Documentation Can Prevent Litigation: Patient Safety Impact Story
The Doctors Company is continually working to identify potential sources of risk and enhance patient safety. Our Patient Safety INSIGHT Services and extensive library of resources and tools take a data-driven approach to help you reduce adverse events while increasing patient safety and satisfaction. Here is one story of how our Patient Safety/Risk Management team reduced risk in a member practice.
The Challenge
A general surgery practice had an established after-hours call policy, with each surgeon answering a call documenting details in the EHR. Practice leaders were adamant the policy was being followed.
The Doctors Company conducted a Practice Risk INSIGHT analysis, and an audit was recommended. The most recent five months of after-hours calls were reviewed.
The Results of the Audit
227 calls were received
175 calls (77 percent) were undocumented in the EHR
The Severity of the Problem
A real-life claim: Five days post-op for the repair of a lower extremity tendon on the patient, a family member called. The surgeon took the call via an after-hours answering service. The patient was experiencing rapid breathing, shortness of breath, tachycardia, chest discomfort, weakness, and leg swelling. The patient was instructed to go to the ER to be evaluated. The patient did not go. Four days later, the patient died of a pulmonary embolism. There was no medical record documentation of the call. The surgeon had zero recollection of the call.
Intervention to Drive Reliability
Incomplete documentation of patient or family communication diminishes the ability to prevail in litigation. A few moments to document critical details of care after a call may prevent patient harm, adverse outcomes, and litigation.
Build safe and reliable processes that standardize operating procedures without undue effort, and link those processes to behaviors to reinforce a culture of safety and high reliability.
- Acknowledge and verify the problem: Our Patient Safety/Risk Management team audited the practice’s process and presented the evidence-based data back to the practice leaders. All leaders and all providers were exposed to the documented results from individual surgeons and their teams.
- Educate on the benefits: Our team developed and moderated extensive CME programs for all clinical staff on the liability exposure of undocumented patient dialog. These programs included claims data related to after-hours calls from The Doctors Company database.
- Continuous process improvement: Our team established new, operationally sensitive processes to reconcile after-hours calls with daily documentation efficiently and effectively.
Patient Safety Impact
The call documentation rate for individual surgeons increased to 82 percent.
- Improved documentation rates were delivered by seven of eight doctors.
- Four doctors increased documentation rates to 100 percent.
We’re Here to Help
Members of The Doctors Company can request a comprehensive risk assessment by our Patient Safety/Risk Management experts. We will partner with you to tailor a survey to your practice and provide a customized service plan. To request a survey, contact us at (800) 421-2368 or by email.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
10/23