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Chapter 11

Hospital Departments & Allied Health Professionals

LEARNING OBJECTIVES

  • Describe a variety of negligent errors by allied health professionals.
  • Discuss the purpose of certification, licensure, and reasons for revocation of licenses.
  • Describe helpful advice for caregivers.

PROFESSIONAL ETHICS

  • Standards or codes of conduct by specific profession.
  • Created in response to actual or anticipated ethical conflicts.
  • Examples
  • Falsifying records
  • Sexual improprieties
  • Sharing confidential patient information

Chiropractor

  • Standard of care required
  • degree of care, judgment, & skill exercised by other reasonable chiropractors under like or similar circumstances.

Emergency Department

  • Objectives of Emergency Care
  • treatment must begin as rapidly as possible
  • function is to be maintained or restored
  • scarring & deformity are to be minimized
  • treatment regardless of ability to pay.

Jury Returns Largest Medical Malpractice Verdict

  • A man arrived at the ER with severe neck pain and numbness in his arms and legs. A doctor diagnosed his condition as neck strain and released the man from the hospital. A few hours later, the man became completely paralyzed from the chest down… The jury awarded the plaintiff $15 million; $10 million of which was for non-economic damages. −Mark Bello, The Legal Examiner, December 30, 2012

No Duty to Patient
Who Left ED Untreated

  • 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

  • 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 & Contradictory

  • ED physician failed to evaluate the patient & to initiate care within first few minutes of patient's entry into the emergency facility. The emergency physician had an obligation to determine who was waiting for physician care & how critical the need was for that care.

−Fenney v. New England Medical Ctr.

EMTALA – I

  • In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA) that forbids Medicare-participating hospitals from dumping patients out of emergency departments.

EMTALA
42 U.S.C.A. § 1395dd(a) (1992)

  • in the case of a hospital that has a hospital emergency department, 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 . . .

Emergency Medical Condition

  • (A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy . . . .

EMTALA Text Cases

  • Stabilizing the patient
  • Transfer Prior to Stabilizing Patient
  • Inappropriate Transfer

Wrong Record: Fatal Mistake – I

  • Terry was taken to the hospital after 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.

−Trahan v. McManus

  • Who is responsible for Terry’s death?

Wrong Record: Fatal Mistake – II

  • The ED physician by his own admissions 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 are expected to notify specialty on-call physicians when their particular skills are required in the ED.
  • Timely Response Required
  • Failure to Contact On-Call Physician
  • Failure to Respond to Call
  • Notice of Inability to Respond to Call

Telephone Medicine Costly – I

  • Lauren was taken to the hospital ED. Hospital personnel contacted the physician by phone. He returned the call & prescribed a Phenergan injection. He did not go to the hospital & had not been given Lauren's vital signs when he suggested such an injection, & 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's went into respiratory failure & eventually died.

Futch v. Attwood

  • Was the physician liable?

Yes!

  • The trial court allocated $98,000 for the conscious pain & 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.

Preventing ED Lawsuits – I

  • Courteous & prompt treatment
  • Treatment regardless of ability to pay
  • Triage – setting treatment priorities
  • Establishing on-call roster procedures
  • Providing consultation by specialists
  • Communicating to ensure complete & accurate picture of the patient's symptoms & complaints.
  • Ensuring caregivers effectively communicating.
  • Provide continuing education programs.
  • Not taking lightly any patient's complaint.

Preventing ED Lawsuits – II

  • All patients must be treated.
  • Hospital determines types of patients & levels of care they can safely address.
  • Knowing when to admit or transfer a patient.
  • Provide follow-up instructions.
  • Hospitals need to determine what types of patients & levels of care they can safely address. If there are several hospitals in a community, they must learn to communicate with one another & include emergency medical services personnel in addressing transport & care issues.

The Right Hospital?

  • If Hospital A has no neurologist, neurosurgeon, or stroke team & 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?

Yes!

  • Its 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?

Stabilizing the Patient

  • When there is no other hospital within a reasonable distance to stabilize the patient.

Emergency Department’s
Vital to Public Safety

  • The hospital itself has come to be perceived as the provider of medical services. According to this view, 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 the physician.

[Martin C. McWilliams, Jr. & Hamilton E. Russell, III, Hospital Liability for Torts of Independent Contractor Physicians, 47 S.C. L. REV. 431, 473 (1996).]

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.

Laboratory Services – I

  • Provides vital data
  • Monitors therapeutic ranges
  • Measures blood levels for toxicity
  • Places & monitors instrumentation on patient units
  • Provides education for lab & other disciplines as necessary

Laboratory Services – II

  • Provides valuable data utilized in research studies
  • Provides data on most effective and economical antibiotic for treating patients
  • Serves consultation role
  • Provides valuable data as to the nutritional needs of patients . . . .

Laboratory Services – III

  • Failure to follow transfusion protocol
  • Mismatched blood

Failure to Detect Changes in Pap Smear

  • 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.

Nutritional Services

  • Need to provide nutrition
  • Failure to do so can result in a lawsuit
  • Nursing facility patient’s highly vulnerable
  • Lambert v. Beverly Enterprises
  • Patient suffered malnutrition
  • Motion to dismiss case denied

Paramedic – I

  • Legislation – civil immunity for paramedics
  • Wrong Dosage Administered
  • Patient Refuses Transport and Expires

City Council Approves $1.75M Settlement in Ambulance Case

  • The Chicago City Council today approved a $1.75 million settlement with the family of a 13-year-old girl who died a decade ago after city paramedics allegedly botched her care amid an asthma attack.

