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Avoiding Major Clinical Errors

Practicing medicine in the US is demanding. I’ll undoubtedly make mistakes and deal with a couple of lawsuits or medical board complaints over my career. Hopefully, I can avoid major clinical errors which are hard to recover from.

But there is value in practicing medicine in the US or anywhere in the world. It’s just that I have to figure out the part of the practice that appeals to me and how to avoid major clinical disasters.

Along the way, we read about malpractice suits or medical board complaints which take the wind out of the sails. I often feel defeated and want to give up on medicine altogether.

Malpractice Suits Against Clinicians

I came across the article below, which is sad because of the pain and suffering of the patient. But it’s also sad because it’s a commentary on the US medical system.

The article, “Iowa jury awards man $27M after he was sent home with the flu. It was really meningitis,” discusses the case of a 48 yo M who arrived at an urgent care clinic in February 2017.

The PA on staff diagnosed him with influenza and sent him home. The patient had dizziness, fevers, and tachycardia and may have been combative. He returned to an ER a few days later and was admitted to the ICU for meningitis.

Committing Major Clinical Errors in Medicine

I have made plenty of mistakes taking care of patients. I am sure that some of my patients suffered or died from these mistakes. To think otherwise would be a bit arrogant or ignorant.

I’ve worked in very busy urgent cares and ERs. I’ve also worked in primary care clinics in significantly underserved neighborhoods where the baseline patient is quite sick.

Clinicians are going to make mistakes. It’s these mistakes that we will learn from. No matter how undesirable it is to be on the receiving end of a clinical error, it’s built into the limited resource system we call the US healthcare system.

Learning from Mistakes

From a societal perspective, I want community physicians to make mistakes as long as they are taught how to learn from them.

As an individual, I want no physician ever to make a mistake regarding my health.

How do we balance this dichotomy?

Often this is solved on a political or policy level. We allow some mistakes so physicians can learn, but we also hold them accountable enough that patients feel represented.

Avoiding Defensive Medicine

Our current healthcare model creates defensive clinicians. We become ever more conservative to avoid that 1:1,000 chance of an error.

Why?

Because major clinical errors don’t just cost us money but our reputation and careers, too.

If I speed on the freeway and get a ticket, I can live with that. But when I get sued or investigated by a state medical board, I risk losing my job and hurting my future employment opportunities.

Unfortunately, I retaliate by sending every patient to the ER. Even when the ER is slammed, I’ll just kick the can down the road. In such a zero-sum game, someone will get hurt.

As a physician, I need protection in this healthcare system to avoid practicing defensive medicine.

Midlevels vs. Physicians

This article isn’t about a PA or NP versus an MD or DO. If you’re a clinician, then you are a clinician. It’s not my place now to discuss whether midlevels merit the same clinical privileges as physicians.

This same thing could have happened to a physician, so I don’t see the point in arguing this semantic.

However, this is a significant point of contention in our current medical community.

The Culture of Medicine Today

I don’t think that Reddit accurately reflects the medical community’s stance as a whole. But this identical article was posted on Reddit, and the comments by physicians, medical students, and residents were disappointing.

A layperson wrote this lawsuit article. And the court case likely had facts that weren’t admissible.

To pass judgment on the PA or the clinical scenario based on this article would be misinformed and disingenuous.

My name would be just as publicized if I committed such a clinical error. And I’d be hung by my peers just as likely on a public forum.

This makes me sad but I understand that I’m capable of the same.

Lessons Learned From This Case

Again, I have no insight into the details of this case other than what was reported. But I still want to reflect on what I need to learn in order to avoid major clinical errors in the urgent care setting.

1. Triaging a Patient

In my Telemedicine Course, I discuss how critical triaging a patient is. It’s the first thing we should do.

“Is this patient too sick for this current setting?”

You might be working at 3 different clinics. One setting can handle very sick patients. Another might not be so well equipped.

Redirecting the patient should always be my priority.

2. Abnormal Vital Signs

Sending a patient home with tachycardia, tachypnea, fever, significant weight gain or weight loss, or low oxygen is risky.

We do it ALL the time, no doubt. But it’s critical to explain in your SOAP note why the heart rate is up, why the oxygen is low, and why you decided to do whatever you did based on those results.

I will argue that most urgent cares aren’t well-equipped to properly work up a patient with multiple abnormal vital signs.

3. Close Follow-Up

A patient who is ill needs a recheck, referral, or close follow-up.

Bringing the patient back later in the day or the next morning for a recheck can prevent many headaches later. Having a colleague offer a second opinion is worthwhile even if it’s not with you.

I brought a 15-year-old boy in for a recheck the next day when I saw him for a nasty sinus infection. The next day he developed eye swelling, which resulted in a CT, so my colleague, fortunately, diagnosed an abscess with cerebral extension.

4. Escalating Care

I’ve learned not to be so nice when it comes to escalating care. If I think my patient needs an ambulance or be in the ER, I won’t let them talk me out of it.

Admittedly, this is hard. Their significant other almost always will push back, and they’ll complain that the ER is expensive or the wait is long.

I can’t imagine a malpractice case where the urgent care physician got sued for sending the patient to the ER.

5. Working with Support

Many urgent cares these days are run with little support. You are often working alone or siloed enough that you can’t run things by a fellow clinician.

Unless you are getting paid a lot of money, working in a high-acuity urgent care with little support is of little value.

Ideally, pick up shifts where there is another receptive clinician by whom you can run things. Or else have a colleague available on speed-dial.

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