwent daily international normalized ratio (INR) testing, resulting in several discontinuations of warfarin therapy. At the time of discharge, the patient's INR was measured at 2.2—below the patient's therapeutic range. As a result, she was given a new prescription for warfarin (2 mg/d).

At the patient's follow-up office appointment, the cardiologist checked her INR level, which was 3.1. Eight days later, the patient was seen in the office again, and a call was made to the cardiologist six days after that visit, but no further blood tests were performed.

Eight days after the call, the woman was found unresponsive, with evidence of gastrointestinal bleeding. She was taken to an emergency department, where her INR level was at least 24.4—the highest level it was possible for the equipment to measure. The patient also had evidence of bleeding in the lungs and other areas. She died early the following morning.

The plaintiff claimed that the defendants (ie, the defendant cardiologist and his practice group) failed to monitor the decedent's INR properly, although the defendant cardiologist knew the importance of monitoring the INR in a patient using warfarin.

The defendant claimed that the INR level taken after the decedent's hospital stay was within normal range and that monitoring performed at the hospital and at his office was appropriate in frequency. The defendant also claimed that the decedent's death was the result of sepsis, not exsanguination.

Outcome
According to a published account, a verdict of $1,136,648 was returned. After adjustment according to California's Medical Injury Compensation Reform Act, the total recovery was $386,648.

Comment
From the facts given, we know that the patient had unstable warfarin levels postoperatively, requiring that the dose be withheld "several times" during her hospitalization.

Eight days after discharge, the cardiologist saw the patient. Fourteen days later, the patient bled fatally with an INR of 24.4. Thus, it is apparent that the INR was not checked for 22 days following the patient's discharge.

Given the fact that warfarin had to be stopped several times during the patient's hospitalization—and the probability that she had a new target INR, following valve replacement with a mechanical valve—most jurors would have little difficulty concluding that the standard of care was breached.

It is unclear whether the cardiologist or perhaps the patient's primary care provider was to follow her INR postdischarge. That was the causative problem: uncertainty over whose responsibility it was to perform this important monitoring.

While drawing analogies between sports and medicine is often unsuitable, a baseball analogy serves well. A pop fly is hit to deep outfield between two outfielders. Each could easily catch the ball, yet each thinks the other will act. Neither one acts, so the ball drops between the two players, and the team, charged with an error, faces possible loss of the game.

Many malpractice cases involve such a "pop fly" misjudgment: Clinicians fail to act on the mistaken belief that another will. The consequence of an easily handled matter is error and perhaps death.

This problem can be prevented. Within your referral network, establish clear guidelines to determine which clinician is responsible for surveillance, monitoring, and maintenance for any given condition. In the absence of a clear, mutually understood plan, each clinician should take the initiative to manage the patient or conclusively establish who will. This understanding should be shared with the patient and communicated in the record. Many lives may be saved if the responsibilities among clinicians are clear. —DML

In July 2009, a 59-year-old California woman was diagnosed with atrial fibrillation and congestive heart failure. She was seen by the on-call cardiologist, who prescribed warfarin but discontinued it after a few days.

The patient then underwent heart surgery and was placed on warfarin again to prevent potential clotting associated with a mechanical heart valve. While in the hospital, the patient underwent daily international normalized ratio (INR) testing, resulting in several discontinuations of warfarin therapy. At the time of discharge, the patient's INR was measured at 2.2—below the patient's therapeutic range. As a result, she was given a new prescription for warfarin (2 mg/d).

At the patient's follow-up office appointment, the cardiologist checked her INR level, which was 3.1. Eight days later, the patient was seen in the office again, and a call was made to the cardiologist six days after that visit, but no further blood tests were performed.

Eight days after the call, the woman was found unresponsive, with evidence of gastrointestinal bleeding. She was taken to an emergency department, where her INR level was at least 24.4—the highest level it was possible for the equipment to measure. The patient also had evidence of bleeding in the lungs and other areas. She died early the following morning.

The plaintiff claimed that the defendants (ie, the defendant cardiologist and his practice group) failed to monitor the decedent's INR properly, although the defendant cardiologist knew the importance of monitoring the INR in a patient using warfarin.

The defendant claimed that the INR level taken after the decedent's hospital stay was within normal range and that monitoring performed at the hospital and at his office was appropriate in frequency. The defendant also claimed that the decedent's death was the result of sepsis, not exsanguination.

Outcome
According to a published account, a verdict of $1,136,648 was returned. After adjustment according to California's Medical Injury Compensation Reform Act, the total recovery was $386,648.

Comment
From the facts given, we know that the patient had unstable warfarin levels postoperatively, requiring that the dose be withheld "several times" during her hospitalization.

Eight days after discharge, the cardiologist saw the patient. Fourteen days later, the patient bled fatally with an INR of 24.4. Thus, it is apparent that the INR was not checked for 22 days following the patient's discharge.

Given the fact that warfarin had to be stopped several times during the patient's hospitalization—and the probability that she had a new target INR, following valve replacement with a mechanical valve—most jurors would have little difficulty concluding that the standard of care was breached.

It is unclear whether the cardiologist or perhaps the patient's primary care provider was to follow her INR postdischarge. That was the causative problem: uncertainty over whose responsibility it was to perform this important monitoring.

While drawing analogies between sports and medicine is often unsuitable, a baseball analogy serves well. A pop fly is hit to deep outfield between two outfielders. Each could easily catch the ball, yet each thinks the other will act. Neither one acts, so the ball drops between the two players, and the team, charged with an error, faces possible loss of the game.

Many malpractice cases involve such a "pop fly" misjudgment: Clinicians fail to act on the mistaken belief that another will. The consequence of an easily handled matter is error and perhaps death.

This problem can be prevented. Within your referral network, establish clear guidelines to determine which clinician is responsible for surveillance, monitoring, and maintenance for any given condition. In the absence of a clear, mutually understood plan, each clinician should take the initiative to manage the patient or conclusively establish who will. This understanding should be shared with the patient and communicated in the record. Many lives may be saved if the responsibilities among clinicians are clear. —DML

In July 2009, a 59-year-old California woman was diagnosed with atrial fibrillation and congestive heart failure. She was seen by the on-call cardiologist, who prescribed warfarin but discontinued it after a few days.

The patient then underwent heart surgery and was placed on warfarin again to prevent potential clotting associated with a mechanical heart valve. While in the hospital, the patient underwent daily international normalized ratio (INR) testing, resulting in several discontinuations of warfarin therapy. At the time of discharge, the patient's INR was measured at 2.2—below the patient's therapeutic range. As a result, she was given a new prescription for warfarin (2 mg/d).

At the patient's follow-up office appointment, the cardiologist checked her INR level, which was 3.1. Eight days later, the patient was seen in the office again, and a call was made to the cardiologist six days after that visit, but no further blood tests were performed.

Eight days after the call, the woman was found unresponsive, with evidence of gastrointestinal bleeding. She was taken to an emergency department, where her INR level was at least 24.4—the highest level it was possible for the equipment to measure. The patient also had evidence of bleeding in the lungs and other areas. She died early the following morning.

The plaintiff claimed that the defendants (ie, the defendant cardiologist and his practice group) failed to monitor the decedent's INR properly, although the defendant cardiologist knew the importance of monitoring the INR in a patient using warfarin.

The defendant claimed that the INR level taken after the decedent's hospital stay was within normal range and that monitoring performed at the hospital and at his office was appropriate in frequency. The defendant also claimed that the decedent's death was the result of sepsis, not exsanguination.

Outcome
According to a published account, a verdict of $1,136,648 was returned. After adjustment according to California's Medical Injury Compensation Reform Act, the total recovery was $386,648.

Comment
From the facts given, we know that the patient had unstable warfarin levels postoperatively, requiring that the dose be withheld "several times" during her hospitalization.

Eight days after discharge, the cardiologist saw the patient. Fourteen days later, the patient bled fatally with an INR of 24.4. Thus, it is apparent that the INR was not checked for 22 days following the patient's discharge.

Given the fact that warfarin had to be stopped several times during the patient's hospitalization—and the probability that she had a new target INR, following valve replacement with a mechanical valve—most jurors would have little difficulty concluding that the standard of care was breached.

It is unclear whether the cardiologist or perhaps the patient's primary care provider was to follow her INR postdischarge. That was the causative problem: uncertainty over whose responsibility it was to perform this important monitoring.

While drawing analogies between sports and medicine is often unsuitable, a baseball analogy serves well. A pop fly is hit to deep outfield between two outfielders. Each could easily catch the ball, yet each thinks the other will act. Neither one acts, so the ball drops between the two players, and the team, charged with an error, faces possible loss of the game.

Many malpractice cases involve such a "pop fly" misjudgment: Clinicians fail to act on the mistaken belief that another will. The consequence of an easily handled matter is error and perhaps death.

