Risk Management
One of the day-to-day difficulties is how
to practice risk management in the emergency department's real-world
environment. Risk management is about preventing loss of life,
loss of well being, loss of money and loss of time spent in depositions
and in front of juries.
Every emergency physician must always consider
the high-risk clinical probabilities for each presenting complaint.
For instance, with abdominal pain the differential diagnosis of
myocardial infarction, appendicitis, ectopic pregnancy, testicular
torsion and AAA must be considered. The key is to develop risk
management practice habits that include: documentation, observation,
re-examination and adequate provision for follow up. Follow up
can be a re-examination after six hours, a return to the emergency
department after 12 hours, guaranteed follow up with a private
physician or admission for observation.
Myocardial infarction is another good example
where risk management practice habits are vital. It has clearly
been demonstrated that more than half of the missed AMI litigation
could be prevented with the use of checklists, protocols, data
collection forms and algorithms that provide predictive values.
Emergency physicians must be adept at recognizing
atypical presentations and must not be misled by bedside maneuvers
such as administering a GI cocktail, which has no predictive value.
Again, good documentation, observation, re-examination and proper
follow up are crucial elements in good risk management. Legally,
the emergency physician is expected to do only what is reasonable
under the circumstances.
If most emergency physicians cannot make
a particular diagnosis, you are not expected to either. However,
it will appear you did not do your job properly if the documentation
does not look good in trial.
Finally, reviews of malpractice litigation
routinely find the following reasons as the most provocative in
the genesis of a lawsuit: Delivering information poorly and devaluing
or failing to understand the patient and/or family's perspective
or views.
The literature consistently shows that
the quality of the patient-physician relationship has a significant
impact on the frequency of malpractice litigation. Simple steps
such as touching the patient in greeting, sitting down and maintaining
eye contact can change a patient's perception of their care.
In particular with pediatric patients,
never walk out of the room until the parents are convinced you
did an adequate exam of their child.
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