Death After Outpatient Surgery page 3

Medical Liability for Referrals to Specialists page 4

Patient Handoffs: More Than a Formality page 5

Issue 1 March 2015Arizona Issue

PROVIDING MEDICAL PROFESSIONAL LIABILITY IN ARIZONA, COLORADO, NEVADA AND UTAH

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(602) 956-5276(800) 352-0402www.mica-insurance.com

Nine Yearsand $310Million!

Over the past nine years, MICAhas distributed a policyholderdividend each year to ourqualifying members. Our nine-year total of dividendsdistributed to MICA policyholdersis $310 Million.

Dividends declared for a policy yearreflect the Company’s financialperformance during that year. Past performance does not guaranteefuture dividends.

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MICA was founded in 1976 after the largest medical professional liability (MPL) insurance carrier announced it was no longer underwriting MPL insurance coverage for the physicians of Arizona. MICA offers stability through the peaks and valleys of the insurance cycle.

Our mission is to protect and defend the practice of medicine in Arizona, Colorado, Nevada and Utah. Our vision is to be the insurance company of choice for physicians and their groups, medical facilities and nurse practitioners.

Our values include outstanding service to our mem-bers, affordable insurance coverage, prudent underwrit-ing principles, relevant risk management programs to educate and protect our members, aggressive defense against claims, and paying dividends to our members when financial conditions warrant. In fact, over the past ten years, we have paid $337 million in dividends to our members*.

Our mission is to protect and defend the practice of medicine in Arizona, Colorado, Nevada and Utah.

Executive Staff: James F. Carland, III, M.D. President & Chief

Executive Officer Ronald E. Malpiedi, Vice President & Chief

Operating OfficerEdward G. Marley, MBA, Vice President &

Chief Financial Officer Darren J. Palmer, Vice President & Chief

Information OfficerRobin L. Charles, MBA, CIC Vice President,

Marketing & Corporate Communication Walt Davis, Vice President, Claims

Mary K. Hedin, MBA, RPLU, Vice President, Underwriting

Leon W. Kochan, M.C.Ed, Vice President, Human Resources

Julie A. Ritzman, MBA, Vice President, Risk Management Service

Board of Trustees: James F. Carland, III, M.D., Chairman

Marc L. Leib, M.D., Vice ChairmanJoseph W. Hanss, Jr., M.D., Secretary

Douglas P. Jensen, M.D., Treasurer Phyllis I. Biedess

James G. Leiferman, M.D. Steven P. Matteucci, J.D. Jeffrey W. Morgan, D.O. Karen J. Nichols, D.O.

David A. Pedersen, M.D. J. Greg Rula, M.D.

Amy A. Silverthorn, M.D. Walter K. Sosey, M.D.

Charles W. Swetnam, M.D.Michael A. Trainor, D.O.

About us

* Dividends declared in a given policy year reflect the Company’s financial performance during that year. Past performance does not guarantee future dividends.

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43-year-old male under-went laparoscopic repair of a left inguinal hernia in an ambulatory surgery center

(ASC). The patient was transferred to the PACU where he remained for three hours until discharge. During his recovery phase, the patient complained of significant pain and was given Fentanyl and Dilaudid on four separate occasions. Despite the pa-tient’s persistent elevated blood pressure and complaints of pain, the patient was discharged from the facility.

During the night the patient’s condition worsened and early the next morning he was taken to an Emergency Department. The patient expired less than five hours af-ter reaching the hospital. His final diagno-sis was sepsis resulting from a perforated bowel.

The patient’s wife filed a lawsuit nam-ing the PACU nurse and the facility. The allegations were failure to adequately monitor the patient and failure to inform the surgeon of the patient’s persistent pain and hypertension. During the course of the lawsuit it was discovered that the anesthe-siologist had signed the authorization to discharge the patient before the surgery was performed. The anesthesiologist was added as a defendant in the lawsuit. The jury found for the plaintiff and awarded a verdict in the high six figure range.

