Discussion 06.2: Premature Discharge?
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9781284069754_SLID_CH10.pptx
Chapter 10
Medical Staff Organization
and
Physician Liability
Learning Objectives
Describe medical staff organization & committee structure.
Describe the credentialing and privileging process & the purpose of physician supervision & monitoring.
Know medical errors involving patient assessment, diagnosis, treatment, discharge, & follow-up care.
Explain how the physician–patient relationship can be improved.
Chapter Overview
Overview of medical ethics
Medical staff organization
Credentialing process
Review of pertinent legal cases
Where physicians are most vulnerable
Medical Staff Organization
Committees
Executive Committee
Recommends medical staff structure
Develops a process for reviewing credentials
Recommends appointments to the medical staff
Develops processes for delineating clinical privileges
Executive Committee (cont’d)
Performance improvement activities
Peer review
Fair hearing process
Reviews and acts on reports of medical staff departmental chairpersons and medical staff committees
Bylaws
Organization of the medical staff is described in its bylaws, rules, and regulations.
Bylaws must be approved by the governing body.
Bylaws must be kept current and the governing body must approve recommended changes.
Bylaws describe various membership categories of the medical staff (e.g., active, courtesy, consultative).
Blood and Transfusion
Develops blood usage policies and procedures
Monitors transfusion services
Monitors
Indications for transfusions
Blood ordering practices
Each transfusion episode
Transfusion reactions
Credentials
Oversees application process for medical staff applicants, requests for clinical privileges, and reappointments to the medical staff.
Makes its recommendations to the medical executive committee.
Infection Control
Generally responsible for the development of policies and procedures for investigating, controlling, and preventing infections
Medical Records
Develops policies and procedures, including
Release, security, and storage
Determining the format of medical records
Monitoring records for accuracy
Completeness, legibility, and timely completion and clinical pertinence
Ensures records reflect condition and progress of the patient, including results of all tests and therapy given and makes recommendations for disciplinary action as necessary
Pharmacy and Therapeutics
Policies and procedures (e.g., selection; procurement; distribution; handling, use, and safe administration of drugs, biologicals, and diagnostic testing material)
Oversees development and maintenance of formulary
Evaluates and approves protocols for the use of investigational or experimental drugs
Pharmacy and Therapeutics (cont’d)
Oversees
Tracking of medication errors
Adverse drug reactions
Management, control, effective and safe use of medications through monitoring and evaluation
Monitoring of problem-prone, high-risk, and high-volume medications
Quality Improvement Council
Functions as a patient-care assessment and improvement committee
Tissue
Provides surgical case reviews, including
Justification and indications for surgical procedures
Utilization Review
Monitors and evaluates utilization issues such as medical necessity and appropriateness of admission and continued stay, as well as delay in the provision of diagnostic, therapeutic, and supportive services
Ensures each patient is treated at the appropriate level of care
Utilization Review (cont’d)
Objectives of the committee include
Transfer of patients requiring alternate levels of care
Promotion of efficient and effective use of resources
Adherence to quality utilization standards of third-party payers
Maintenance of high-quality, cost-effective care
Identification of opportunities for improvement
Medical Director
Serves as a liaison between medical staff and organization’s governing body and management
Responsibilities include enforcing the bylaws of the governing body and medical staff and monitoring the quality of medical care in the organization
Medical Staff Privileges
Screening process
Application
Medial staff bylaws
Physical and mental status
Consent for release of information
Certificate of insurance
State licensure
National practitioner data bank
References
Interview process
Medical Staff Privileges (cont’d)
Delineation of clinical privileges
Limitations on privileges requested
Practicing outside field of competency
Governing body responsibility
Misrepresentation of credentials
Appeal process
Reappointments
COMMON MEDICAL ERRORS
Patient Assessment
Diagnosis
Treatment
Discharge
Follow-up care
Patient Assessments
Involve the systematic collection and analysis of patient-specific data necessary to determine a patient’s care and treatment plan.
A patient’s plan of care is dependent on the quality of assessments conducted by practitioners of various disciplines (e.g., physicians, nurses, dietitians).
Patient Assessments Cases
Unsatisfactory History and Physical
Assessment of Unconscious Patient
Failure to Obtain a Second Opinion
Assessments Sometimes Require Referral to a Specialist
Aggravation of Patient’s Condition
Diagnosis
Refers to the process of identifying a possible disease or disease process, thus providing the physician with treatment options
Diagnosis, cont’d
Failure to order diagnostic tests
Ophthalmologist Fails to Order Tests
Misdiagnosis of Appendicitis
Efficacy of test questioned
Failure to promptly review test results
Diagnosis, cont’d
Timely diagnosis
Failure to Read X-Ray Report
Radiologists Fail to Make a Timely Diagnosis
Failure to Monitor Patient
Diagnosis, cont’d
Imaging studies
Failure to Order Appropriate Imaging Studies
Image Misinterpretation Leads to Death
Failure to Consult with Radiologist
Failure to Read Images
Delay in Conveying Imaging Results
Failure to Communicate Imaging Results
Diagnosis, cont’d
Most frequently cited injury event in malpractice suits against physicians.
Medicine is not an exact science and linking a patient’s symptoms to a specific ailment is complicated at best.
Sometimes things go wrong despite all the advances of modern medicine.
Diagnoses based on spurious test results
Can lead to harmful treatments
Misdiagnosis Cases
Mitral Valve Malfunction
Failure to Form a Differential Diagnosis
Appendicitis
Diabetic Acidosis
Pathologist Fails to Diagnose Cancer
Radiologist Misreads Patient’s X-rays
Failure to Make a Timely Diagnosis
Wrongful Diagnosis of AIDS
Accident Victim Misdiagnosis
The police department physician examined an unconscious man who had been struck by an automobile.