−Hal Dardick, Chicago Tribune, February 15, 2012

Pharmacy: Medications

  • Immense variety & complexity of medications.
  • Impossible for nurses or doctors to keep up with the information required for safe medication use.
  • The pharmacist has become an essential resource in modern hospital practice.

FD Finds Safety Problems
at Specialized Pharmacies

  • Federal inspectors have found dozens of potentially dangerous safety problems at 30 specialized pharmacies, months after tainted steroid shots made by a Massachusetts pharmacy triggered the worst drug disaster in decades.

−Lena H. Sun, The Washington Post, April 12, 2013

Common Prescription Errors

  • Wrong patient
  • Wrong drug
  • Inappropriate drug ordered due to known drug allergies or drug-drug and food-drug interactions
  • Wrong dose
  • wrong route
  • wrong frequency
  • transcription errors due to illegible handwriting or improper use of abbreviations
  • inadequate review of drug appropriateness

Common 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

Common 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 the MAR
  • Discontinued order not noted on the MAR
  • Medication wasted and not recorded

Control of Drugs

  • Federal Controls
  • Controlled Substance Act
  • Federal, Food, Drug & Cosmetic Act
  • State Regulations
  • Storage of drugs
  • Hospital Formulary

Decreasing Med Misadventures:
Helpful Tips – I

  • Be sure handwriting is legible; print if necessary.
  • For clarity, do not use felt-tip pens.
  • Abbreviations should be used per hospital policy.
  • Do not write ambiguous orders.
  • Always add a zero prior to a decimal.
  • Hold orders should be accompanied by a time frame.
  • Know about the med that you are prescribing.
  • Administered by the proper route.

Role of Pharmacists – I

  • Duty to monitor patient’s medications
  • Computer systems monitor for:
  • Drug-drug interactions
  • Drug-food interactions
  • Warning patients - potential for overdose
  • Refuse to honor questionable prescriptions
  • Limited Duty to Warn
  • Pharmacists cannot possibly warn caregivers & patients of every potential danger of a drug.

Role of Pharmacists – II

  • Intravenous Admixture Service
  • Dispensing and Administration of Drugs
  • Duty to Monitor Patient’s Medications
  • Warning Patients About Potential for Overdose
  • Questionable Prescription
  • Internet Pharmacy

Physical Therapy
Interpreting Physician’s Orders

  • Plaintiff alleged that defendant failed to exercise degree of care & skill ordinarily exercised by physical therapists, failed to heed his protests that he could not perform the physical therapy treatments she was supervising, & 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.

  • What was the court’s finding?

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 & that therapist’s care fell below the standard of other physical therapists.

Physicians Assistant

  • Graduate of an accredited PA educational training.
  • Nationally certified and state-licensed to practice medicine.
  • with the supervision of a physician.
  • Scope of practice defined by each state.
  • PAs responsible for own negligent acts.

Podiatrist

  • Legal concerns
  • Misdiagnosis
  • Negligent surgery
  • Failure to adhere to standard of care

Podiatrist

  • Podiatrist in Strauss v. Biggs was found to have failed to meet the standard of care required of a podiatrist & 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.
  • Podiatrist acted improperly by failing to refer the patient, stop the procedure after the first incision, inform the patient of possible nerve injury…

Respiratory Therapist

  • Failure to remove endotracheal tube
  • Multiple use of same syringe
  • Failure to properly restock the Code Cart

Licensing
Healthcare Professionals – I

  • 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 – II

  • Authority grants permission to a qualified individual to perform certain specified activities.
  • 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 health care profession.

Licensing
Healthcare Professionals – III

  • Suspension & Revocation of License
  • procurement of a license by fraud
  • unprofessional, dishonorable, immoral, or illegal conduct
  • performance of specific actions prohibited by statute; and malpractice.

Licensing
Healthcare Professionals – IV

  • Commonly stated objectives of licensing laws are to
  • limit & control admission to the different health care occupation
  • protect the public from unqualified practitioners by promulgating & enforcing standards of practice

PROFESSIONAL MISCONDUCT

  • Reporting medical misconduct
  • Sexual Improprieties
  • Dentist
  • Physician
  • Psychiatrist

Helpful Advice for Caregivers – I

  • Abide by the ethical code of one’s profession.
  • Do not criticize the professional skills of others.
  • Maintain complete and adequate medical records.
  • Seek the aid of consultants when indicated.
  • Inform the patient of the risks, benefits, & alternatives to proposed procedures.
  • Practice specialty in which you have been trained.
  • Participate in continuing education programs.
  • Keep patient information confidential.

Helpful Advice for Caregivers – II

  • Check equipment & monitor it for safe use.
  • When terminating a professional relationship with a patient, provide adequate written notice to the patient.
  • Authenticate all telephone orders.
  • Obtain a qualified substitute when you will be absent from your practice.
  • Be a good listener, & allow each patient sufficient time to express fears and anxieties.

Helpful Advice for Caregivers – III

  • Develop & implement an interdisciplinary plan of care for each patient.
  • Safely administer patient medications.
  • Closely monitor each patient’s response to treatment
  • Provide education & teaching to patients.
  • Foster a sense of trust & feeling of significance.
  • Communicate with the patient & other caregivers.

REVIEW QUESTIONS – I

What was the reasoning for enacting the EMTALA?

Should medical advice be dispensed on the telephone? Explain your opinion.

Discuss why you think the prescribing, control, administration, and monitoring of medications has become a major area of legal concern for health care professionals.

Describe the difference between the certification and licensing of a health care professional.