This problem can be prevented. Within your referral network, establish clear guidelines to determine which clinician is responsible for surveillance, monitoring, and maintenance for any given condition. In the absence of a clear, mutually understood plan, each clinician should take the initiative to manage the patient or conclusively establish who will. This understanding should be shared with the patient and communicated in the record. Many lives may be saved if the responsibilities among clinicians are clear. —DML

The medical record has evolved considerably since it originated in ancient Greece as a narrative of cure.¹ For one thing, it’s now electronic. For another, it’s no longer a medical record but a health record. According to the US Department of Health and Human Services, the distinction is not a trivial one. A medical record is used by clinicians mostly for diagnosis and treatment, whereas the health record focuses on the total wellbeing of the patient.² The medical record is used primarily within a practice. The electronic health record (EHR) reaches across borders to other offices, institutions, and clinicians.

Use of the EHR has been stimulated by the Health Information Technology for Economic and Clinical Health Act,³ which offers grants and incentives for “meaningful use” of electronic records.⁴ After 2014, medical practices that do not use EHRs will face a financial penalty that amounts to 2% of 2013 clinical revenue.

EHRs have been hailed as a panacea and derided as anathema. Whatever your perspective, there is no denying that they dramatically increase the immediate and easy availability of information and, therefore, influence decision-making in regard to medical care, cost-effectiveness, and patient safety. EHRs have the potential to improve communication, broaden access to information, and help guide clinical decision-making through the use of best-practice algorithms. When used properly—which means taking advantage of the EHR’s full potential and adapting to the way information is organized and analyzed—the EHR can reduce adverse events and help defend the appropriateness of the care provided. This lowers your medicolegal risk. When used improperly or haphazardly, they may increase that risk. In this article, we elaborate on both.

EHRs have many benefits

Improved communication. EHRs facilitate communication between healthcare providers. A primary care physician can access a consultant’s report practically as it is written. Providers also can carry on a dialogue electronically, planning together for care that will best serve the patient, with less redundancy and time.

The EHR also facilitates communication between physician and patient, allowing the physician to see the patient’s recent history and plan her management while speaking to her on the phone. Issues can be addressed with greater accuracy and expediency, leading to reduced anxiety for the patient and increased compliance.

Seamless integration. Information can be entered into the EHR and integrated into the full record more seamlessly than it is with written records. And data can be entered once and used many times.

Enhanced decision-making. Decision-making depends on careful analysis of a clinical scenario. Protocols, templates, and order sets embedded in the EHR can reduce medical errors by identifying scenarios for the physician to review.^5,6

The EHR can also highlight adverse drug-drug interactions and help avoid potential allergic reactions. Murphy and colleagues reported a reduction of medical errors by utilizing a pharmacy-driven EHR component—a reduction from 90% to 47% on the surgical unit and from 57% to 33% on the medicine unit.⁷

Improved documentation. The EHR can enhance documentation by offering specific and detailed templates for informed consent, making it more comprehensive than a handwritten notation of the risks and benefits.

Decipherability is another strength of the EHR. Because physicians are notorious for poor handwriting skills, some hospitals now require a writing sample as part of their privileging process. The EHR avoids this issue entirely.⁸ Typos and grammatical errors are minimized by spellchecking and grammar-correcting programs written into the EHR.

Quality assurance. Timely evaluation of approaches to clinical care is available to physicians as well as hospitals that use EHRs.⁹ An individual physician can perform personal quality-assurance audits. And hospital management can gather cumulative statistics more quickly and easily.^5,6,10,11

Patient data can be accessed independent of medical department, with lab tests, imaging studies, and pathology reports readily available for review. And accessibility is available regardless of geographic location.

Risks are bountiful, too

EHRs are not perfect, and neither are their users. EHRs present the potential for problems related to absent or erroneous data entry, patient privacy issues, misunderstanding and misuse of software, and development of metadata.

With initial use, EHRs can create documentation gaps with the transition from paper to electronic records. In addition, inadequate provider training can create new error pathways, and a failure to use EHRs consistently can lead to loss of data and communication errors. These gaps and errors can increase medicolegal risk, as can the more extensive documentation often seen with early use, which creates more discoverable data. The temptation to cut and paste risks repeating earlier errors and omitting new information.

Another area of risk involves communication with the patient via email. A failure to reply could result in claims of negligence, and information overload could obscure pertinent pieces of information. And a departure from clinical decision support could be used by the patient to defend allegations of negligence.

With widespread use of EHRs, improved access to data could change the “duty” owed to the patient. In addition, clinical decision support embedded within the software could become the de facto “standard of care.”

The learning curve can be steep

The learning curve for EHRs may be steep and, at times, discouraging. One reason is that data are organized differently than in the conventional paper record, where information is read and analyzed in a progressive and stepwise manner, as in an analog or vertical system. The EHR is a digital format, so finding information requires digital (horizontal) inquiry. Information is, therefore, utilized in both horizontal and vertical formats in everyday situations. If data are entered incorrectly, all subsequent decisions could be flawed. And if the EHR suggests a plan, and that plan is not performed by the provider, the risk of liability could increase.

Privacy could be jeopardized

Inadvertent violation of the Health Insurance Portability and Accountability Act (HIPAA) with an EHR could increase medicolegal risk. For example, HIPAA allows for patients to make corrections to inaccurate information in their personal documents, but access by the patient could require the physician to review all records viewed by the patient after visit notes have been entered. This could drive up the cost of practice and reduce face-to-face time between physician and patient. Patients are not necessarily the best judges of which information is most important in their medical records.

Internet access raises concerns about the privacy of sensitive issues and misuse of information. Making a patient’s protected health information accessible electronically leaves physicians and hospitals at risk for a government fine or lawsuit. In several instances, the US Department of Health and Human Services (HHS) has levied fines against small practices and government agencies.

In one case, HHS fined Phoenix Cardiac Surgery in Phoenix, Arizona, $100,000 for posting surgery and appointment schedules on an Internet-based calendar that was accessible to the public.¹² In another, HHS fined the Massachusetts Eye and Ear Infirmary in Boston $1.5 million after it reported the loss of an encrypted personal laptop containing the protected health information of patients and research subjects.¹³ The Alaska Department of Health and Social Services (DHSS) agreed to pay HHS $1.7 million after it reported the loss of a USB drive—possibly containing protected health information—from the vehicle of a DHSS employee.¹⁴

In traditional physician practices that employ handwritten records, the potential for compromise of patient information is limited. An organization may lose a few patient charts in the office and recover from the loss without incident. With the EHR, the loss poses a significant threat. The cases mentioned above were attributed to negligence or ignorance. The consequences could be worse if the compromise of EHR data is determined to be intentional. On September 4, 2010, hackers may have exposed the personal information of approximately 9,493 patients at Southwest Seattle Orthopaedics and Sports Medicine in Burien, Washington. Even with the best encryption technology, any electronic system remains vulnerable to external attack.

Metadata reveal how original data are used

Another concern regarding EHRs involves metadata—”data about data content.”¹⁵ Metadata is structured information that describes, locates, explains, or manages information. Metadata relevant to the EHR includes the data and time it was reviewed by the provider and whether it was manipulated in any way. Clearly, there is a potential for use and misuse by third-party reviewers.

Specialty-specific EHRs are recommended

Many ObGyns have found that most EHR systems are inadequate to the task of recording and analyzing information relevant to their specialty. Obstetric care is episodic and frequent. Data are added into the flow that must be considered at each visit, such as gestational age, fetal growth, labs (and normative values), prenatal diagnostic studies, and so on, representing both vertical and horizontal processing.¹⁶

The legal discovery process poses challenges that have not yet been resolved

The legal discovery process grants all parties to a lawsuit equal access to information. Under ideal circumstances, the EHR can provide comprehensive data more quickly than traditional records can. The problem is determining what constitutes relevant data and which party has the burden or benefit of making that decision. Uncontrolled access has the potential to violate privacy and privilege requirements.

Rules regarding discovery are still being debated in regard to their applicability to digital discovery.¹⁷ Even before a lawsuit is filed, the potential for “data mining” by third parties could lead to allegations of malpractice.

How to use EHRs responsibly without increasing risk

Good communication between patient and provider is paramount in the provision of quality medical care. Adherence to evidence-based standards with thorough documentation always serves the best interests of both patients and providers. The EHR can facilitate this process.

Our recommendations for appropriate use of your EHR include:

• Spend time learning the ins and outs of your particular EHR, and make sure your staff does the same. This will help reduce the likelihood that errors will be introduced into the record and ensure consistent use.
• Use individual sign-ons for anyone involved in data entry. This step facilitates the identification of users responsible for inaccurate use or errors, so that the situation can be addressed efficiently.
• Do not let third parties enter or manipulate data. This could jeopardize patient privacy, as well as the integrity of the record itself.
• Track all data entry on a regular basis. The frequency of tracking should be a function of routine as well as clinical circumstance. All new data from the previous interval should be reviewed at the time of the subsequent visit in order to direct care and ensure proper data entry.

