LAW IS NEXT
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finallesson4.pptxChapter 12
Hospital Departments
and Allied
Professionals
Learning Objectives
Describe a variety of legal issues that occur in patient care settings.
Discuss the purpose of the Emergency Medical Treatment and Active Labor Act.
Describe the purpose of certification and licensure, and the reasons for revocation of licenses.
Explain the importance of a multidisciplinary approach to patient care.
Dying at the Hospital’s Door: Communications Breakdown
A child’s death
A lawsuit occurs
A court awards damages
But what has changed?
Lessons learned: Triage the patient.
Don’t make hasty judgments about a patient.
Paramedic
Scope of Practice focuses on state statutes
Common levels of EMS personnel
Emergency medical responder
Emergency medical technician
Advanced emergency medical technician
Paramedic
Paramedic: Legal Cases
Wrong Dosage Administered
Protected by Good Samaritan Statute
Failure to intubate the patient
Inability to Diagnose the Extent of Injury
Lidocaine Administered 44 Times Normal Dosage
Failure to Transport Patient
Paramedic License Denied
Emergency Department
Emergency Medical Treatment & Active Labor Act
In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA).
The Act forbids Medicare-participating hospitals from dumping patients out of emergency departments (EDs).
EMTALA 42 U.S.C.A. § 1395dd(a) (1992)
. . . if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition . . . exists.
EMTALA Cases
Screening Determined Appropriate
Stabilizing the Patient
Failure to Stabilize Patient
Inappropriate Transfer
Screening and Discharge Appropriate
Discharge Found Appropriate
EMTALA Claim Against Hospital Valid
Wrong Record: Grave and Fatal Mistake (1 of 2)
Terry was taken to the hospital after being injured in an automobile accident.
Upon ordering discharge, the ED physician had not realized that he had made a fatal mistake.
The physician looked at the wrong chart in determining Terry’s status, thus discharging Terry.
Terry died at home in his father's arms as his head slumped forward.
Trahan v. McManus
Who is responsible for Terry’s death?
Wrong Record: Grave and Fatal Mistake (2 of 2)
The ED physician, by his own admission, stated that he acted negligently when he discharged Terry and that his actions led to Terry's death.
Duty to Contact On-Call Physician
Hospitals expected to notify specialty on-call physicians when their particular skills are required in the ED.
A physician who is on call and fails to respond to a request to attend a patient can be liable for patient injuries.
Failure to contact on-call physician
Physician’s failure to respond to call
Timely response required
Notice of inability to respond to call
Objectives of Emergency Care
Treatment must begin as rapidly as possible.
Function is to be maintained or restored.
Scarring and deformity are to be minimized.
Treatment is provided regardless of ability to pay.
Patient Leaves ED Without Notice: No Duty to Stop Patient
In a wrongful death medical malpractice action alleging negligence, the trial court properly granted summary judgment because, under Ohio law, an emergency room nurse had no duty to interfere with an individual who left the ED without telling anyone and who refused treatment.
Griffith v. University Hospitals of Cleveland
Failure to Admit
The physician was found negligent in failing to hospitalize the patient or failing to inform her of the serious nature of her illness.
The trial court found that had the patient been hospitalized on her first visit, her chances of survival would have been increased.
Roy v. Gupta
Documentation: Sparse and Contradictory
The ED physician failed to evaluate the patient and to initiate care within the first few minutes of the patient’s entry into the emergency facility.
The emergency physician had an obligation to determine who was waiting for physician care and how critical the need was for that care.
Fenney v. New England Medical Ctr.
Telephone Medicine Costly: Futch v. Attwood (1 of 2)
Lauren was taken to the hospital ED.
Hospital personnel contacted the physician by phone.
He returned the call and prescribed a Phenergan injection.
He did not go to the hospital and had not been given Lauren’s vital signs when he suggested such an injection, and further failed to order any blood or urine tests.
Hospital records revealed that Lauren’s glucose level was 507 at the time of admission.
Lauren went into respiratory failure and eventually died.
Was the physician liable for practicing telephone medicine?
Telephone Medicine Costly: Futch v. Attwood (2 of 2)
Yes!
The trial court allocated $98,000 for the conscious pain and suffering of Lauren.
The defendant complained that the award of $98,000 was excessive.