Problems with this case: Inadequate documentation made it difficult for the defense to demonstrate the patient was appropriately monitored during his post-procedure recovery. There was no docu-mentation of the patient’s response to each administration of pain medication or of the patient’s condition at discharge. There was a 90 minute gap in the documentation which gave the plaintiff’s attorney an opportunity to argue that the nurse neglected to check on the patient during that time.

The anesthesiologist’s practice of signing the discharge form before the procedure created significant problems for the de-fense. The anesthesiologist testified it was his customary practice to evaluate patients in the PACU before discharge. The jury, however, believed the anesthesiologist never saw the patient after leaving him in the PACU.

Discussion: Advances in technology, economic consid-erations, and convenience have contributed to the expanding number of procedures per-formed in ASCs and office-based settings. Licensure is generally required for ASCs, and many are also accredited. Licensure and ac-creditation require certain standards for per-sonnel, equipment, monitors, physical space, and administrative policies. Most states do not have the same regulatory requirements for the office-based setting and in the states that do, there is a wide variation in the scope and level of enforcement.

There are important safety considerations for the monitoring of patients receiving minimal or moderate sedation, just as there are for those receiving deep sedation or general anesthesia. Adequate moni-toring requires sufficiently educated and trained personnel, as well as appropriate monitoring equipment. Vigilant post-pro-cedure monitoring is critical for identifying immediate complications or unanticipated outcomes and ensuring an appropriate medical response.

Documentation is necessary for provid-ing evidence of the care rendered during the patient’s peri-procedure experience. Periodic vital signs, level of consciousness, actions taken to address patient com-plaints and the patient’s response to these actions are important elements in creating a clear picture of the care rendered. With-out adequate documentation it is extremely difficult to substantiate that certain aspects

of patient care were accomplished. Docu-mentation in advance of an event can lead to lapses in the patient’s continuing care and destroy the credibility of the physician and the medical record. The patient did not appear to have the benefit of a final assessment by the anesthesiologist. The nurse simply followed the written authori-zation and discharged the patient.

Communication failures among the mem-bers of the care team can expose patients to serious medical errors. We will never know how this patient’s story may have ended if the nurse would have notified the surgeon of the patient’s continued complaints of pain. Additionally, clear discharge instructions may have assisted the patient and his wife in recognizing the need to seek medical attention sooner.

Despite all precautions, any patient can experience a complication from a surgery or procedure. The following management of risk plan can help improve patient out-comes and minimize liability risk.• Use a recognized scoring system,

such as Aldrete’s, in the recovery phase and establish clear discharge criteria.

• Monitor the patient’s response to medical interventions and document the results.

• Ensure abnormal findings are commu-nicated to the attending physician in a timely manner.

• Provide a written copy of the dis-charge instructions and carefully explain them to the patient and ac-companying responsible adult.

• Include emergency contact informa-tion in the discharge instructions.

• Document the patient’s medical condi-tion at discharge.

• Call the patient 24 hours after the procedure to determine how their recovery is progressing and document the conversation.

Death After Outpatient Surgery

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f a patient requires treatment out-side the treating physician’s experi-ence and training, then referral to another physician in the appropri-ate specialty is likely indicated.

If the patient sues, the lawsuit will prob-ably name both the referring physician and specialist. In the event of litigation, the referring physician will be held to the standard of what, in the opinion of the plaintiff’s expert, the reasonable and pru-dent physician making a referral would do under the same or similar circumstances.

Physicians cannot avoid all medical liabil-ity when a referral to a specialist is made. In these cases, the referring physician’s responsibilities may include choosing the right specialty, choosing a qualified physi-cian in the specialty, supplying all relevant information, and sometimes even partici-pating in obtaining the patient’s informed consent.

The selection of the specialist must be a reasonable one given the patient's condi-tion. If the patient has chest pain, then referral first to a cardiologist rather than to a gastroenterologist may be the most ap-propriate referral under the circumstances. The referring physician may nonetheless be criticized for not having referred to a gastroenterologist. However, it is usually prudent to initially send the patient for a work-up for the higher risk condition, in this example, a cardiac condition.