Because of the considerable risk of liability claims in ObGyn practice, it is critical that the medical record accurately and precisely reflects the circumstances of each case. The EHR can be an effective and useful tool to document what occurred (and when) in a clinical scenario.¹⁸ As with all medical records, completeness and accuracy are the first and best defense against allegations of medical malpractice.

The medical record has evolved considerably since it originated in ancient Greece as a narrative of cure.¹ For one thing, it’s now electronic. For another, it’s no longer a medical record but a health record. According to the US Department of Health and Human Services, the distinction is not a trivial one. A medical record is used by clinicians mostly for diagnosis and treatment, whereas the health record focuses on the total wellbeing of the patient.² The medical record is used primarily within a practice. The electronic health record (EHR) reaches across borders to other offices, institutions, and clinicians.

Use of the EHR has been stimulated by the Health Information Technology for Economic and Clinical Health Act,³ which offers grants and incentives for “meaningful use” of electronic records.⁴ After 2014, medical practices that do not use EHRs will face a financial penalty that amounts to 2% of 2013 clinical revenue.

EHRs have been hailed as a panacea and derided as anathema. Whatever your perspective, there is no denying that they dramatically increase the immediate and easy availability of information and, therefore, influence decision-making in regard to medical care, cost-effectiveness, and patient safety. EHRs have the potential to improve communication, broaden access to information, and help guide clinical decision-making through the use of best-practice algorithms. When used properly—which means taking advantage of the EHR’s full potential and adapting to the way information is organized and analyzed—the EHR can reduce adverse events and help defend the appropriateness of the care provided. This lowers your medicolegal risk. When used improperly or haphazardly, they may increase that risk. In this article, we elaborate on both.

EHRs have many benefits

Improved communication. EHRs facilitate communication between healthcare providers. A primary care physician can access a consultant’s report practically as it is written. Providers also can carry on a dialogue electronically, planning together for care that will best serve the patient, with less redundancy and time.

The EHR also facilitates communication between physician and patient, allowing the physician to see the patient’s recent history and plan her management while speaking to her on the phone. Issues can be addressed with greater accuracy and expediency, leading to reduced anxiety for the patient and increased compliance.

Seamless integration. Information can be entered into the EHR and integrated into the full record more seamlessly than it is with written records. And data can be entered once and used many times.

Enhanced decision-making. Decision-making depends on careful analysis of a clinical scenario. Protocols, templates, and order sets embedded in the EHR can reduce medical errors by identifying scenarios for the physician to review.^5,6

The EHR can also highlight adverse drug-drug interactions and help avoid potential allergic reactions. Murphy and colleagues reported a reduction of medical errors by utilizing a pharmacy-driven EHR component—a reduction from 90% to 47% on the surgical unit and from 57% to 33% on the medicine unit.⁷

Improved documentation. The EHR can enhance documentation by offering specific and detailed templates for informed consent, making it more comprehensive than a handwritten notation of the risks and benefits.

Decipherability is another strength of the EHR. Because physicians are notorious for poor handwriting skills, some hospitals now require a writing sample as part of their privileging process. The EHR avoids this issue entirely.⁸ Typos and grammatical errors are minimized by spellchecking and grammar-correcting programs written into the EHR.

Quality assurance. Timely evaluation of approaches to clinical care is available to physicians as well as hospitals that use EHRs.⁹ An individual physician can perform personal quality-assurance audits. And hospital management can gather cumulative statistics more quickly and easily.^5,6,10,11

Patient data can be accessed independent of medical department, with lab tests, imaging studies, and pathology reports readily available for review. And accessibility is available regardless of geographic location.

Risks are bountiful, too

EHRs are not perfect, and neither are their users. EHRs present the potential for problems related to absent or erroneous data entry, patient privacy issues, misunderstanding and misuse of software, and development of metadata.

With initial use, EHRs can create documentation gaps with the transition from paper to electronic records. In addition, inadequate provider training can create new error pathways, and a failure to use EHRs consistently can lead to loss of data and communication errors. These gaps and errors can increase medicolegal risk, as can the more extensive documentation often seen with early use, which creates more discoverable data. The temptation to cut and paste risks repeating earlier errors and omitting new information.

Another area of risk involves communication with the patient via email. A failure to reply could result in claims of negligence, and information overload could obscure pertinent pieces of information. And a departure from clinical decision support could be used by the patient to defend allegations of negligence.

With widespread use of EHRs, improved access to data could change the “duty” owed to the patient. In addition, clinical decision support embedded within the software could become the de facto “standard of care.”

The learning curve can be steep

The learning curve for EHRs may be steep and, at times, discouraging. One reason is that data are organized differently than in the conventional paper record, where information is read and analyzed in a progressive and stepwise manner, as in an analog or vertical system. The EHR is a digital format, so finding information requires digital (horizontal) inquiry. Information is, therefore, utilized in both horizontal and vertical formats in everyday situations. If data are entered incorrectly, all subsequent decisions could be flawed. And if the EHR suggests a plan, and that plan is not performed by the provider, the risk of liability could increase.

Privacy could be jeopardized

Inadvertent violation of the Health Insurance Portability and Accountability Act (HIPAA) with an EHR could increase medicolegal risk. For example, HIPAA allows for patients to make corrections to inaccurate information in their personal documents, but access by the patient could require the physician to review all records viewed by the patient after visit notes have been entered. This could drive up the cost of practice and reduce face-to-face time between physician and patient. Patients are not necessarily the best judges of which information is most important in their medical records.

Internet access raises concerns about the privacy of sensitive issues and misuse of information. Making a patient’s protected health information accessible electronically leaves physicians and hospitals at risk for a government fine or lawsuit. In several instances, the US Department of Health and Human Services (HHS) has levied fines against small practices and government agencies.

In one case, HHS fined Phoenix Cardiac Surgery in Phoenix, Arizona, $100,000 for posting surgery and appointment schedules on an Internet-based calendar that was accessible to the public.¹² In another, HHS fined the Massachusetts Eye and Ear Infirmary in Boston $1.5 million after it reported the loss of an encrypted personal laptop containing the protected health information of patients and research subjects.¹³ The Alaska Department of Health and Social Services (DHSS) agreed to pay HHS $1.7 million after it reported the loss of a USB drive—possibly containing protected health information—from the vehicle of a DHSS employee.¹⁴

In traditional physician practices that employ handwritten records, the potential for compromise of patient information is limited. An organization may lose a few patient charts in the office and recover from the loss without incident. With the EHR, the loss poses a significant threat. The cases mentioned above were attributed to negligence or ignorance. The consequences could be worse if the compromise of EHR data is determined to be intentional. On September 4, 2010, hackers may have exposed the personal information of approximately 9,493 patients at Southwest Seattle Orthopaedics and Sports Medicine in Burien, Washington. Even with the best encryption technology, any electronic system remains vulnerable to external attack.

Metadata reveal how original data are used

Another concern regarding EHRs involves metadata—”data about data content.”¹⁵ Metadata is structured information that describes, locates, explains, or manages information. Metadata relevant to the EHR includes the data and time it was reviewed by the provider and whether it was manipulated in any way. Clearly, there is a potential for use and misuse by third-party reviewers.

Specialty-specific EHRs are recommended

Many ObGyns have found that most EHR systems are inadequate to the task of recording and analyzing information relevant to their specialty. Obstetric care is episodic and frequent. Data are added into the flow that must be considered at each visit, such as gestational age, fetal growth, labs (and normative values), prenatal diagnostic studies, and so on, representing both vertical and horizontal processing.¹⁶

The legal discovery process poses challenges that have not yet been resolved

The legal discovery process grants all parties to a lawsuit equal access to information. Under ideal circumstances, the EHR can provide comprehensive data more quickly than traditional records can. The problem is determining what constitutes relevant data and which party has the burden or benefit of making that decision. Uncontrolled access has the potential to violate privacy and privilege requirements.

Rules regarding discovery are still being debated in regard to their applicability to digital discovery.¹⁷ Even before a lawsuit is filed, the potential for “data mining” by third parties could lead to allegations of malpractice.

How to use EHRs responsibly without increasing risk

Good communication between patient and provider is paramount in the provision of quality medical care. Adherence to evidence-based standards with thorough documentation always serves the best interests of both patients and providers. The EHR can facilitate this process.

Our recommendations for appropriate use of your EHR include:

• Spend time learning the ins and outs of your particular EHR, and make sure your staff does the same. This will help reduce the likelihood that errors will be introduced into the record and ensure consistent use.
• Use individual sign-ons for anyone involved in data entry. This step facilitates the identification of users responsible for inaccurate use or errors, so that the situation can be addressed efficiently.
• Do not let third parties enter or manipulate data. This could jeopardize patient privacy, as well as the integrity of the record itself.
• Track all data entry on a regular basis. The frequency of tracking should be a function of routine as well as clinical circumstance. All new data from the previous interval should be reviewed at the time of the subsequent visit in order to direct care and ensure proper data entry.

