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风险管理评论:医疗事故

Patient Disregards Physician's Recommendations for Immediate Treatment; Complications Result, 导致医疗事故诉讼

Theodore Passineau,法学博士,人力资源管理,RPLU, CPHRM, FASHRM


介绍

几十年来,医生们一直在处理病人不坚持护理和治疗的问题. 经常, 当病人无视医生的建议,事情进展不顺利时, 他们试图责怪医生. 这一挑战往往是复杂的,当医生是一个大的一部分, often multispecialty network rather than a solo or small group practice (where he/she might more easily develop personal relationships with patients). 这起发生在美国西北部的案件说明了一个案件是多么容易“偏离正道”.” 


事实

病人是一位52岁的男性,曾见过医生. T, 一个MedPro-insured内科医生, 在需要的基础上,通过大型的多专科诊所. T是相关联的. Dr. T had treated him 8 years earlier following a motor vehicle accident resulting in injury to his cervical spine. 病人已完全康复.

11月2日,患者在家生病. 他在呕吐,头痛,全身疼痛和恶心. 他没有前驱症状,相信自己得了流感.

11月3日,他将自己的简历递交给了李博士. R(另一位medpro保险的内科医生)在诊所的紧急护理设施抱怨发烧, 恶心想吐, 呕吐, 头疼, 和腹痛. 他的体温是103度.3度. 已下令进行适当的实验室检测,但当天没有得到结果. 胸部x光检查也显示可能是肺炎. The doctor prescribed levofloxacin and instructed the patient to contact the clinic if his symptoms worsened. 两天后,, the lab results were available and indicated elevated liver enzymes; the patient was called and asked to return to the office, 他那天做了什么. Dr. R saw the patient again and informed the patient that elevated liver enzymes and bilirubin appeared on his test results. 行腹部及骨盆CT检查, 显示肾上有囊肿,可能还有肝脏. An ultrasound of the right upper abdominal quadrant also was performed; it was positive for gallstones. 重复肝酶有所改善,脂肪酶在正常范围内.

Dr. R explained to the patient that he had gallstones and would need to be monitored to see if his liver enzymes continued to normalize. Dr. R also explained to the patient that he would need surgery because a serious complication could result from this condition in the absence of surgical treatment.

11月7日,病人和他的妻子去看医生. R为后续护理. 他的胆红素, 碱性磷酸酶, and lipase were all within normal limits; the alanine aminotransferase and aspartate aminotransferase were elevated but were lowering. 病人解释说,他知道医生的病情. R建议他去看外科医生治疗胆囊, 但他感觉很好, 于是,他和妻子打算在第二天开始一个计划已久的假期. Dr. R曾犹豫是否要批准病人的计划,但最终还是默许了. He explained that he would have the surgery department contact the patient to arrange an appointment for after their return. Dr. R’s documentation of this conversation was as follows: “Discussed surgery if desired and if symptoms return again.”

不幸的是,健康记录中没有任何迹象表明. R要求外科随访,患者声称没有来电. 因为他感觉很好,病人没有再联系诊所.

12月16日, the patient presented to the emergency department (ED) with a sudden onset of crampy abdominal pain “after eating cereal."他感到恶心并吐了三次. 化验结果显示肝和胰酶升高. 病人被诊断为胰腺炎而住院. Dr. T and a member of the clinic’s surgery department saw the patient every day during this hospitalization. The plan at that time was watchful waiting to allow the pancreas to improve/heal and then proceed to surgery if needed. 

On December 20, the patient had continued pain in the abdomen with the introduction of clear liquids. 外科医生注意到CT显示胰腺头部仍然有炎症. 治疗方案包括腹部继续休息. 

12月21日, 因为持续的疼痛和无法忍受液体, 放置鼻胃管减压. 病人自己取出了管子,抱怨这让他感觉更糟,让他呕吐. 然后管子被重新插入,病人的不适得到了缓解.

12月24日,NG管被夹住,患者似乎有所好转. 他毫不费力地吃着冰片. 他的疼痛得到了控制,计划第二天就让他出院. 12月25日,患者自己拔了NG管. 他起床了,和家人一起开怀大笑. 外科医生同意用透明液体出院回家. 然而, 病人解释说“透明液体”包括布丁, 肉汤, 运动饮料, 其他液体, 和饼干.

12月28日,患者返回急诊科,被诊断为腹痛和肠梗阻. 他用恩丹西酮和氢吗啡酮治疗. 他的淀粉酶是76, 脂肪酶是427, 白细胞计数为14k /uL, 有83%的中性粒细胞. 随叫随到的医生同意出院,建议病人去看医生. 如果他出现寒战、恶心、呕吐或发烧,3天后返回急诊科. 病人误解了看医生的说明. 3天内完成; he contended that he was told “to call” Dr. 3天内完成.

1月4日,这位病人又去找了医生. 腹部重复CT显示胰腺和胆囊持续改变. 不能排除胰腺坏死. Dr. T recalls deliberating as to whether outpatient management was possible or if admission that day was necessary. 他决定安排病人去看外科医生,让他在家休养.

1月6日, the patient had a sudden onset of projectile 呕吐 and was admitted to the hospital with acute and chronic pancreatitis. CT显示胰腺炎恶化,可能有脓肿/坏死性感染. Dr. T将患者送入重症监护室,并咨询了外科医生, 传染性疾病, 和重症监护室.

