In 2019, the World Health Organization categorized burnout as a syndrome resulting from chronic workplace stress that has not been successfully managed. While burnout was a concern before COVID-19, its onset has exacerbated the problem.

According to an ACEP October 2020 poll, 87% of emergency physicians reported feeling more stressed since the start of the pandemic, and 72% reported experiencing more burnout on the job.

On the surface, burnout may be classified as a workforce issue; however, its far-reaching effects can threaten patient safety. In fact, research suggests that physicians experiencing burnout are twice as likely to make a medical error. Burnout should absolutely be considered one of the root causes of medical error.

[3 MIN READ]

When most people think of triage, they think of nurses making sense of the chaos caused by 141 million annual visits to the ED.

Patients who are part of this massive onslaught of unscheduled care arrive daily at any hour, and the first person they see is someone in triage, usually a nurse, whose job is to quickly figure out who needs to be seen in what order.

In my early practice years, my ignorant impression was that triage was for dummies – all one had to do was just sit there and assign patients to a room.

Many years of experience and observation have taught me otherwise – that triage is where the best and brightest nurses should be. 

[7 MIN READ]

Among physicians, surgeons are at increased medico-legal risk compared to non-surgeons; they also have more medical malpractice claims and claims paid per year. Jena et al.¹ found that the probability of facing a claim varied from 15.3% in general surgery to only 5.2% in family general practice. In a recent review of National Practitioner Data Bank (NPDB) records, Schaffer et al.² noted that the number of paid claims per 1,000 physician years was 30.0 for general surgeons and only 7.1 for internal medicine. Although there are a number of factors responsible for this wide variation, the correlation between the physician-patient relationship and the risk of a medical malpractice suit is well established.

A recent study by Tibble et al.³ explored the incidence and classification of complaints about physicians, finding that surgeons attracted 2.3 times as many complaints as non-surgeon physicians. Although the thrust of the article remains valid and the implications are concerning, there are a few factors that modify the severity of the concern. 

[8 MIN READ]

We are all fallible. Despite their best efforts, physicians, nurses, other healthcare workers, and indeed all humans, make errors. It is an essential component of our being. It is widely accepted that a systems approach to error prevention can counteract this fallibility. Nonetheless, errors do occur. These failures can often be explained by the “Swiss Cheese Model” of error. Multiple processes are designed to prevent a type of error. Each individual process may be imperfect but used in combination one process will succeed where another may fail. Like the holes in Swiss cheese, when these imperfections are aligned and multiple processes fail, errors occur.

Below I present three cases from which we can gain perspective on how poor communication, systems errors, and cognitive bias contribute to surgical errors.

[3 MIN READ]

Apology laws have always been a quandary. I have repeatedly said they make docs feel more comfortable about apology but have little legal value. Most would assume apology laws reduce medial malpractice claims but a study by Stanford Law Review shows that this is not the case. In states with apology laws, non-surgeon physicians saw higher rates of medical malpractice lawsuits and dollars paid out. Defense lawyers should want to use the evidence created in a disclosure process if a case goes to trial.

[7 MIN READ]

Obtaining the informed consent of the patient is required in all states before an invasive procedure that carries a material risk of harm is performed.

This is a non-delegable duty of the practitioner who is going to perform the procedure; this means that the practitioner is ultimately responsible for the validity of the consent and cannot avoid liability by claiming that it was someone else’s responsibility.

However, obtaining informed consent should not be construed to be an obstacle. Obtaining informed consent can be a mechanism for reconciling the expectations of all parties involved.

[5 MIN READ]

In prior blogs, I reviewed the bare-bones of EMTALA, highlighted recent studies of EMTALA investigations, and summarized recently settled cases of EMTALA violations. In this installment, I outline the requirements of EMTALA as they relate to the role of the on-call physician.

EMTALA was passed to prevent the dumping of “non-paying” patients between hospitals. With the enactment of EMTALA, the dumping problem has diminished. The on-call physician plays a key role in patient management under EMTALA.

The “emergency medical system” depends upon emergency department access, availability of specialist physicians through the on-call roster, hospital bed and staff availability, and a referral system for tertiary or highly specialized care.

[8 MIN READ]

I recently reviewed the bare-bones of what EMTALA is and highlighted recent studies of EMTALA investigations.

In this installment, I have summarized nine recently settled EMTALA cases in which monetary penalties were levied by OIG against the hospital that serve to illustrate the factors responsible for alleged violations.

[5 MIN READ]

EMTALA violations can be a costly lesson for both healthcare providers and organizations. EMTALA is an acronym for the “Emergency Medical Treatment and Labor Act.” This statute was enacted in 1986 for the original purpose of preventing dumping – the practice of refusing service to patients in the emergency department for financial reasons. The final EMTALA statute now extends beyond this initial noble goal and prohibits discrimination against ED patients for any reason.

Regulations, rules, litigation, and medical errors are not the most popular topics for the busy clinician. Most of us would rather gargle nuclear waste than spend a precious evening reading about these issues that plague the pure and honorable practice of medicine. However, we avoid such matters at the peril of our patients’ safety as well as our own personal and professional well-being.

Since few (if any) of us will invest in a treatise the length of War and Peace on the subject, I have assembled the following short list of “10 Medical-Legal Basics Every Provider Must Know” for the busy physician, nurse, and advanced practice clinician.