Two medical malpractice claims involving electronic health record (EHR) issues are discussed by TMLT risk management professionals Tanya Babitch and Tony Passalacqua. This is first in a series of podcasts exploring actual closed claims studies from TMLT. To maintain social distancing, this recording was conducted virtually. Due to some portions of the podcast being hard to hear, a transcript of the conversation can be found below.
Tony Passalacqua: Our goal today is to discuss a case close vignette. For any of our listeners out there, the close claim studies found in this podcast are based on actual medical malpractice claims from Texas Medical Liability Trust. They illustrate how actions by the physician led to allegations of medical liability and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. The ultimate goal on this podcast is to help physicians practice safe medicine. When writing close claim studies, TMLT staff make every effort to eliminate identifying information without compromising the clinical details of the case. Dates and locations have been changed, and names of the patients and physicians have been removed. If you recognize a claim, please be assured that this is presented only to emphasize the important issues in this case.
Hello, and now joining us from our Risk Management Department is our director, Tanya Babitch. Tanya, can you tell us a little bit about yourself?
Tanya Babitch, 1:01: Yeah! Hi, Tony. I have been with TMLT for almost 19 years. I have experience in risk management, physician education, and health information management.
Tony Passalacqua, 1:19: Title: Failure to treat Group B strep.
Presentation: a 28-year-old woman came to her ob-gyn and advised the physician that she wanted to become pregnant. She reported a history of a miscarriage five years earlier. Three months passed, and the patient returned in late September. The patient tested positive for pregnancy. It was determined that she was five weeks along, and her estimated date of delivery was late May.
Physician action: the ob-gyn provided routine prenatal care and the patient's progress was noted to be normal. During her 35-week gestation, the physician ordered lab studies including tests for Group B streptococcus. Two days later, the results returned as a positive finding. However, the patient's Group B strep status was entered as negative on the patient's lab flow sheet. The lab flow sheet and the prenatal flow sheets were faxed to the hospital four weeks prior to the patient's estimated date of delivery. The flow sheets indicated incorrectly that the patient was negative for Group B strep. The patient came to the hospital twice before her estimated delivery date with complaints of elevated blood pressure. She was discharged after serial blood pressure testing. A few weeks later, the patient was admitted for pregnancy-induced hypertension. During the second day of hospitalization and labor, the ob-gyn performed a Cesarian delivery, the seven-pound two-ounce boy was delivered. His APGAR scores were eight and nine. Shortly after birth, the newborn began exhibiting signs of respiratory distress. He was transferred to a local neonatal facility. He underwent extensive testing including a culture that confirmed he was positive for Group B strep. The newborn’s condition deteriorated, and he did not respond to extracorporeal membrane oxygenation. He passed away eight days after his delivery.
Allegations: a lawsuit was filed against the ob-gyn. The allegations included failure to send correct lab results to the hospital and failure to properly administer prophylactic antibiotics to the mother when she arrived at the hospital.
So, with this case here, it there looks like there's a couple of different things that we could talk about. I think one of the first things is the hybrid recordkeeping that they had, where the individual was using like a sticky note. Can you kind of tell us what a sticky note is, and maybe what they could have done differently?
Tanya Babitch, 03:42: Yeah, well, this case was interesting. And actually, this was a completely electronic system. So, the sticky note was not actually a paper sticky note, it was an electronic sticky note which was an interesting feature of their EHR. So, you know, while the staff member entered the incorrect Group B strep status on the lab flow sheet in the EHR, the physician actually was aware of the positive result, which was the correct result. The physician reviewed the lab results and placed a note, a sticky note electronic, about the positive Group B strep in the EHR, and this popped up whenever the patient's chart was opened. However, the group B strep results on the electronic sticky note was never reconciled with the lab flow sheet results, and the contradictory information stayed in the record. The information from the sticky note was never meant to be a permanent part of the electronic record and wasn't generated when the record was faxed to the labor and delivery department.
Tony Passalacqua, 4:41: So, from a practice’s perspective, do you think it would be good for them to have some sort of policies and procedures set up, maybe a different way of handling the labs? Especially if there's a, let's say, a conflict in the results?
Tanya Babitch, 4:54: Well, you know, I think human error exists, so it's going to be hard to set up a policy that says, “Make sure you enter the correct lab results on to the lab flow sheet.” I mean, obviously, we know that that's something that a policy can't necessarily control. However, I think physicians want to be sure that however the way that they're using their electronic record is to the best of its capabilities, and that they understand the limitations. For example, that, say, an electronic sticky note is not going to end up as part of the permanent record. We definitely would recommend that physicians ensure that they're documenting their review of test results in a method that's both a permanent part of the record and that can be accurately extracted from their system for the stakeholders who need it.
Tony Passalacqua, 5:40: I know a lot of the times we spent a lot of time focusing a lot on what the physicians could do differently. But as a person who is a patient, one of the things that I always think of is, are there any things that I could do that I could maybe discuss with my physician to make sure that I can catch maybe some of these terrors before they become anything significant?