On appeal, the appellate court could not find that the trial court had erred in concluding what sum was fair to both parties.
Improving Emergency Department Care (1 of 6)
Treat each patient courteously and promptly regardless of ability to pay.
Require timely response by on-call physicians.
Do not take lightly any patient’s complaint.
Triage, assess, and treat seriously ill patients first.
Communicate with the patient and family to ensure a complete and accurate picture of the patient’s symptoms and complaints.
Improving Emergency Department Care (2 of 6)
Provide an appropriate examination of the patient based on the presenting complaint(s) and symptoms.
Obtain patient consent for procedures when possible.
Provide a mechanism for obtaining consultations when necessary.
Require that hospitals determine what types of patients and levels of care they can safely address.
Improving Emergency Department Care (3 of 6)
Know when to admit or stabilize and transfer a patient.
Maintain thorough and complete medical records for each patient treated.
Ensure that each patient’s records treated in other settings within the organization (e.g., ambulatory care settings) are readily available.
Establish criteria for admission and discharge.
Improving Emergency Department Care (4 of 6)
Ensure that all patients are assessed and treated by a physician prior to discharge.
Ensure that patient education is provided in the ED prior to discharging each patient.
Ensure that all documentation is completed prior to discharge.
Provide a procedure for reading imaging studies when there is no radiologist readily available.
Improving Emergency Department Care (5 of 6)
Institute a preventive maintenance program for ED equipment.
Determine which diagnoses can be safely addressed within the organization.
Assure open lines of communications between hospitals and emergency medical services personnel when addressing transport and care issues.
Make appropriate arrangements, when required, for transfer.
Improving Emergency Department Care (6 of 6)
Provide continuing education programs for all staff members.
Require mandatory administrative rounds to the ED by the risk manager, medical director, chief nursing officer, and chief executive officer.
Emergency Departments Vital to Public Safety
ED has come to be perceived as provider of emergency services. Patients come to the hospital to be cured, and the doctors who practice there are the hospital’s instrumentalities, regardless of the nature of the private arrangements between the hospital and physician. Whether or not this perception is accurate seemingly matters little when weighed against the momentum of changing public perception and attendant public policy.
—Martin C. McWilliams, Jr. & Hamilton E. Russell, III Hospital Liability for Torts of Independent Contractor Physicians 47 S.C. L. REV. 431, 473 (1996)
The Right Hospital? (1 of 2)
If Hospital A has no neurologist, neurosurgeon, or stroke team, and Hospital B, 1 mile away, has all of that plus a Level I trauma center, would it be fair to say that a suspected stroke victim should be transported to Hospital B?
The Right Hospital? (2 of 2)
Yes!
It is not just any hospital, it is the right hospital that saves lives.
Taking the patient to Hospital A raises both ethical and legal issues.
Under what circumstances would Hospital B be the first hospital of choice?
When there is no other hospital within a reasonable distance to stabilize the patient
State Regulations
Legislation in many states imposes a duty on hospitals to provide emergency care.
The statutes implicitly, and sometimes explicitly, require hospitals to provide some degree of emergency service.
Laboratories (1 of 3)
Georgetown University Hospital Shuts Lab after Problems with Cancer Tests
Georgetown University Hospital has shut down a lab that performs genetic analysis for breast cancer patients and has had 249 women’s tissue samples independently retested while federal officials investigate procedures at the lab.
—The Washington Post, Lena H. Sun, August 6, 2010
Laboratories (2 of 3)
Provide data vital to a patient’s treatment
Monitor therapeutic ranges
Measure blood levels for toxicity
Place and monitor instrumentation on patient units
Provide education for staff (e.g., glucose monitoring)
Laboratories (3 of 3)
Provide data utilized in research studies
Provide data on the most effective and economical antibiotic for treating patients
Serve in a consultation role
Provide valuable data as to the nutritional needs of patients
Laboratory Cases (1 of 2)
Confusion of laboratory specimens
Test results and misdiagnosis
Blood transfusions
Failure to Follow Transfusion Protocol
Mismatched Blood
Blood Transfusion Constitutes a Provision of Service
Blood Transfusions and the Feres Doctrine
Transfusion of Wrong Blood
Laboratory Cases (2 of 2)
Refusal to work with certain specimens
Failure to diagnose cervical cancer
Lost Chance of Survival
Surgical specimens
Laboratory: Lost Chance of Survival: Pap Smear
The court determined evidence relating to negligence claims pertaining to Pap tests taken more than 2 years before filing the action were admissible because the patient had a continuing relationship with the clinical laboratory as a result of her physician submitting her Pap tests to the laboratory over a period of time.