Because of the considerable risk of liability claims in ObGyn practice, it is critical that the medical record accurately and precisely reflects the circumstances of each case. The EHR can be an effective and useful tool to document what occurred (and when) in a clinical scenario.¹⁸ As with all medical records, completeness and accuracy are the first and best defense against allegations of medical malpractice.

The medical record has evolved considerably since it originated in ancient Greece as a narrative of cure.¹ For one thing, it’s now electronic. For another, it’s no longer a medical record but a health record. According to the US Department of Health and Human Services, the distinction is not a trivial one. A medical record is used by clinicians mostly for diagnosis and treatment, whereas the health record focuses on the total wellbeing of the patient.² The medical record is used primarily within a practice. The electronic health record (EHR) reaches across borders to other offices, institutions, and clinicians.

Use of the EHR has been stimulated by the Health Information Technology for Economic and Clinical Health Act,³ which offers grants and incentives for “meaningful use” of electronic records.⁴ After 2014, medical practices that do not use EHRs will face a financial penalty that amounts to 2% of 2013 clinical revenue.

EHRs have been hailed as a panacea and derided as anathema. Whatever your perspective, there is no denying that they dramatically increase the immediate and easy availability of information and, therefore, influence decision-making in regard to medical care, cost-effectiveness, and patient safety. EHRs have the potential to improve communication, broaden access to information, and help guide clinical decision-making through the use of best-practice algorithms. When used properly—which means taking advantage of the EHR’s full potential and adapting to the way information is organized and analyzed—the EHR can reduce adverse events and help defend the appropriateness of the care provided. This lowers your medicolegal risk. When used improperly or haphazardly, they may increase that risk. In this article, we elaborate on both.

EHRs have many benefits

Improved communication. EHRs facilitate communication between healthcare providers. A primary care physician can access a consultant’s report practically as it is written. Providers also can carry on a dialogue electronically, planning together for care that will best serve the patient, with less redundancy and time.

The EHR also facilitates communication between physician and patient, allowing the physician to see the patient’s recent history and plan her management while speaking to her on the phone. Issues can be addressed with greater accuracy and expediency, leading to reduced anxiety for the patient and increased compliance.

Seamless integration. Information can be entered into the EHR and integrated into the full record more seamlessly than it is with written records. And data can be entered once and used many times.

Enhanced decision-making. Decision-making depends on careful analysis of a clinical scenario. Protocols, templates, and order sets embedded in the EHR can reduce medical errors by identifying scenarios for the physician to review.^5,6

The EHR can also highlight adverse drug-drug interactions and help avoid potential allergic reactions. Murphy and colleagues reported a reduction of medical errors by utilizing a pharmacy-driven EHR component—a reduction from 90% to 47% on the surgical unit and from 57% to 33% on the medicine unit.⁷

Improved documentation. The EHR can enhance documentation by offering specific and detailed templates for informed consent, making it more comprehensive than a handwritten notation of the risks and benefits.

Decipherability is another strength of the EHR. Because physicians are notorious for poor handwriting skills, some hospitals now require a writing sample as part of their privileging process. The EHR avoids this issue entirely.⁸ Typos and grammatical errors are minimized by spellchecking and grammar-correcting programs written into the EHR.

Quality assurance. Timely evaluation of approaches to clinical care is available to physicians as well as hospitals that use EHRs.⁹ An individual physician can perform personal quality-assurance audits. And hospital management can gather cumulative statistics more quickly and easily.^5,6,10,11

Patient data can be accessed independent of medical department, with lab tests, imaging studies, and pathology reports readily available for review. And accessibility is available regardless of geographic location.

Risks are bountiful, too

EHRs are not perfect, and neither are their users. EHRs present the potential for problems related to absent or erroneous data entry, patient privacy issues, misunderstanding and misuse of software, and development of metadata.

With initial use, EHRs can create documentation gaps with the transition from paper to electronic records. In addition, inadequate provider training can create new error pathways, and a failure to use EHRs consistently can lead to loss of data and communication errors. These gaps and errors can increase medicolegal risk, as can the more extensive documentation often seen with early use, which creates more discoverable data. The temptation to cut and paste risks repeating earlier errors and omitting new information.

Another area of risk involves communication with the patient via email. A failure to reply could result in claims of negligence, and information overload could obscure pertinent pieces of information. And a departure from clinical decision support could be used by the patient to defend allegations of negligence.

With widespread use of EHRs, improved access to data could change the “duty” owed to the patient. In addition, clinical decision support embedded within the software could become the de facto “standard of care.”

The learning curve can be steep

The learning curve for EHRs may be steep and, at times, discouraging. One reason is that data are organized differently than in the conventional paper record, where information is read and analyzed in a progressive and stepwise manner, as in an analog or vertical system. The EHR is a digital format, so finding information requires digital (horizontal) inquiry. Information is, therefore, utilized in both horizontal and vertical formats in everyday situations. If data are entered incorrectly, all subsequent decisions could be flawed. And if the EHR suggests a plan, and that plan is not performed by the provider, the risk of liability could increase.

Privacy could be jeopardized

Inadvertent violation of the Health Insurance Portability and Accountability Act (HIPAA) with an EHR could increase medicolegal risk. For example, HIPAA allows for patients to make corrections to inaccurate information in their personal documents, but access by the patient could require the physician to review all records viewed by the patient after visit notes have been entered. This could drive up the cost of practice and reduce face-to-face time between physician and patient. Patients are not necessarily the best judges of which information is most important in their medical records.

Internet access raises concerns about the privacy of sensitive issues and misuse of information. Making a patient’s protected health information accessible electronically leaves physicians and hospitals at risk for a government fine or lawsuit. In several instances, the US Department of Health and Human Services (HHS) has levied fines against small practices and government agencies.

In one case, HHS fined Phoenix Cardiac Surgery in Phoenix, Arizona, $100,000 for posting surgery and appointment schedules on an Internet-based calendar that was accessible to the public.¹² In another, HHS fined the Massachusetts Eye and Ear Infirmary in Boston $1.5 million after it reported the loss of an encrypted personal laptop containing the protected health information of patients and research subjects.¹³ The Alaska Department of Health and Social Services (DHSS) agreed to pay HHS $1.7 million after it reported the loss of a USB drive—possibly containing protected health information—from the vehicle of a DHSS employee.¹⁴

In traditional physician practices that employ handwritten records, the potential for compromise of patient information is limited. An organization may lose a few patient charts in the office and recover from the loss without incident. With the EHR, the loss poses a significant threat. The cases mentioned above were attributed to negligence or ignorance. The consequences could be worse if the compromise of EHR data is determined to be intentional. On September 4, 2010, hackers may have exposed the personal information of approximately 9,493 patients at Southwest Seattle Orthopaedics and Sports Medicine in Burien, Washington. Even with the best encryption technology, any electronic system remains vulnerable to external attack.

Metadata reveal how original data are used

Another concern regarding EHRs involves metadata—”data about data content.”¹⁵ Metadata is structured information that describes, locates, explains, or manages information. Metadata relevant to the EHR includes the data and time it was reviewed by the provider and whether it was manipulated in any way. Clearly, there is a potential for use and misuse by third-party reviewers.

Specialty-specific EHRs are recommended

Many ObGyns have found that most EHR systems are inadequate to the task of recording and analyzing information relevant to their specialty. Obstetric care is episodic and frequent. Data are added into the flow that must be considered at each visit, such as gestational age, fetal growth, labs (and normative values), prenatal diagnostic studies, and so on, representing both vertical and horizontal processing.¹⁶

The legal discovery process poses challenges that have not yet been resolved

The legal discovery process grants all parties to a lawsuit equal access to information. Under ideal circumstances, the EHR can provide comprehensive data more quickly than traditional records can. The problem is determining what constitutes relevant data and which party has the burden or benefit of making that decision. Uncontrolled access has the potential to violate privacy and privilege requirements.

Rules regarding discovery are still being debated in regard to their applicability to digital discovery.¹⁷ Even before a lawsuit is filed, the potential for “data mining” by third parties could lead to allegations of malpractice.

How to use EHRs responsibly without increasing risk

Good communication between patient and provider is paramount in the provision of quality medical care. Adherence to evidence-based standards with thorough documentation always serves the best interests of both patients and providers. The EHR can facilitate this process.

