Thursday, September 5, 2013

In Case of Emergency: Is Your Clinic Ready?

By: Allison Adams - Attorney

Physicians are continually reminded about the significance of patient safety.  Malpractice defense attorneys such as myself often speak on the importance of preventing medical errors, effectively communicating with nursing staff and patients, and ensuring proper charting – all with the goal of helping physicians decrease the chances of being named in a medical malpractice lawsuit.  However, safety does not stop at the hospital doors.  The basics of patient safety must be carried back to your clinic office or you risk exposing both you and your clinic to potential litigation.


            Of particular importance to patient safety in the office setting is the ability to effectively and rapidly respond to a medical emergency.  While life-threatening emergencies in the office setting are rare, they can and do arise, and the ramifications of being caught unprepared can be severe.  Some of the more common office-based situations which can lead to a lawsuit include: (1) the lack of functioning equipment and up-to-date supplies; (2) the failure to document maintenance checks on equipment; and (3) the failure to properly train staff on how to respond in an urgent situation.


            Take for instance an elderly patient who comes to your office for a routine check up.  While in the examination room, you notice the patient is having difficulty breathing.  She tells you that she left her oxygen tank at home and cannot seem to catch her breath.  Concerned, you instruct your nurse to retrieve the clinic’s oxygen tank.  The tank is brought into the room, hooked up, turned on, and….nothing.  As your patient struggles for breath, you realize the tank is empty.  Now consider how that situation will appear to a jury in the hands of a skilled plaintiff’s attorney:


Deposition Examination of Defendant Doctor by Plaintiff’s Attorney


Attorney:   Doctor, what did you do when Ms. Patient began experiencing breathing difficulties in your office?


Doctor:      I had my nurse get our oxygen tank and bring it to the examination room where Ms. Patient was located.  I then hooked up the cannula, placed it on Ms. Patient, and turned on the oxygen.


Attorney:   Those actions did not relieve Ms. Patient’s breathing difficulties, did they?


Doctor:      No, unfortunately they did not.


Attorney:   And the reason the oxygen tank did not help Ms. Patient with her breathing difficulties is because there was no oxygen in the tank, correct?

Doctor:      I don’t know if there was no oxygen at all, but yes the tank was low.
Attorney:   It was so low, in fact, that it was not providing oxygen to Ms. Patient at her time of distress, correct?
Doctor:      She was not getting oxygen from the tank, correct.
Attorney:   When was the last time you checked the oxygen levels in that tank?
Doctor:      I am not sure of the exact date.
Attorney:   When was the last time someone on your staff checked the tank’s oxygen levels?
Doctor:      I do not know.
Attorney:   Well, did you have a checklist on the tank which would indicate when it was last checked?
Doctor:      No, not that I am aware of.
Attorney:   Was there a checklist anywhere in your clinic which would show when the oxygen tank was checked last?
Doctor:      I do not believe so.
Attorney:   Now you’re aware that the oxygen in the tank gets depleted over time with use, aren’t you?
Doctor:      Yes.
Attorney:   And you’ve used that oxygen tank in the past on other patients, haven’t you?
Doctor:      Yes, we’ve used it on other patients before.
Attorney:   So you’re telling me that you knew the tank had been used before, you knew the oxygen levels went down with use, and yet you had no plan in place to periodically check the tank to ensure that it was ready to assist the next patient who might need it.  Doctor, wouldn’t you consider it good medicine to make sure your oxygen tanks actually have oxygen in them?
This deposition excerpt is something no physician or malpractice attorney wants to encounter.  With an investment of time and effort, however, this scenario can often be avoided.  Below are some suggestions that are aimed at not only reducing the likelihood of litigation but, more importantly, optimizing patient safety in the office setting. 
Develop an action plan.  Having a predetermined plan of action with personnel trained to carry out the plan in a rapid and efficient manner is essential for managing any emergent situation.  Generally, it is best to have a plan that delineates the specific responsibilities unique to each staff member.  In other words,  make sure that your staff knows who is supposed to be doing what when an emergency arises – i.e., the receptionist will be responsible for calling 911, nurse # 1 will retrieve the crash cart, nurse # 2 will meet the EMS personnel at the entrance and direct them to the patient, etc. 
Train your staff.  Staff education is paramount to implementing an effective response to an urgent clinical situation.  Train your employees, both clinical and non-clinical staff members, on where the emergency equipment is located and how to use it properly.  Update your training as your equipment changes or is upgraded.  In addition, make sure to document any training sessions your staff undergoes in case questions arise as to when and whether a certain employee was aware of the action plan or equipment procedures.  It may also be advantageous to conduct mock emergency drills to allow your staff to practice all the steps in the action plan and become comfortable with the protocol. 
Take an inventory of the medications and supplies on your crash cart.  Pay special attention to the expiration dates on medications.  If a medication is outdated, dispose of it and replace it.  Make sure that the seals are unbroken and that the equipment is clean.  Also check to see if your supplies have all the proper parts and attachments.  Does your AMBU bag have a mask?  Does your intubation box have the appropriate stylets?  The worst time to find out that your equipment is missing connectors or the right attachments is during the midst of an emergency.
Check to ensure that equipment is functioning properly.  Like the oxygen tank scenario posed above, there is nothing worse that having the right equipment, but failing to make sure it is in good working order.  Routine tests and checks should be performed on all equipment to ensure batteries are fully charged, suction devices work, and pressure gauges show an adequate volume of oxygen.
Stock an adequate variety of equipment.  The selection of emergency supplies that will be kept on-site at a clinic will vary depending on your particular type of practice and your clinic’s patient population.  For example, a clinic that sees children and adolescents in addition to adults should generally keep a wider array of equipment sizes on hand than an adult-only clinic setting. 
Document regular maintenance checks.
  The supplies and equipment you keep on hand for emergencies should be inspected regularly and all maintenance checks should be documented.  I recommend keeping a checklist of when each item was inspected, who performed the check, and any findings or actions taken.  Monitor your staff to ensure that these maintenance checks are done routinely, legibly, and correctly.  In addition, it is easy to overlook the restocking of a crash cart in the aftermath of an emergency, so make sure that someone performs a re-check of the equipment and supplies after each use.  Replace any used, opened, or soiled supplies.
The above-referenced suggestions are not a one-size-fits-all solution to office safety.  Each physician must make his or her own determination as to what types of equipment to keep on hand and which policies to implement.  These decisions should be guided by several factors including, but not limited to, the volume of patients seen at the office, the demographics and medical profile of your patients, the complexity and types of procedures performed in-office, and the proximity of your office to a hospital.  In sum, tailoring your emergency plan to your individual clinic needs, devoting the time and effort into ensuring that your clinic is properly stocked with functioning equipment, and adequately training your staff will undoubtedly pay dividends if you are ever faced with an in-office emergency.
Any inquiries can be directed to Allison J. Adams, Esq. at:
            Starnes Davis Florie LLP
            100 Brookwood Place, 7th Floor
            Birmingham, Alabama 35209
            Phone:  (205) 868-6075
            Fax:  (205) 868-6099

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