Sander v. Geib, Elston, Frost Prof’l Ass’n
Medical Assistant
An unlicensed person who provides administrative, clerical, and/or technical support to a licensed practitioner.
Employment of medical assistants is expected to grow much faster than the average for all occupations.
Those in large practices tend to specialize in a particular area, under supervision.
Case: Poor Communications
Nutritional Services
News: Malnutrition: A Serious Concern for Hospitals
Failure to provide adequate nutrition
Nursing facility patients highly vulnerable
Lambert v. Beverly Enterprises
Pharmacy
Immense variety and complexity of medications
Impossible for nurses or doctors to keep up with the information required for safe medication use
Pharmacist has become an essential resource in modern hospital practice
Medication Errors
Prescription
Dispensing
Administration
Documentation
Government Control of Drugs
Federal controls
Controlled Substance Act
Federal Food, Drug, and Cosmetic Act
State regulations
Storage of drugs
Hospital formulary
Dispensing and administration
Drug substitution
Expanding Role of Pharmacist
Duty to monitor patient’s medications
Warning patients about medication usage
Refuse to honor questionable prescription
Limited duty to warn
Refusal to fill prescription
Failure to consult with the patient’s physician
Intravenous Admixture Service
Prepared in Admixture Room
Proper Labeling
Patient’s Name, ID, Date of Birth,
Drug, Strength, Infusion Period, Flow Rate
News: Error That Led to Baby’s Death Slipped Through Many Hands
Medications: Helpful Tips (1 of 5)
There is a process for documenting a complete listing of a patient’s current medications upon admission to the hospital or other healthcare setting.
The attending physician decides which medications should be continued during the patient’s stay.
Handwriting is legible and printed if necessary for readability.
Felt-tip pens are avoided.
Medications: Helpful Tips (2 of 5)
Orders are clear.
A zero is added prior to a decimal.
Abbreviations are avoided except where permitted by hospital policy.
A process is in place for validating interpretation of illegible medication orders.
Hold orders are accompanied by a time frame.
Medications: Helpful Tips (3 of 5)
Drugs are safely stored, ordered, and distributed.
Potentially dangerous look-alike drugs are separated.
High-risk drugs are easily identified and standardized when feasible.
Look-alike medications are repackaged or relabeled, as necessary, in the pharmacy.
Medications are labeled as to dosage and expiration date.
Medications: Helpful Tips (4 of 5)
Medications are administered at proper time in prescribed dosage by correct route (e.g., IV, intramuscular, oral).
Complete list of medications is available to next provider when patient is transferred from one setting to another within or outside organization.
Upon discharge, attending physician instructs patient as to which drugs should be continued or discontinued.
Risk reduction activities are in place to reduce likelihood of adverse drug reactions and medication errors.
Medications: Helpful Tips (5 of 5)
Staff members who participate in codes are periodically tested for competency.
Mechanism is in place for approving and overseeing the use of investigational drugs.
Causes and trends of medication errors are tracked and changes made in the process as necessary to improve outcomes.
Educational processes have been implemented to reduce likelihood of medication errors and adverse drug events.
Prescription Errors
Wrong patient
Wrong drug
Inappropriate drug ordered due to: known drug allergies, drug–drug interactions, and food–drug interactions
Wrong dose
Wrong route
Inadequate review of medication for appropriateness
Dispensing Errors
Improper preparation of medication
Failure to properly formulate medications
Dispensing expired medications
Mislabeling containers
Wrong patient
Wrong dose
Wrong route
Misinterpretation of physician order
Documentation Errors
Transcription errors often due to:
Illegible handwriting
Improper use of abbreviations
Inaccurate transcription to medication administration record (MAR)
Charted but not administered
Administered but not documented on MAR
Discontinued order not noted on MAR
Medication wasted and not recorded
Physical Therapy
The art and science of preventing & treating neuromuscular or musculoskeletal disabilities
Through evaluation of an individual’s disability and rehabilitation potential
The application of physical agents (heat, cold, ultrasound, electricity, water, and light) and use of neuromuscular procedures that, through their physiologic effect, improve or maintain the patient’s optimum functional level
Physical Therapy: Incorrectly Interpreting Physician’s Orders
Plaintiff alleged that defendant failed to exercise degree of care and skill ordinarily exercised by physical therapists, failed to heed his protests that he could not perform the physical therapy treatments she was supervising, and failed to stop performing treatments after he began to complain he was in pain.
