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The CMG Voice

Avoiding Misdiagnosis: Tips for Doctors, Patients, and Health Care Organizations

Posted Monday, May 5, 2014 by Tyler Goldberg-Hoss

The most recent edition of Inside Medical Liability includes an article titled “Minimizing Diagnostic Error: 10 Things You Could Do Tomorrow.”

In it, the author describes the current state of diagnostic errors in healthcare. Approximately 1 out of every 1,000 diagnostic encounters results in harm due to a diagnostic error, while the number is much higher when including errors that don’t result in harm. Diagnostic errors resulted in lawsuits more than any other type of claim, and it’s not the rare diseases that get missed. Most often it’s the common ones.

The article ends with 10 tips for doctors, 10 tips for healthcare organizations and 10 tips for patients to avoid diagnostic errors.

For doctors, these tips include taking time to think, really listen to your patient, and taking advantage of resources such as other doctors for second opinions.

For health care organizations, tips include encouraging communication when there is an error, encouraging communication between radiologists and laboratory doctors with the front line physicians, and empowering patients.

Finally, patients can help to avoid diagnostic errors by taking control over their care, including asking for second opinions and coordinating follow up visits, speaking up about their symptoms, and asking doctors questions to learn more about the condition.

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Florida strikes down caps on non-economic damages in medical malpractice cases.

Posted Tuesday, April 29, 2014 by Tyler Goldberg-Hoss

Recently, the Florida Supreme Court found, by a 5-2 vote, that caps on non-economic damages in medical malpractice cases violated the Florida equal protection clause.

Caps were originally set, not only in Florida but in many other states, as a response to worries of a medical malpractice “crisis,” which includes insurance rates rising and doctors being forced to move their practices out of state.

What this Court found was that such a “crisis” was not supported by available data. This decision will not significantly affect access to health care, but will allow families to be rightfully compensated for the negligence of health care providers.

Read the article here:

Florida Supreme Court Throws Out Statutory Caps on Wrongful Death Cases

Fortunately, victims of malpractice in Washington are not faced with such caps on damages. Although every year there is some threat in the legislature to “reform” laws governing medical malpractice, victims of heath care errors have thus far been spared serious erosion of their rights.

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Time loss is brain loss: timely treatment for strokes possible, but not probable in today’s world

Posted Wednesday, April 23, 2014 by Tyler Goldberg-Hoss

A recently published article in the Journal of the American Medical Association (JAMA) has shed some light on the availability for treatment of stroke victims, as well as the barriers there are in getting victims the treatment they need within the time when it makes a difference.

The medication is tPA – officially “Tissue Plasminogen Activator” and colloquially a “clotbusting” drug. Victims of ischemic strokes who are treated quickly – within 60 minutes of experiencing stroke symptoms – have the best chance to avoid brain damage or death. Certainly, tPA is given after this time for patients in the hopes of being effective, but this article highlights the idea that sooner is better.

The problem is, for many reasons, most victims eligible for the treatment do not receive it within this “golden hour.”

The JAMA article details the ways in which hospitals can shorten the time from “Door-to-Needle.” This includes improved communication between ambulance staff and the emergency department, educating the public on how to identify a person who is having a stroke, and even having specialized ambulances bring the treatment to the stroke victim, complete with tPA, a CT scanner, lab equipment, and a neurologist.

As of now, only 30% of stoke victims receive tPA within 60 minutes. JAMA and the American Stroke Association have collaborated on “Target:Stroke,” which is designed to improve the quality of stroke treatment nationally. Target:Stroke is recognizing hospitals who meet their goal of treating at least 50% of stroke victims within an hour.

You can read an article summarizing the JAMA article here:

Hospitals Can Speed Stroke Treatment, But It’s Not Easy

You can find the full JAMA article for free here:

Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative

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Deception in Medicine

Posted Friday, February 21, 2014 by Tyler Goldberg-Hoss

Taking a proper clinical history is one of the most important things doctors do when they treat their patients. Unfortunately, that communication isn’t always ideal. Patients aren’t always the best reporters of their symptoms, doctors don’t always ask the right questions, and sometimes actual deception is involved.

So says Dr. Sandeep Jauhar in an Op Ed for the New Your Times. Read it here:

The Lies That Doctors and Patients Tell

Certainly, deception can have its place in medicine. Think of the cancer doctors who aren’t entirely upfront with a patient’s prognosis. Hope can help fight disease.

And it’s understandable in the example that Dr. Jauhar uses – an elderly woman he is convinced he can save with more treatment.

But it’s not understandable when deception is used to perform surgeries and other treatments that have questionable value, especially when the patient isn’t fully informed about the possibilities that such treatment will work.

A good example can be found in recent studies that show a huge increase in the number of lumbar spine fusions being done on older patients with chronic low back pain. It is uncommon for the patient to experience a significant improvement, and worse outcomes occur on a frequent basis. The operations are also expensive, but Medicare pays for them without advance approval. That may be a factor in the willingness of surgeons to recommend the procedures. Hospitals also benefit from the facility and other costs associated with the hospital stay required for the surgeries.

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“Sloppy and paste” charting in electronic medical records dangerous for patients.

Posted Monday, February 17, 2014 by Tyler Goldberg-Hoss

“Sloppy and paste” charting in electronic medical records is dangerous for patients.

A recent study in Critical Care Medicine found that physicians and residents often used the cut and paste feature to more quickly chart patient notes into the electronic health records (EHR) system.

You can read a review of the study from the Washington Academy of Family Physicians website here:

“Sloppy and paste” endures despite patient safety risk

The study found that 82% of all residents’ and 74% of all attending notes contained at least 20% copied information. Doctors and residents argue that without copying and pasting, there is simply not enough time to chart on patients.

But copying and pasting also has the potential to cause serious harm to patients. The article relates a story about a patient who was supposed to get an anticoagulant medication, and the chart note stated the patient “would” receive it. Unfortunately, the same chart note was copied and pasted four days in a row, the woman was discharged without getting the medication, and was later re-hospitalized after suffering a life threatening pulmonary embolism.

In our own practice, it is common for us to review records that show the same language in successive chart notes.

It’s unclear whether physicians need more time to responsibly chart, or the system somehow needs fixing to prevent this problem. What is clear is that patients can suffer serious harm when “sloppy and paste” occurs.

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