To avoid a claim of "negligent referral," as-certain whether the physician or treatment center to which you refer is well-qualified. If you refer to an institution, you may want to specify a physician with experience in the patient's disorder. For example, if the patient has a spine condition that might require surgery, the choice of a physi-cian not experienced with spine surgery cases could create a liability issue for the

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referring physician. Similarly, if the refer-ring physician is aware that a specialist has an extensive medical board disciplin-ary history, a lack of board certification, or a lot of malpractice actions, these facts could pose a problem for the referring phy-sician if the outcome is adverse.

Informed consent can also become an issue. Referring physicians have, in some cases, been held liable in part for the treating specialist's failure to obtain informed consent. Determine whether the specialist wants you to participate in the informed consent process. If not, document that the patient will rely upon the specialist for the informed consent discussion. If you are going to be involved, be sure you are qualified to participate in the discussion. Otherwise, defer to the specialist, and let the patient know that the specialist will be responsible for the informed consent discussion.

Communication, with the patient and specialist, is important throughout the referral process. The referring physician should follow up to make sure the patient knows why it's important to see a special-ist. Remember, breakdown in communica-tion between and among physicians is a frequent cause of adverse outcomes and malpractice suits. Don't assume that a specialist will keep you informed. Contact the specialist if he or she does not report back to you and establish the parameters of your continued involvement with the patient.

Physicians are legally responsible only for their own treatment decisions, including referrals. A referring physician will be held to a reasonable standard of care for his or her own judgment in making the referral. However, once a referral is made, set the parameters for what role, if any, you will continue to play in connection with the patient’s continued care and treatment.

Medical Liability for Referrals to Specialists

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The patient “handoff”, the transfer of care from one clinician to another, is an area of high risk with the potential for dire consequences for the patient if relevant information is not communicated effectively. When the handoff is not done well, crucial informa-

tion may be missed and others on the healthcare team may make critical errors based on erroneous assumptions.

The most common flaw in patient handoffs is the tendency to view the exchange of patient information as a “data transfer rather than a higher level information exchange,” according to Meghan Dierks, M.D., a faculty member at Harvard Medical School and a member of the Clinical Decision Making Group at MIT. The hand-off should be an exchange of very complex, abstract information such as how the patient’s status is or is not consistent with the expected.

According to Dr. Dierks, healthcare team members should contex-tualize the information at handoff to give the receiver the ability to anticipate potential problems. An explanation of the patient’s antic-ipated progress as well as contingency plans if certain events play out differently should be included in the handoff. The quality of the patient handoff declines as more people are involved suggesting that specific information is not being processed by each recipient.

There are several communication models that outline the infor-mation that should be exchanged for an effective handoff. The STARS model is an example:

• Situation: give a framework so the recipient understands the context.

• Timing: Express the degree of urgency (time) or the frequency (repetition) for action.

• Action: What are the specific actions to be taken?• Responsibility: Who is to do what? Name names. Don’t use

pronouns.• Summarize: Boil it down into one or two sentences.

The degree to which the information is discussed will depend on the individual patient and situation, but certain broad areas should always be covered such as:

• Baseline benchmarks• Most recent phase of care• Current status• Expectations• Housekeeping issues

Remember, the goal for the effective handoff is a meaningful discussion about the patient’s status and treatment.

TPatient Handoffs: More than a Formality

PRSRT STDU.S. POSTAGE

PAID

SALT LAKE CITY, UTPERMIT NO. 571

2602 E Thomas Rd Phoenix, AZ 85016

© 2015 Mutual Insurance Company of Arizona

2014

Medical Professional Liability Insurance

(602) 956-5276(800) 352-0402 www.mica-insurance.com

Dividends declared for a given policy year

reflect the Company’s financial performance

during that year. Past performance does not

guarantee future dividends.

But MICA’s history of dividend

payments extends well beyond the

last ten years. In fact, since our

founding in 1976, MICA has

distributed over half a billion dollars

in dividends to its members.

MICA announces tenthconsecutive year ofdividends.

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