Plaintiff’s expert testified defendant deviated from standard of care by introducing a type of exercise not prescribed by the physician.
Pontiff, in Pontiff v. Pecot & Assoc.
Court’s Finding? Incorrectly Interpreting Physician’s Orders
For the plaintiff!
The appeals court found that the trial court was correct in its determination that the plaintiff presented sufficient evidence to show that this duty was breached and that the therapist’s care fell below the standard of other physical therapists.
Termination of Contracted Services
The hospital claimed that its attempt to establish a hospital-based physical therapy program would have been disrupted if the independent therapist had been permitted to continue treating patients.
Armintor v. Community Hospital of Brazosport
What was the court’s decision?
Termination of Contracted Services: Court’s Decision
For the hospital!
Exclusion of a therapist is an administrative matter within the board’s discretion.
The therapist entering the hospital without the permission of a staff physician would constitute trespass and would be in violation of hospital policy.
Neglect
A physical therapist had been charged with resident neglect for refusing to allow an 82-year-old nursing facility resident to go to the bathroom before starting his therapy treatment session.
Zucker v. Axelrod
Neglect: Court’s Decision
The court held that the finding of resident neglect was supported sufficiently by the evidence.
Physical Therapist License Revoked
Physical therapist license was found to have been properly revoked in several other states.
Girgis v. Board of Physical Therapy
Physician’s Assistants
Physician’s assistants (PAs) as physician extenders
Scope of practice defined by each state
PAs responsible for own negligent acts
Respodeat superior
The employer of a PA can also be liable for the PA’s negligent acts.
Radiology
Unnecessary tests and physician kickbacks
Patient falls
X-ray cassette falls on patient’s head
Schopp v. Our Lady of the Lake Hospital, Inc.
Improper lead shielding
Misdiagnosis
Respiratory Therapist (1 of 2)
Allied health profession responsible for the treatment, management, diagnostic testing, and control of patients with cardiopulmonary deficits
Respiratory Therapist (2 of 2)
Failure to remove endotracheal tube
Multiple use of same syringe
Restocking the code cart
Chiropractor
Standard of care required
Degree of care, judgment, and skill exercised by other reasonable chiropractors under like or similar circumstances
Lawsuits
Failure to diagnose
Harm suffered from treatment
Neck and spine manipulation
Dentistry Cases (1 of 2)
Drill Bit Left in Tooth
Failure to Refer
Lack of Consent
Removal of teeth without consent
Failure to Prescribe Antibiotics
Risk of not prescribing an antibiotic is that bacteria can flow through the bloodstream to the heart.
Dentistry Cases (2 of 2)
Failure to Follow Sterile Technique
Failure to wear protective gloves.
Practicing Outside Scope of Competency
Dentist performed several elective cosmetic procedures, including a face lift, eyelid revision, and facial laser resurfacing.
Failure to Supervise Dental Assistant
Dental Hygienist Administers Nitrous Oxide
Poditary
Branch of medicine involving the study of, diagnosis, and medical treatment of disorders of the feet, ankles, and lower extremities
Podiatrist
The legal concerns of podiatrists, similar to those of surgeons, include misdiagnosis and negligent surgery.
The podiatrist in Strauss v. Biggs was found to have failed to meet the standard of care required of a podiatrist and that failure resulted in injury to the patient.
The podiatrist, by his own admission, stated that his initial incision in the patient’s foot had been misplaced.
The podiatrist acted improperly by failing to refer the patient, stop the procedure after the first incision, and inform the patient of possible nerve injury.
Security
Hospitals have a duty to implement and maintain reasonable measures to protect patients from the criminal acts of third parties.
However, if an attack and injury to a patient is not foreseeable, the hospital’s actions cannot be the proximate cause of the patient’s injuries.