1月8日,手术治疗胰腺脓肿并伴有坏死. 取下胆囊,置入空肠切开术管. 伤口是开放的,需要包扎和引流. 病人和他的妻子争辩说,当外科医生那天早上看到他们时,她说, “如果现在胰腺坏死, 那天是星期五,需要做手术.”

从1月8日到2月28日, 病人在医院里康复了, 因术后十二指肠狭窄而造成的十二指肠梗阻正在接受治疗. 除了, 2月11日, 患者被诊断为左股静脉和胫骨后静脉血栓. 2月28日,他被转移到一家过渡护理医院. He ultimately required additional treatment at a tertiary care center for a ductal fistula that had formed between the pancreas and biliary duct remnant. 到那年8月,他已经完全康复,没有留下任何永久性损伤. 

同年晚些时候,一场医疗事故的诉讼被提起,诉讼对象是这个团体执业的Dr. R,博士. T. 经过广泛的发现, 该案已送交审判, 判决结果对医生和团体都有利. 国防费用在非常高的范围内.


讨论

An examination of this case shows that basically all of the providers’ failures were related to communication in one form or another. 不幸的是, 这种失败在日常实践中并不少见, 他们可以对病人的护理和医疗事故的辩护有显著的影响.

很容易看出Dr. Rmanbetx体育下载11月7日手术的谈话记录可能会被误解. The documentation of “Discussed surgery if desired and if symptoms return again” becomes problematic in more than one way. 这么短而迟钝的笔记对Dr. R,如果他后来试图回忆他写这本书时的想法. 另外,另一个医生可能很难理解Dr. R的意思.

A purpose of documentation that is less commonly recognized is its use to re-create the treatment circumstances at a later time, 或者作为同行评审过程的一部分, 医学调查委员会, 或在随后的法律程序中. Unclear and incomplete documentation is of little value when trying to reconstruct the case later (sometimes much later).

很明显,Dr. R的预定转诊到外科没有发生. 导致这种情况的原因有很多,比如Dr. R being interrupted just as he was preparing to enter the referral (it was an electronic order entering system), 输入信息错误(例如日期错误), 或者只是忘记了去做.

A simple solution (which works equally well with tracking test results) is to enlist the patient as a “fail-safe” technique. 当医生表示他/她将安排检查、会诊等.,他/她应该告诉病人:“你应该在未来7天内得到手术结果. 如果你不知道,请告诉我,以便我跟进.这个声明做了两件事. 第一个, the typical patient is less likely to forget about it when he/she is expecting a call within a certain timeframe. 第二个, 这让病人承担了一些责任, 在这种有争议的交流发生的情况下,哪些是有益的.

12月28日, 当病人从急诊科出院时, 预计他将在3天内来练习, 他误解的指示. 虽然出院小结无法查看, 如果它没有明确说他将在12月31日来实践, 他可能会误解是不足为奇的, 尤其是当他之前误解了“透明液体”的含义时.”

Discharge instructions are very valuable to facilitate patient adherence as well as document what the patient was told; however, 他们必须清楚, 简洁的, 易于理解,确保患者理解. 值得注意的是,患者也没有打电话给诊所.

最后, 有个问题是外科医生所说的, “如果现在胰腺坏死, 是在周五,需要手术.尽管外科医生是否真的这么说还存在争议, 如果她做了, 这显然是不恰当的,不应该说. 这类言论很少能作为玩忽职守的证据, 但它们可以作为一种动力,让不太开心的病人联系律师.


总结建议

The following suggestions may be valuable to physicians treating patients who are demonstrating less than full adherence to treatment recommendations:

  •  确保你和病人的口头交流是清晰易懂的. 包括诊断和治疗计划, 并解释不遵守治疗计划的后果. 使用以下技术:teach-back” can help facilitate patient comprehension and identify potential issues or areas of misunderstanding.
  • 类似的, ensure that documentation of clinically significant conversations with patients are clear and understandable. 患者是否应该回电核实信息, 有必要准确地确定患者最初被告知的内容.
  • 实施可靠且一致的流程来跟踪和监控诊断测试的状态, 推荐, 以及那些需要随访的病人. 让患者对预期的活动进行“双重检查”,例如转诊电话或测试结果.
  • 提供一份访视总结和出院指示. 确保出院指示清楚, 病人可以理解, 用病人的母语. 如果病人不能很容易地理解总结和说明是没有价值的.
  • 在评论其他医护人员的护理时要谨慎. 你可能不能完全理解他说了什么或者确切的情况, 什么会导致评论不准确和潜在的损害.


结论

不幸的是, there will always be patients who don’t adhere to recommendations and treatment plans for many reasons, 包括误解, 恐惧, 固执, 或者只是“不明白”.”

每一次有临床意义的谈话都应该考虑到这一事实. You cannot change your patient; you can only arm your patient with accurate information in a way that maximizes his/her chances of understanding. 一定要始终完整地记录你与病人的对话.



This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. 因为适用于你的情况的事实可能会有所不同, 或者在你的管辖范围内适用的法律可能不同, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, 州或联邦法律, 合同的解释, 或其他法律问题.

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