Our recommendations for appropriate use of your EHR include:

• Spend time learning the ins and outs of your particular EHR, and make sure your staff does the same. This will help reduce the likelihood that errors will be introduced into the record and ensure consistent use.
• Use individual sign-ons for anyone involved in data entry. This step facilitates the identification of users responsible for inaccurate use or errors, so that the situation can be addressed efficiently.
• Do not let third parties enter or manipulate data. This could jeopardize patient privacy, as well as the integrity of the record itself.
• Track all data entry on a regular basis. The frequency of tracking should be a function of routine as well as clinical circumstance. All new data from the previous interval should be reviewed at the time of the subsequent visit in order to direct care and ensure proper data entry.

Because of the considerable risk of liability claims in ObGyn practice, it is critical that the medical record accurately and precisely reflects the circumstances of each case. The EHR can be an effective and useful tool to document what occurred (and when) in a clinical scenario.¹⁸ As with all medical records, completeness and accuracy are the first and best defense against allegations of medical malpractice.

Shoulder dystocia is an obstetric complication that occurs in up to 1.4% of deliveries.¹ Although the vast majority can be managed successfully, the complication is associated with risk of fetal injury. The most serious injury is brachial plexus palsy, which occurs in 4% to 40% of shoulder dystocia cases, although less than 10% of these injuries are permanent. Other injuries include fractures of the clavicle and humerus; in rare instances the complication may be associated with fetal asphyxia and death. Early recognition of the complication followed by an orderly approach to management will reduce the risk of fetal injury.

First, recognize shoulder dystocia and take control

Recognition of shoulder dystocia immediately followed by avoidance of further impaction, particularly of the anterior shoulder against the symphysis pubis, will likely increase the chances of successful resolution.

These factors should lead you to anticipate shoulder dystocia during delivery:

• suspected macrosomia
• diabetic parturient
• prolonged second stage.

However, a high percentage of cases occur in women without risk factors. Because persistent or forceful traction, used in an attempt to deliver the anterior shoulder, may be one of the causes of brachial plexus injury, early recognition of shoulder dystocia, followed by a halt of further traction, reduces the risk of that injury.

In my experience, if some movement of the anterior shoulder does not occur after 2 to 3 seconds of gentle downward guidance, you need to consider the possibility of shoulder dystocia. It is also important to take control of the situation: Instruct the patient to stop pushing and family members to stop urging the patient to push.

Avoid panic. Initiate a care-team management algorithm.

Having a management algorithm that can be quickly recalled and initiated allows the care team to proceed in an orderly fashion and remain calm and avoid panic, particularly if the dystocia is severe. In obstetric emergencies, panic is your enemy, leading to inefficient activity, team confusion, and an increased likelihood that an error in judgment (too much traction, fundal pressure) may occur. I advise my residents that whenever there are risk factors for shoulder dystocia, or it is suspected for any reason, to do a mental run-through of the management steps.

Rehearse the algorithm. It will make a difference in the delivery room.

To most effectively use a management algorithm, rehearsal using team training drills or simulation is necessary. Studies support simulation and team training even for individuals who have completed training in obstetrics or midwifery. Crofts and colleagues videotaped 450 simulations of shoulder dystocia involving 95 certified nurse midwives and 45 physicians.² The authors noted that 1) shoulder dystocia could not be resolved in 57% of cases, and 2) there was frequent confusion regarding how to perform the internal maneuvers, with poor communication among team members. This same group of researchers later demonstrated that skills in managing shoulder dystocia improved significantly after simulation training. In fact, a high proportion of “trainees” maintained their skill level when tested a year later.³

Finally, when evaluating the impact of training on actual clinical outcomes in their hospital, Crofts and colleagues noted that the rate of obstetric brachial plexus injury fell from 7.4% in a 4-year period prior to training, to 2.3% in a 4-year period after training.⁴

Practice within your own L&D unit

The use of in situ simulation (ie, simulation within the labor and delivery unit) has two major advantages:

• It is more realistic than practicing within a lab. Systems issues, such as lack of a uniform procedure for getting help or a lack of chairs in the labor room to assist with performance of suprapubic pressure, can be identified.
• The full team, including ward clerks and other support personnel, can be part of the simulation more readily.

The box on this page provides a possible process to use in managing shoulder dystocia. If there has not been an opportunity for this training, practitioners, at the very least, should be cognizant of the steps they are going to take in managing such cases.

What should you do after primary maneuvers fail?

Try to deliver the posterior arm. Although the order of maneuvers in the proposed algorithm may vary, a recent study using a database of more than 130,000 deliveries suggests that use of posterior arm delivery after failure of primary maneuvers, such as McRoberts or suprapubic pressure, may more likely result in resolution.⁵

Start from the beginning, and try again. If the first set of maneuvers does not resolve the problem, running through them again usually leads to success. Although the risk of fetal hypoxia increases the longer it takes to resolve the dystocia, it may actually facilitate delivery because fetal tone may also decrease.

Zavanelli maneuver. In general, use of the Zavanelli maneuver with replacement of the fetal head accompanied by cesarean section is a last resort; there is a lack of data to support its use earlier in the process or more frequently. This maneuver requires reversing the cardinal movements related to head descent in order to successfully complete replacement.

Shoulder dystocia in obese patients proves more difficult

In my own experience with obese patients, suprapubic pressure is often ineffective due to the presence of a large fat pad or pannus. Use of an anterior Rubin’s maneuver to rotate the shoulders about 30° to the oblique often facilitates delivery.

Liberal use of episiotomy to facilitate posterior arm delivery or rotational maneuvers is often necessary with obese patients.

Documentation is key

Documentation of the dystocia event in the patient’s permanent record should not occur until after the care team has discussed the case. This will ensure that the maneuvers utilized and the related timing of events are recorded accurately. This is critically important should a lawsuit occur, since discrepancies or errors in charting will hamper defense of the case. A checklist, such as the one provided by the American College of Obstetricians and Gynecologists, lists key points that should be recorded and outlines important steps related to the event.⁶

We want to hear from you! Tell us what you think.

Shoulder dystocia is an obstetric complication that occurs in up to 1.4% of deliveries.¹ Although the vast majority can be managed successfully, the complication is associated with risk of fetal injury. The most serious injury is brachial plexus palsy, which occurs in 4% to 40% of shoulder dystocia cases, although less than 10% of these injuries are permanent. Other injuries include fractures of the clavicle and humerus; in rare instances the complication may be associated with fetal asphyxia and death. Early recognition of the complication followed by an orderly approach to management will reduce the risk of fetal injury.

First, recognize shoulder dystocia and take control

Recognition of shoulder dystocia immediately followed by avoidance of further impaction, particularly of the anterior shoulder against the symphysis pubis, will likely increase the chances of successful resolution.

These factors should lead you to anticipate shoulder dystocia during delivery:

• suspected macrosomia
• diabetic parturient
• prolonged second stage.

However, a high percentage of cases occur in women without risk factors. Because persistent or forceful traction, used in an attempt to deliver the anterior shoulder, may be one of the causes of brachial plexus injury, early recognition of shoulder dystocia, followed by a halt of further traction, reduces the risk of that injury.

In my experience, if some movement of the anterior shoulder does not occur after 2 to 3 seconds of gentle downward guidance, you need to consider the possibility of shoulder dystocia. It is also important to take control of the situation: Instruct the patient to stop pushing and family members to stop urging the patient to push.

Avoid panic. Initiate a care-team management algorithm.

Having a management algorithm that can be quickly recalled and initiated allows the care team to proceed in an orderly fashion and remain calm and avoid panic, particularly if the dystocia is severe. In obstetric emergencies, panic is your enemy, leading to inefficient activity, team confusion, and an increased likelihood that an error in judgment (too much traction, fundal pressure) may occur. I advise my residents that whenever there are risk factors for shoulder dystocia, or it is suspected for any reason, to do a mental run-through of the management steps.

Rehearse the algorithm. It will make a difference in the delivery room.

To most effectively use a management algorithm, rehearsal using team training drills or simulation is necessary. Studies support simulation and team training even for individuals who have completed training in obstetrics or midwifery. Crofts and colleagues videotaped 450 simulations of shoulder dystocia involving 95 certified nurse midwives and 45 physicians.² The authors noted that 1) shoulder dystocia could not be resolved in 57% of cases, and 2) there was frequent confusion regarding how to perform the internal maneuvers, with poor communication among team members. This same group of researchers later demonstrated that skills in managing shoulder dystocia improved significantly after simulation training. In fact, a high proportion of “trainees” maintained their skill level when tested a year later.³

Finally, when evaluating the impact of training on actual clinical outcomes in their hospital, Crofts and colleagues noted that the rate of obstetric brachial plexus injury fell from 7.4% in a 4-year period prior to training, to 2.3% in a 4-year period after training.⁴

Practice within your own L&D unit

The use of in situ simulation (ie, simulation within the labor and delivery unit) has two major advantages:

• It is more realistic than practicing within a lab. Systems issues, such as lack of a uniform procedure for getting help or a lack of chairs in the labor room to assist with performance of suprapubic pressure, can be identified.
• The full team, including ward clerks and other support personnel, can be part of the simulation more readily.

