failure to insist on ems transport

Case Closed

a case study to help you manage risk.

presentation

At 8:30 a.m., a patient’s wife called her husband’s family physician and requested an appointment because her husband was experiencing chest pain that began the previous evening. The wife reported that her husband refused to go to the emergency department (ED).

The patient was a 61-year-old man and his medical history included low back pain, hypercholesterolemia, and hypertension. He had been a smoker for 40 years.

presentation

The patient’s wife was instructed by the physician’s staff to take her husband directly to the ED, yet the patient insisted on being seen by the physician. The wife was told to bring him to the office.

presentation

Upon arrival, the patient’s blood pressure was 95/65 mm Hg and his pulse was 57 bpm. The family physician noted bilateral wheezing in the patient’s lungs. EKG results indicated ST elevation and some disturbance in the inferior leads. The physician interpreted the EKG results as abnormal and noted “probably acute inferior infarction” on the EKG printout.

presentation

The physician called the ED and spoke to the on-call cardiologist advising him of the patient’s symptoms and EKG results. He asked the cardiologist to meet the patient in the ED.

presentation

The physician spoke to the patient’s wife advising her that the patient needed to go to the ED to determine if the patient was having a myocardial infarction. The physician handed them a copy of the EKG printout and offered them the option of traveling to the ED by ambulance or private car.

presentation

They declined the ambulance and chose to travel by private car, believing that it would be faster. This discussion was not documented in the patient’s chart. On the way to the hospital, the patient experienced cardiac arrest and died.

allegations

A lawsuit was filed against the family physician. The allegations included failure to call EMS to take the patient to the hospital and failure to take measures to prevent the cardiac arrest.

The plaintiffs alleged that the patient might have survived if he had been transported to the hospital by ambulance.

legal implications

TMLT consultants who reviewed this case did not support the family physician’s decision to allow the patient to go by car to the hospital. He should have insisted on EMS transportation, which would have been safer for the patient.

Consultants also had concerns about the phone call documentation in the patient’s chart. The notes documenting the wife’s initial call to the office appeared to have been written after the office was notified of the patient’s death. The physician encounter notes and instructions to the patient appeared to have been added at a later time as well.

legal implications

Also affecting the outcome of this case was the patient’s noncompliance and poor judgment. His refusal to go to the ED as initially instructed contributed to the poor outcome.

legal implications

This case was settled on behalf of the family physician.

disposition

Based on the patient’s symptoms and cardiac risk factors, TMLT consultants who reviewed the case stated he should have been firmly directed to go to the ED. They felt the patient should not have been given a choice in the matter.

risk management considerations

The wife’s phone call and the physician’s instructions were recorded as late entries and were not identified as such. As a result, the entry was perceived as an alteration to the medical record.

Medical records should never be altered. Late entries should always be annotated with the time and date along with the reason for the late entry.

risk management considerations

Although the patient was appropriately referred to the ED, it is recommended that well-defined telephone triage protocols be developed and followed by staff. Physicians and staff should document actions to demonstrate that protocols are followed. Emergency protocols should also be developed.

risk management considerations

disclaimer

This closed claim is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physician(s) led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physician and the patient.© Copyright 2016 TMLT.

about tmlt

With more than 19,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. www.tmlt.org

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