The physician concluded the patient’s confusion was due to intoxication and he was placed in jail instead of a hospital.
The man remained semiconscious for several days and was finally taken to a hospital at the insistence of family; he subsequently died.
The autopsy revealed massive skull fractures.
Did the physician commit malpractice?
Accident Victim Misdiagnosis (cont’d)
Yes!
A patient is entitled to a thorough examination as his or her condition and attending circumstances warrant.
This did not happen.
Treatment
The attempt to restore the patient to health following a diagnosis
Involves the application of various remedies and medical techniques, including surgery and medications
Forms of Treatment
Active treatment is directed immediately to the cure of the disease or injury.
Causal treatment is directed against the cause of a disease.
Conservative treatment is designed to avoid radical medical therapeutic measures.
Palliative treatment is designed to relieve pain and distress with no attempt to cure.
Forms of Treatment (cont’d)
Preventive/prophylactic treatment is aimed at the prevention of disease and illness.
Supportive treatment is directed mainly to sustaining the strength of the patient.
Symptomatic treatment is meant to relieve symptoms without effecting a cure.
Treatment Choice of Treatment
Two schools of thought
Under this doctrine, a physician will not be liable for medical malpractice if he or she follows a course of treatment supported by reputable, respected, and reasonable medical experts.
Use of unprecedented procedures that create an untoward result may cause a physician to be found negligent even though due care was followed.
Treatment Cases
Selecting the wrong treatment
Delay in Treatment
Lab Results Buried in Files
Untimely Cesarean Section
Failure to Treat Known Condition
Treatment Cases (cont’d)
Failure to Treat Evolving Emergency
Failure to Respond to Emergency Calls
Medication errors
Wrong Dosage
Abuse in Prescribing Medications
Wrongful Supply of Medications
Treatment Cases (cont’d)
Surgery
Retained Surgical Items
Phantom Surgeon
Wrong Patient Surgery
Correct Surgery: Wrong Site
Treatment Cases (cont’d)
Surgery (cont’d)
Wrong Site Surgery
Wrong Site Surgery: Fraud
Foreign Objects Left in Patients
Needle Fragment Left in Patient
Procedure Improper
Inadequate Airway
Treatment Cases (cont’d)
Improper Positioning of Arm
Sciatic Nerve Injury
Preventing Surgical Mishaps
Require 2nd Opinions
Qualified Credentialed Physician for Proposed Procedure
Patient Informed as to Risks Benefits & Alternatives
Consent Forms Executed
Equipment, Supplies & Staff Prepared for Procedure
Preventing Surgical Mishap, cond’t
History and Physical Exams Completed
Pre-anesthesia Assessment Conducted
Correlation of Pathologic & Diagnostic Findings
Vital signs & Surgical Site Assessments Continuously Monitored
Discharge and Follow-Up Care
The premature discharge of a patient is risky business.
The intent of discharging patients more expeditiously is often a result of a need to reduce costs.
Discharge and Follow-Up Care Cases
Untimely Discharge
Failure to Provide Follow-Up Care
Failure to Follow-Up on Test Results
Abandonment
Abandonment
Elements necessary to recover damages
Medical care unreasonably discontinued
Discontinuance against patient’s will
Failure to assure follow-up care for patient
Foresight: Failure could result in patient injury
Actual harm was suffered by patient
Infections
Failure to effectively manage infection
Poor infection-control technique
Preventing spread of infection
Psychiatry
Commitment
Involuntary Commitment
Involuntary Commitment Ordered
Continuation of Commitment
Involuntary Commitment Invalid
Commitment by Spouse
Commitment by Oarent
Patient Due Process Rights
Release Denied
Psychiatry (cont’d)
Untimely Discharge
Electroshock Therapy
Duty to Warn
Exceptions to duty to warn
Suicidal patients
Flawed Evaluation
Inadequate Care
Principles of Medical Ethics Code of Medical Ethics
Principles adopted by the American Medical Association are not laws, but rather standards of conduct that define the essentials of honorable behavior for the physician.
A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
Principles of Medical Ethics Code of Medical Ethics (cont’d)
A physician shall respect the law and also recognize a responsibility to seek changes in those requirements that are contrary to the best interests of the patient.
A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
A physician shall continue to study, apply, and advance scientific knowledge; maintain a commitment to medical education; make relevant information available to patients, colleagues, and the public; obtain consultation; and use the talents of other health professionals when indicated.
Principles of Medical Ethics Code of Medical Ethics (cont’d)
A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
A physician shall support access to medical care for all people.
Physician-Patient Relationship
Personalize treatment.
Conduct a thorough assessment.
Develop a problems list and comprehensive treatment plan.
Provide sufficient time and care to each patient.
Request consultations when indicated and refer if necessary.
Physician-Patient Relationship (cont’d)
Closely monitor patient progress.
Make adjustments to treatment plan as the patient’s condition warrants.
Maintain timely, legible, complete, and accurate records.
Do not make erasures.
Do not guarantee treatment outcomes.
Provide for cross-coverage during days off.
Physician-Patient Relationship (cont’d)
Do not over-extend your practice.
Avoid prescribing over the telephone.
Do not become careless because you know the patient.
Seek the advice of counsel should you suspect the possibility of a malpractice claim.
Maintain the patient’s privacy rights.
Review Questions
Describe various principles identified in the medical code of ethics.
Explain medical staff organization and committee structure.
Describe the privileging and credentialing process.
Describe common medical errors as they relate to patient assessment, diagnosis, treatment, and follow-up care.
Review Questions (cont’d)
Explain how the physician–patient relationship can be improved.
Describe common legal issues for behavioral health professionals.