The box on this page provides a possible process to use in managing shoulder dystocia. If there has not been an opportunity for this training, practitioners, at the very least, should be cognizant of the steps they are going to take in managing such cases.

What should you do after primary maneuvers fail?

Try to deliver the posterior arm. Although the order of maneuvers in the proposed algorithm may vary, a recent study using a database of more than 130,000 deliveries suggests that use of posterior arm delivery after failure of primary maneuvers, such as McRoberts or suprapubic pressure, may more likely result in resolution.⁵

Start from the beginning, and try again. If the first set of maneuvers does not resolve the problem, running through them again usually leads to success. Although the risk of fetal hypoxia increases the longer it takes to resolve the dystocia, it may actually facilitate delivery because fetal tone may also decrease.

Zavanelli maneuver. In general, use of the Zavanelli maneuver with replacement of the fetal head accompanied by cesarean section is a last resort; there is a lack of data to support its use earlier in the process or more frequently. This maneuver requires reversing the cardinal movements related to head descent in order to successfully complete replacement.

Shoulder dystocia in obese patients proves more difficult

In my own experience with obese patients, suprapubic pressure is often ineffective due to the presence of a large fat pad or pannus. Use of an anterior Rubin’s maneuver to rotate the shoulders about 30° to the oblique often facilitates delivery.

Liberal use of episiotomy to facilitate posterior arm delivery or rotational maneuvers is often necessary with obese patients.

Documentation is key

Documentation of the dystocia event in the patient’s permanent record should not occur until after the care team has discussed the case. This will ensure that the maneuvers utilized and the related timing of events are recorded accurately. This is critically important should a lawsuit occur, since discrepancies or errors in charting will hamper defense of the case. A checklist, such as the one provided by the American College of Obstetricians and Gynecologists, lists key points that should be recorded and outlines important steps related to the event.⁶

We want to hear from you! Tell us what you think.

Shoulder dystocia is an obstetric complication that occurs in up to 1.4% of deliveries.¹ Although the vast majority can be managed successfully, the complication is associated with risk of fetal injury. The most serious injury is brachial plexus palsy, which occurs in 4% to 40% of shoulder dystocia cases, although less than 10% of these injuries are permanent. Other injuries include fractures of the clavicle and humerus; in rare instances the complication may be associated with fetal asphyxia and death. Early recognition of the complication followed by an orderly approach to management will reduce the risk of fetal injury.

First, recognize shoulder dystocia and take control

Recognition of shoulder dystocia immediately followed by avoidance of further impaction, particularly of the anterior shoulder against the symphysis pubis, will likely increase the chances of successful resolution.

These factors should lead you to anticipate shoulder dystocia during delivery:

• suspected macrosomia
• diabetic parturient
• prolonged second stage.

However, a high percentage of cases occur in women without risk factors. Because persistent or forceful traction, used in an attempt to deliver the anterior shoulder, may be one of the causes of brachial plexus injury, early recognition of shoulder dystocia, followed by a halt of further traction, reduces the risk of that injury.

In my experience, if some movement of the anterior shoulder does not occur after 2 to 3 seconds of gentle downward guidance, you need to consider the possibility of shoulder dystocia. It is also important to take control of the situation: Instruct the patient to stop pushing and family members to stop urging the patient to push.

Avoid panic. Initiate a care-team management algorithm.

Having a management algorithm that can be quickly recalled and initiated allows the care team to proceed in an orderly fashion and remain calm and avoid panic, particularly if the dystocia is severe. In obstetric emergencies, panic is your enemy, leading to inefficient activity, team confusion, and an increased likelihood that an error in judgment (too much traction, fundal pressure) may occur. I advise my residents that whenever there are risk factors for shoulder dystocia, or it is suspected for any reason, to do a mental run-through of the management steps.

Rehearse the algorithm. It will make a difference in the delivery room.

To most effectively use a management algorithm, rehearsal using team training drills or simulation is necessary. Studies support simulation and team training even for individuals who have completed training in obstetrics or midwifery. Crofts and colleagues videotaped 450 simulations of shoulder dystocia involving 95 certified nurse midwives and 45 physicians.² The authors noted that 1) shoulder dystocia could not be resolved in 57% of cases, and 2) there was frequent confusion regarding how to perform the internal maneuvers, with poor communication among team members. This same group of researchers later demonstrated that skills in managing shoulder dystocia improved significantly after simulation training. In fact, a high proportion of “trainees” maintained their skill level when tested a year later.³

Finally, when evaluating the impact of training on actual clinical outcomes in their hospital, Crofts and colleagues noted that the rate of obstetric brachial plexus injury fell from 7.4% in a 4-year period prior to training, to 2.3% in a 4-year period after training.⁴

Practice within your own L&D unit

The use of in situ simulation (ie, simulation within the labor and delivery unit) has two major advantages:

• It is more realistic than practicing within a lab. Systems issues, such as lack of a uniform procedure for getting help or a lack of chairs in the labor room to assist with performance of suprapubic pressure, can be identified.
• The full team, including ward clerks and other support personnel, can be part of the simulation more readily.

The box on this page provides a possible process to use in managing shoulder dystocia. If there has not been an opportunity for this training, practitioners, at the very least, should be cognizant of the steps they are going to take in managing such cases.

What should you do after primary maneuvers fail?

Try to deliver the posterior arm. Although the order of maneuvers in the proposed algorithm may vary, a recent study using a database of more than 130,000 deliveries suggests that use of posterior arm delivery after failure of primary maneuvers, such as McRoberts or suprapubic pressure, may more likely result in resolution.⁵

Start from the beginning, and try again. If the first set of maneuvers does not resolve the problem, running through them again usually leads to success. Although the risk of fetal hypoxia increases the longer it takes to resolve the dystocia, it may actually facilitate delivery because fetal tone may also decrease.

Zavanelli maneuver. In general, use of the Zavanelli maneuver with replacement of the fetal head accompanied by cesarean section is a last resort; there is a lack of data to support its use earlier in the process or more frequently. This maneuver requires reversing the cardinal movements related to head descent in order to successfully complete replacement.

Shoulder dystocia in obese patients proves more difficult

In my own experience with obese patients, suprapubic pressure is often ineffective due to the presence of a large fat pad or pannus. Use of an anterior Rubin’s maneuver to rotate the shoulders about 30° to the oblique often facilitates delivery.

Liberal use of episiotomy to facilitate posterior arm delivery or rotational maneuvers is often necessary with obese patients.

Documentation is key

Documentation of the dystocia event in the patient’s permanent record should not occur until after the care team has discussed the case. This will ensure that the maneuvers utilized and the related timing of events are recorded accurately. This is critically important should a lawsuit occur, since discrepancies or errors in charting will hamper defense of the case. A checklist, such as the one provided by the American College of Obstetricians and Gynecologists, lists key points that should be recorded and outlines important steps related to the event.⁶

We want to hear from you! Tell us what you think.

Inadequate Management of Wheezing, Coughing Infant
A six-week-old infant was brought to a Mississippi hospital emergency department (ED) at about 10:30 PM with signs of wheezing, coughing, and decreased playfulness. Thirty minutes later, he was evaluated by the emergency physician. Initial test results included an oxygen saturation (SaO2) level of 100%, but she suspected pneumonia and ordered further tests.

The child underwent a breathing treatment, and his condition appeared to be improving. About 45 minutes after his initial evaluation, while being transported for a chest x-ray, he experienced cardiorespiratory arrest. Resuscitation was unsuccessful.

The plaintiff claimed that the emergency physician should have consulted a pediatrician, conducted continuous electronic monitoring of the infant, and administered oxygen.

The defendant claimed that the infant was properly monitored and that oxygen was not required, since his oxygen saturation level was 100%. Additionally, the defendant claimed she was cross-trained as a pediatrician and that the outcome would have been the same, regardless of treatment, because the child had advanced, severe pneumonia.

Outcome
According to a published account, a defense verdict was returned for the defendant emergency physician. Claims involving the defendant hospital were subject to decision by the court, which was also a defense verdict.

Comment
This case illustrates the potential pitfalls of relying too heavily on any one diagnostic element. In this case, there was an arguable overreliance on pulse oximetry values to exclude a clinically significant respiratory condition.

Diagnosing pneumonia can be difficult, and the clinical gestalt must be considered. A low pulse oximetry reading itself should be concerning, whereas normal pulse oximetry itself should not be reassuring when the patient exhibits tachypnea or other signs of distress. In one study, pulse oximetry was studied to determine whether it could be used to exclude pneumonia in children younger than 2 years presenting with respiratory complaints. It could not.¹ In sum, SaO2 levels may be normal in patients with pathology, and while initially reassuring, may plummet after the patient tires.