Tanya Babitch, 6:00: I think, I think that's a great question. You know, physicians often say, you know, when a lab result or something falls through the cracks, you know they often say, “Hey, where's the patient responsibility?” And in this case, it's a little bit tricky, because once again, the wrong result was entered on the lab flow sheet. However, we definitely would encourage any patient to be an advocate for their own health and to ask, “Okay, what studies are you going to be doing on me during the course of my treatment? What are the important results I need to know?” And then during that education process, for example, in a case like this, perhaps the error would have been caught. I mean, certainly the patient is in no way to blame in any way for what happened in this case. However, you know, had there been a good patient education process where, you know, the patient understood what testing was being done. The physician talked with the patient about what the results were. Once again, it could have been caught that the lab results were inconsistent, that the physician knew there was a positive step result, and that, antibiotics would be needed.
Tony Passalacqua, 7:08: Tanya, are there any ways the patient could access their own results?
Tanya Babitch, 7:12: That's a great, that's a great point actually, Tony. We would strongly recommend that patients, if they have the option to access their own records through portals that they use it. Now, once again, in this case, that lab flow sheet would have shown the wrong result. So, you know, in this case, I don't know that that would have solved the problem. But we absolutely believe that patients should be advocates for their own health, and access those results whenever they can. And then contact their health care providers if they have questions about any of those results.
Tony Passalacqua, 7:42: Thank you, Tanya, for your help with those risk management considerations. Let's move on to our second vignette.
Title: Delay in diagnosis of breast cancer.
Presentation: a 77-year-old woman with a history of cigarette smoking and COPD, came to her family physician reporting a lump on her right breast.
Physician action: the family physician ordered a diagnostic mammogram, and the patient went to the local hospital for the test. The results of the mammogram were normal. So, the radiology technician requested an ultrasound. The order was obtained from the family physician’s group [practice]. The ultrasound revealed a complex mask suspicious for a neoplastic process. A chest CT was suggested for further evaluation. The radiology reports for the mammogram and the ultrasound were sent to the physician’s group practice where an employee filed them in the electronic health care record. The family physician reviewed the mammogram results but was unaware that the ultrasound had been completed. He did not see the ultrasound report. One week later, the patient returned for a follow-up visit related to her COPD. There was no discussion of the breast lump or the recent testing. The patient continued to see the family physician over the next year for her COPD and other chronic health issues. There was no mention of the breast mass or the breast examination. Eighteen months after the mammogram and the ultrasound, the family physician ordered another screening mammogram. The test revealed the mass, and it was discovered that the mass had been identified in previous testing. The diagnosis was breast cancer with possible metastasis to the lungs. Two weeks later, the patient was hospitalized for shortness of breath. She was noted to have advanced COPD, bipolar disorder, hypertension, diabetes, prior chronic perforation, GI bleed, and thrombocytopenia. An oncologist evaluated the patient, but the patient and her family made a decision not to have any intervention done. She was discharged to hospice and died within three weeks of her diagnosis.
Allegations: a lawsuit was filed against the family physician and his group alleging failure to timely diagnose breast cancer.
Hello, Tanya, welcome back. What do you think this practice could have done a little bit differently from a risk management perspective?
Tanya Babitch, 9:54: Thanks, Tony. This case involves another user error of an EHR system. While consultants who reviewed this case were critical of some of the treatment decisions, for example, the failure to order additional studies up front in a patient with a palpable breast lump. There were user issues with the EHR that negatively affected the outcome of this case. The family physician in this case didn't like to use the EHR and relied on staff members to alert him to positive test results. However, the practice’s system was to import results to the physician’s EHR dashboard for review. In this case, a staff member indexed the reports and sent them over to the dashboard, but didn't notify the physician directly. There was a disagreement between the physician and the group about the proper procedures for reviewing test results. The administrator believed this system in place was appropriate and the physician should have reviewed his dashboard and discovered the ultrasound report when he reviewed the mammogram results. In this case, the physician relied on staff members to alert him to these rare results, but this process was not commonly accepted by the rest of the group. The physician also had multiple subsequent patient visits that presented opportunities to review the medical records and note the ultrasound results. The physician didn't review the record in its entirety. Thus, those treatment decisions are based on incomplete information. In general, practices are really encouraged to develop protocols for tracking follow up and review of test results. A written policy approved by the physicians and acknowledged by all providers and staff establishes some best practices and indicates that everybody is on board with the protocol. In addition, once those protocols are established, we would certainly encourage that compliance checks be done. That will help keep everybody on the same page and in agreement about how the systems are meant to work.
Tony Passalacqua, 11:53: Thank you so much, Tanya, for your time and expertise.
Tanya Babitch, 11:56: Thank you, Tony. I enjoyed it.
Tony Passalacqua: 11:57: Thank you for listening to our podcast. If you are a policyholder, please feel free to contact us with any questions by calling 1-800-580-8658 or check out our resources at TMLT.org and clicking on our Resource Hub.