Assault in the Emergency Department Lane v. St. Joseph’s Regional Medical Center (1 of 2)
Patient (Lane) was sitting in the ED waiting room when a teenage boy, D.G., arrived with his mother.
After they had all sat in the waiting room for a short period of time, D.G. walked up to Lane and hit her on her right arm and shoulder.
Lane’s son-in-law, jumped to her aid and struck D.G., knocking him to the floor.
Attack stopped and nothing further happened.
Lane suffered some injuries.
Is the hospital liable for Lane’s injuries?
Assault in the Emergency Department Lane v. St. Joseph’s Regional Medical Center (2 of 2)
No!
Evidence in this case depicts a situation in which attack upon Lane by D.G. was unexpected and unforeseeable.
The center’s actions were not the proximate cause of Lane’s injuries.
Licensure & Certification Healthcare Professionals
Recognition by a governmental or professional association that an individual’s expertise meets the standards of that group.
Some professional groups establish their own minimum standards for certification in those professions that are not licensed by a particular state.
Certification by an association or group is a self-regulation credentialing process.
Licensing Healthcare Professionals (1 of 2)
Process by which a competent authority grants permission to a qualified individual to perform certain specified activities that would be illegal without a license
Licensure refers to the process by which licensing boards, agencies, or departments of the several states grant to individuals who meet certain predetermined standards legal right to practice in a healthcare profession and to use a specified healthcare practitioner’s title.
Licensing Healthcare Professionals (2 of 2)
Commonly stated objectives of licensing laws are to limit and control admission to the different healthcare occupations and to protect the public from unqualified practitioners by promulgating and enforcing standards of practice within the professions.
Suspension and Revocation of License
Licensing boards have authority to suspend or revoke the license of a healthcare professional found to have violated specified norms of conduct.
Such violations may include
Procurement of a license by fraud
Unprofessional, dishonorable, immoral, or illegal conduct
Performance of specific actions prohibited by statute
Malpractice
Certification of Healthcare Professionals
The recognition by a governmental or professional association that an individual’s competencies meet the standards of that group in delivering quality patient care
Certification exams designed to verify an individual has achieved minimum competency standards to assure safe and quality patient care.
Helpful Advice for Caregivers (1 of 6)
Abide by the ethical code of one’s profession.
Do not criticize the professional skills of others.
Maintain complete and adequate medical records.
Inform the patient of the risks, benefits, and alternatives to proposed procedures.
Helpful Advice for Caregivers (2 of 6)
Provide each patient with medical care comparable with national standards.
Be a good listener and allow each patient sufficient time to express fears and anxieties.
Foster a sense of trust and feeling of significance.
Communicate with the patient and other caregivers.
Helpful Advice for Caregivers (3 of 6)
Seek the aid of professional medical consultants when indicated.
Obtain informed consent for diagnostic and therapeutic procedures.
Do not indiscriminately prescribe medications or diagnostic tests.
Practice the specialty in which you have been trained.
Helpful Advice for Caregivers (4 of 6)
Keep patient information confidential.
Check equipment regularly and monitor for safe use.
When terminating a professional relationship with a patient, give adequate written notice to the patient.
Authenticate all telephone orders.
Helpful Advice for Caregivers (5 of 6)
Obtain a qualified substitute when you will be absent from your practice.
Investigate patient incidents promptly.
Develop and implement an interdisciplinary plan of care for each patient.
Safely administer patient medications.
Helpful Advice for Caregivers (6 of 6)
Closely monitor each patient’s response to treatment.
Provide cost-effective care without sacrificing quality.
Provide education and teaching to patients.
Participate in continuing education programs.
Review Questions (1 of 3)
Describe the four common levels of EMS personnel (medical responder, emergency medical technician, advanced emergency medical technician, and paramedic).
Describe the wide variety of legal issues that occur in the emergency department setting.
Discuss the purpose of the Emergency Medical Treatment and Active Labor Act.
Review Questions (2 of 3)
Should medical advice be dispensed on the telephone? Explain your opinion.
Describe negligence-related risks when providing laboratory, nutritional, pharmacy, physical therapy, podiatry, radiology, respiratory, chiropractic, dentistry, and podiatric services.
Discuss why a hospital has a duty to provide adequate security on its premises.
Review Questions (3 of 3)
Describe the purpose of licensure, certification and credentialing.
Describe the importance of teamwork in the provision ok patient care.