In this case, the defendants prevailed. The case report does not provide the patient’s vital signs, but the use of bronchodilators and the x-ray order suggest that there was some degree of respiratory distress. Because the child experienced cardiorespiratory arrest after one hour and 15 minutes in the ED, the defense was likely able to convince the jury that this unfortunate infant faced a high mortality risk even with more aggressive treatment.

Some have called pulse oximetry the “fifth vital sign.” Don’t let it become the only one. The SaO2 must be interpreted in the context of the patient’s overall presentation and in view of the other vitals (especially respiratory rate). —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

References
1. Tanen DA, Trocinski DR. The use of pulse oximetry to exclude pneumonia in children. Am J Emerg Med. 2002;20(6):521-523.

Inadequate Management of Wheezing, Coughing Infant
A six-week-old infant was brought to a Mississippi hospital emergency department (ED) at about 10:30 PM with signs of wheezing, coughing, and decreased playfulness. Thirty minutes later, he was evaluated by the emergency physician. Initial test results included an oxygen saturation (SaO2) level of 100%, but she suspected pneumonia and ordered further tests.

The child underwent a breathing treatment, and his condition appeared to be improving. About 45 minutes after his initial evaluation, while being transported for a chest x-ray, he experienced cardiorespiratory arrest. Resuscitation was unsuccessful.

The plaintiff claimed that the emergency physician should have consulted a pediatrician, conducted continuous electronic monitoring of the infant, and administered oxygen.

The defendant claimed that the infant was properly monitored and that oxygen was not required, since his oxygen saturation level was 100%. Additionally, the defendant claimed she was cross-trained as a pediatrician and that the outcome would have been the same, regardless of treatment, because the child had advanced, severe pneumonia.

Outcome
According to a published account, a defense verdict was returned for the defendant emergency physician. Claims involving the defendant hospital were subject to decision by the court, which was also a defense verdict.

Comment
This case illustrates the potential pitfalls of relying too heavily on any one diagnostic element. In this case, there was an arguable overreliance on pulse oximetry values to exclude a clinically significant respiratory condition.

Diagnosing pneumonia can be difficult, and the clinical gestalt must be considered. A low pulse oximetry reading itself should be concerning, whereas normal pulse oximetry itself should not be reassuring when the patient exhibits tachypnea or other signs of distress. In one study, pulse oximetry was studied to determine whether it could be used to exclude pneumonia in children younger than 2 years presenting with respiratory complaints. It could not.¹ In sum, SaO2 levels may be normal in patients with pathology, and while initially reassuring, may plummet after the patient tires.

In this case, the defendants prevailed. The case report does not provide the patient’s vital signs, but the use of bronchodilators and the x-ray order suggest that there was some degree of respiratory distress. Because the child experienced cardiorespiratory arrest after one hour and 15 minutes in the ED, the defense was likely able to convince the jury that this unfortunate infant faced a high mortality risk even with more aggressive treatment.

Some have called pulse oximetry the “fifth vital sign.” Don’t let it become the only one. The SaO2 must be interpreted in the context of the patient’s overall presentation and in view of the other vitals (especially respiratory rate). —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

References
1. Tanen DA, Trocinski DR. The use of pulse oximetry to exclude pneumonia in children. Am J Emerg Med. 2002;20(6):521-523.

Inadequate Management of Wheezing, Coughing Infant
A six-week-old infant was brought to a Mississippi hospital emergency department (ED) at about 10:30 PM with signs of wheezing, coughing, and decreased playfulness. Thirty minutes later, he was evaluated by the emergency physician. Initial test results included an oxygen saturation (SaO2) level of 100%, but she suspected pneumonia and ordered further tests.

The child underwent a breathing treatment, and his condition appeared to be improving. About 45 minutes after his initial evaluation, while being transported for a chest x-ray, he experienced cardiorespiratory arrest. Resuscitation was unsuccessful.

The plaintiff claimed that the emergency physician should have consulted a pediatrician, conducted continuous electronic monitoring of the infant, and administered oxygen.

The defendant claimed that the infant was properly monitored and that oxygen was not required, since his oxygen saturation level was 100%. Additionally, the defendant claimed she was cross-trained as a pediatrician and that the outcome would have been the same, regardless of treatment, because the child had advanced, severe pneumonia.

Outcome
According to a published account, a defense verdict was returned for the defendant emergency physician. Claims involving the defendant hospital were subject to decision by the court, which was also a defense verdict.

Comment
This case illustrates the potential pitfalls of relying too heavily on any one diagnostic element. In this case, there was an arguable overreliance on pulse oximetry values to exclude a clinically significant respiratory condition.

Diagnosing pneumonia can be difficult, and the clinical gestalt must be considered. A low pulse oximetry reading itself should be concerning, whereas normal pulse oximetry itself should not be reassuring when the patient exhibits tachypnea or other signs of distress. In one study, pulse oximetry was studied to determine whether it could be used to exclude pneumonia in children younger than 2 years presenting with respiratory complaints. It could not.¹ In sum, SaO2 levels may be normal in patients with pathology, and while initially reassuring, may plummet after the patient tires.

In this case, the defendants prevailed. The case report does not provide the patient’s vital signs, but the use of bronchodilators and the x-ray order suggest that there was some degree of respiratory distress. Because the child experienced cardiorespiratory arrest after one hour and 15 minutes in the ED, the defense was likely able to convince the jury that this unfortunate infant faced a high mortality risk even with more aggressive treatment.

Some have called pulse oximetry the “fifth vital sign.” Don’t let it become the only one. The SaO2 must be interpreted in the context of the patient’s overall presentation and in view of the other vitals (especially respiratory rate). —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

References
1. Tanen DA, Trocinski DR. The use of pulse oximetry to exclude pneumonia in children. Am J Emerg Med. 2002;20(6):521-523.

Failure to Order Colonoscopy Despite Patient’s Family History
After receiving care from the defendant primary care physician since 1997, a Massachusetts woman presented in the fall of 2003 complaining of fatigue; she was diagnosed with iron deficiency anemia in January 2004. Two months later, she underwent a diagnostic colonoscopy, which revealed a mass in the transverse colon. Following surgery to remove the obstructing cancer, the patient received palliative care and died at age 52.

Plaintiff claimed that a colonoscopy should have been ordered for the decedent at an age 10 years earlier than the age at which her youngest family member had been diagnosed with colon cancer (ie, a maternal cousin diagnosed in her early 40s, in addition to her mother, diagnosed in her early 50s, and her maternal grandmother, diagnosed at age 75).

The defendant physician claimed that the decedent’s fatigue was due to depression and that she had declined further lab tests. A handwritten entry in the medical record from 1998 indicated that a colonoscopy had been ordered and performed with negative results. However, no report from the gastroenterologist nor any billing information from that procedure was ever found in the record.

The defendant claimed that it was the responsibility of the gastroenterologist, not the named defendant, to make follow-up appointments at appropriate intervals for colonoscopy, given the patient’s family history. The defendant also claimed that the criteria for performing colonoscopies between 1997 and 2004 were still evolving and that no standards had yet been set.

Outcome
According to a published account, a $950,000 settlement was reached.

Comment
The message here is clear: Primary care providers have a responsibility to track screening requirements—even when other specialists are involved and should also have responsibility. In this case, the issue is colonoscopy screening in an individual with a strong family history for colon cancer. The plaintiff correctly argued that a colonoscopy is appropriate at an age 10 years earlier than the affected relative’s age at diagnosis, or at age 40—whichever is younger. Also, the procedure should be repeated at five-year intervals in those at increased risk. These standards were published in 1997, contrary to the defendant’s allegations, and further supported in the literature in 1999.^1,2

The plaintiff began treatment with the primary care provider in 1997, with a report of colonoscopy having been done some time in 1998, yielding normal results. Certainly a primary care provider would want documented evidence of the procedure, not just a note that one had been done. Even if a colonoscopy had been performed and the note is correct that findings were normal, the time for a repeat procedure should have been some time in 2003—the same time as the patient’s report of fatigue. This is the latest that a repeat screening should have been done. Any alarm symptom, such as anemia, weight loss, rectal bleeding, changes in bowel habits, or unexplained abdominal pain would require earlier colonoscopy.

I sympathize with the provider and his/her reliance upon the specialist to make the appropriate reminder. One would hope that reminders of this type would be made by the specialist. Ultimately, a specialist who failed to make a reminder might also be liable. However, the failure of the specialist does not relieve the primary care provider of responsibility.

Further, the allegation that the patient refused a lab test would also require documentation. Without it, we have a “he said, she said” situation with no way to confirm a patient failure to follow suggested medical direction. To a jury, a statement like this appears to be an obvious effort on the defendant’s part to explain away responsibility.

