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                                   July 8, 1990

                          MEDICAL MALPRACTICE PREVENTION
                                    March 1990
                                     Pages 6-7
                text file courtesy of Double Helix at 212-865-7043

    Medical Lessons To Be Learned

    The single greatest factor in the generation of medical malprac-
    tice cases is a breakdown in communications.  Even in those cases
    in which the medical care given is optimal and the appropriate
    tests are ordered, dangers loom in the realm of communication.

    This unfortunate case demonstrates a situation that an error in
    diagnosis was made, but it might not have led to litigation had
    it not been compounded by additional breakdowns in the critical
    exchange of information.

    Several common pitfalls  are  encountered  in  this  case that are readily
    avoidable by using basic risk-management techniques.

        1.  The first error made in this case arose in the actions taken
            when there was confusion regarding interpretation of the x-rays.
            Fractures of the femoral neck began to be seen at the age of 45
            and increase in frequency with age.

         Osteoporosis, with it's weakening effects on the structural integrity
    of the bone, is largely responsible for  because  mild to moderate trauma,
    may occur in falls, may result in neck and intertrochanteric  fractures in
    older patients.

         When examining  x-rays  of  the  hip,  both the superior and inferior
    aspects of the cortex of the femoral  neck  should  form  a smooth concave
    form as they flair to join the head of the femur, best  seen  on  internal
    rotation.  Disruption of  the  cortex  in  this junctional area may be the
    only manifestation of an impacted fracture, the medial cortex is disrupted
    and the lateral aspect of the head/neck junction is sharply angulated.

         An incomplete fracture will reveal cortical irregularity at the
    head/neck junction laterally.  With  both  types  of impactions, increased
    density with disruption of the trabecular pattern may be  evident.   These
    signs may be  subtle  and  overlooked  unless  there  is  a  high index of
    suspicion.

         It is a common practice in community  hospitals for an emergency room
    physician to be  called  upon  to  read  x-rays  on night  shifts,  during
    weekends, or on  holidays when there is no radiologist or other specialist
    on duty.

         While there may reluctance by  the  ER  doctor  to  consult  with the
    appropriate specialist (in this case, the radiologist or  the orthopedist)
    during these "off hours," communication is imperative, especially when the

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    potential need for   hospitalization   of  the  patient  hinges  upon  the
    appropriate interpretation of the study involved.
         In this case the residents were  misled by the absence of the typical
    findings of a hip fracture, that is, shortening and external rotation of
    the leg.  With a non-displaced fracture, physical findings may be least or
    absent, and the only symptoms seen may be pain and difficulty  in  bearing
    weight.  A high  index  of  suspicion  was in order in this case, and when
    coupled with a questionable interpretation  of  the  x-ray,  communication
    with a specialist was clearly indicated.

        2.  The procedures by which discrepancies in x-ray  readings  (or  any
            lab tests) are handled should be very explicit and adhered to
            scrupulously.  Explicit mechanisms to detect differences in ER
            diagnosis and official interpretations of test results must be
            carefully worked out in advance and adhered to.
         When the  cardiologist  reviews  EKGs  taken  in  the ER from the day
    before, for example,  they  should  have  a  means  of  corroborating  the
    consistency of his reading with that of the emergency physician, and when
    there is a significant difference, immediate action should be taken.

         These  procedures  should  be monitored during the inter-departmental
    meetings.  In this case, the radiologist's assumption that "a patient with
    a fractured hip  would  be  admitted  to the hospital" and that no further
    communication was required proved disastrous for all parties involved.

        3.  The review of test results should never be performed by any
            member of the staff other than a physician.  The discrepancies
            involved between "wet" ER and official x-ray readings may escape
            detection by a non-physician, as in this case, and result in
            disaster.

        4.  It is good practice for any physician,  especially an ER physician
            who often  only gets "one-shot" at a patient, to  select  a  small
            number of  his  more  significant charts from the previous day and
            make "call-backs" to see how his patients are doing and to monitor
            compliance.

         In practice, this only takes a  small  amount  of  time  and pays big
    dividends in terms of ensuring both good results and pleased  patients who
    are invariably impressed by their doctors concern for their well being.

         This "communication   enhancement"   technique  should  be  practiced
    routinely, and in this case might have ensured that the patient got to the
    proper specialist in a timely fashion.

        5.  When performing follow-up care  of  a patient who has been treated
            in an  ER or other facility, it is imperative to  check  all  test
            results obtained  elsewhere  and  not  to  rely  on  the patient's
            understanding of his diagnosis.   Obtaining  all  x-ray  readings,
            EKGs, and any other tests is of vital importance.

        6.  Beware  of  the  patient  whose  native  language   presents   the
            possibility of misinterpretation of explanations and instruc-
            tions.

         Zealous efforts   should   be   made   either   to   make  sure  that
    communications are understood,  or   to   find   another  person  (friend,
    interpreter, family member, follow-up physician) who will  ensure that the
    patient gets appropriate care.

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         In summary, one of the essentials of a successful medical interaction
    is good communication.   Without it, when a mistake has occurred, and even
    when exemplary care has been rendered,  a  provider's  best efforts may be
    doomed to failure.

    -Case submitted by:
     Jan K. Lipes, MD
     Doylestown, Pennsylvania

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        Jerry W. Decker.........Ron Barker...........Chuck Henderson
                          Vangard Sciences/KeelyNet
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