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