In my own practice as a family nurse practitioner specializing in gastroenterology, I review active patient files at every visit to confirm screening dates and any need for repeat screening. But often I see a patient only when screening visits actually occur, sometimes 10 years apart. When I am saying goodbye to a screening patient and telling them that we will contact them with a reminder at the time of the next scheduled screening, I also tell them to make a calendar reminder themselves. We use a computer system for reminders, but we all know that computers are fallible, as are humans. Every extra level of safety is important when it comes to these matters. Ultimately, however, the primary care provider is the one who sees a patient on a regular basis and has the opportunity, and thus the responsibility, to assure that screening matters are addressed.

What is also important is that this case and its outcome occurred even before the advent of the “medical home.” With the medical home concept in place, the responsibility would likely become even greater. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

References
1. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. 1997;112 (2):594–642 [published corrections appear in Gastroenterology. 1997;112(3):1060 and 1998; 114(3):625].
2. Read TE, Kodner IJ. Colorectal cancer: risk factors and recommendations for early detection. Am Fam Physician. 1999;59(11):3083-3092.

Failure to Order Colonoscopy Despite Patient’s Family History
After receiving care from the defendant primary care physician since 1997, a Massachusetts woman presented in the fall of 2003 complaining of fatigue; she was diagnosed with iron deficiency anemia in January 2004. Two months later, she underwent a diagnostic colonoscopy, which revealed a mass in the transverse colon. Following surgery to remove the obstructing cancer, the patient received palliative care and died at age 52.

Plaintiff claimed that a colonoscopy should have been ordered for the decedent at an age 10 years earlier than the age at which her youngest family member had been diagnosed with colon cancer (ie, a maternal cousin diagnosed in her early 40s, in addition to her mother, diagnosed in her early 50s, and her maternal grandmother, diagnosed at age 75).

The defendant physician claimed that the decedent’s fatigue was due to depression and that she had declined further lab tests. A handwritten entry in the medical record from 1998 indicated that a colonoscopy had been ordered and performed with negative results. However, no report from the gastroenterologist nor any billing information from that procedure was ever found in the record.

The defendant claimed that it was the responsibility of the gastroenterologist, not the named defendant, to make follow-up appointments at appropriate intervals for colonoscopy, given the patient’s family history. The defendant also claimed that the criteria for performing colonoscopies between 1997 and 2004 were still evolving and that no standards had yet been set.

Outcome
According to a published account, a $950,000 settlement was reached.

Comment
The message here is clear: Primary care providers have a responsibility to track screening requirements—even when other specialists are involved and should also have responsibility. In this case, the issue is colonoscopy screening in an individual with a strong family history for colon cancer. The plaintiff correctly argued that a colonoscopy is appropriate at an age 10 years earlier than the affected relative’s age at diagnosis, or at age 40—whichever is younger. Also, the procedure should be repeated at five-year intervals in those at increased risk. These standards were published in 1997, contrary to the defendant’s allegations, and further supported in the literature in 1999.^1,2

The plaintiff began treatment with the primary care provider in 1997, with a report of colonoscopy having been done some time in 1998, yielding normal results. Certainly a primary care provider would want documented evidence of the procedure, not just a note that one had been done. Even if a colonoscopy had been performed and the note is correct that findings were normal, the time for a repeat procedure should have been some time in 2003—the same time as the patient’s report of fatigue. This is the latest that a repeat screening should have been done. Any alarm symptom, such as anemia, weight loss, rectal bleeding, changes in bowel habits, or unexplained abdominal pain would require earlier colonoscopy.

I sympathize with the provider and his/her reliance upon the specialist to make the appropriate reminder. One would hope that reminders of this type would be made by the specialist. Ultimately, a specialist who failed to make a reminder might also be liable. However, the failure of the specialist does not relieve the primary care provider of responsibility.

Further, the allegation that the patient refused a lab test would also require documentation. Without it, we have a “he said, she said” situation with no way to confirm a patient failure to follow suggested medical direction. To a jury, a statement like this appears to be an obvious effort on the defendant’s part to explain away responsibility.

In my own practice as a family nurse practitioner specializing in gastroenterology, I review active patient files at every visit to confirm screening dates and any need for repeat screening. But often I see a patient only when screening visits actually occur, sometimes 10 years apart. When I am saying goodbye to a screening patient and telling them that we will contact them with a reminder at the time of the next scheduled screening, I also tell them to make a calendar reminder themselves. We use a computer system for reminders, but we all know that computers are fallible, as are humans. Every extra level of safety is important when it comes to these matters. Ultimately, however, the primary care provider is the one who sees a patient on a regular basis and has the opportunity, and thus the responsibility, to assure that screening matters are addressed.

What is also important is that this case and its outcome occurred even before the advent of the “medical home.” With the medical home concept in place, the responsibility would likely become even greater. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

References
1. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. 1997;112 (2):594–642 [published corrections appear in Gastroenterology. 1997;112(3):1060 and 1998; 114(3):625].
2. Read TE, Kodner IJ. Colorectal cancer: risk factors and recommendations for early detection. Am Fam Physician. 1999;59(11):3083-3092.

Failure to Order Colonoscopy Despite Patient’s Family History
After receiving care from the defendant primary care physician since 1997, a Massachusetts woman presented in the fall of 2003 complaining of fatigue; she was diagnosed with iron deficiency anemia in January 2004. Two months later, she underwent a diagnostic colonoscopy, which revealed a mass in the transverse colon. Following surgery to remove the obstructing cancer, the patient received palliative care and died at age 52.

Plaintiff claimed that a colonoscopy should have been ordered for the decedent at an age 10 years earlier than the age at which her youngest family member had been diagnosed with colon cancer (ie, a maternal cousin diagnosed in her early 40s, in addition to her mother, diagnosed in her early 50s, and her maternal grandmother, diagnosed at age 75).

The defendant physician claimed that the decedent’s fatigue was due to depression and that she had declined further lab tests. A handwritten entry in the medical record from 1998 indicated that a colonoscopy had been ordered and performed with negative results. However, no report from the gastroenterologist nor any billing information from that procedure was ever found in the record.

The defendant claimed that it was the responsibility of the gastroenterologist, not the named defendant, to make follow-up appointments at appropriate intervals for colonoscopy, given the patient’s family history. The defendant also claimed that the criteria for performing colonoscopies between 1997 and 2004 were still evolving and that no standards had yet been set.

Outcome
According to a published account, a $950,000 settlement was reached.

Comment
The message here is clear: Primary care providers have a responsibility to track screening requirements—even when other specialists are involved and should also have responsibility. In this case, the issue is colonoscopy screening in an individual with a strong family history for colon cancer. The plaintiff correctly argued that a colonoscopy is appropriate at an age 10 years earlier than the affected relative’s age at diagnosis, or at age 40—whichever is younger. Also, the procedure should be repeated at five-year intervals in those at increased risk. These standards were published in 1997, contrary to the defendant’s allegations, and further supported in the literature in 1999.^1,2

The plaintiff began treatment with the primary care provider in 1997, with a report of colonoscopy having been done some time in 1998, yielding normal results. Certainly a primary care provider would want documented evidence of the procedure, not just a note that one had been done. Even if a colonoscopy had been performed and the note is correct that findings were normal, the time for a repeat procedure should have been some time in 2003—the same time as the patient’s report of fatigue. This is the latest that a repeat screening should have been done. Any alarm symptom, such as anemia, weight loss, rectal bleeding, changes in bowel habits, or unexplained abdominal pain would require earlier colonoscopy.

I sympathize with the provider and his/her reliance upon the specialist to make the appropriate reminder. One would hope that reminders of this type would be made by the specialist. Ultimately, a specialist who failed to make a reminder might also be liable. However, the failure of the specialist does not relieve the primary care provider of responsibility.

Further, the allegation that the patient refused a lab test would also require documentation. Without it, we have a “he said, she said” situation with no way to confirm a patient failure to follow suggested medical direction. To a jury, a statement like this appears to be an obvious effort on the defendant’s part to explain away responsibility.

In my own practice as a family nurse practitioner specializing in gastroenterology, I review active patient files at every visit to confirm screening dates and any need for repeat screening. But often I see a patient only when screening visits actually occur, sometimes 10 years apart. When I am saying goodbye to a screening patient and telling them that we will contact them with a reminder at the time of the next scheduled screening, I also tell them to make a calendar reminder themselves. We use a computer system for reminders, but we all know that computers are fallible, as are humans. Every extra level of safety is important when it comes to these matters. Ultimately, however, the primary care provider is the one who sees a patient on a regular basis and has the opportunity, and thus the responsibility, to assure that screening matters are addressed.

What is also important is that this case and its outcome occurred even before the advent of the “medical home.” With the medical home concept in place, the responsibility would likely become even greater. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

References
1. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. 1997;112 (2):594–642 [published corrections appear in Gastroenterology. 1997;112(3):1060 and 1998; 114(3):625].
2. Read TE, Kodner IJ. Colorectal cancer: risk factors and recommendations for early detection. Am Fam Physician. 1999;59(11):3083-3092.