527500
research-article2014
CPJXXX10.1177/0009922814527500Clinical PediatricsOtillio et al
Article
Effectiveness of a Medicolegal Lecture on Risk-Reduction Medical Record Documentation by Pediatric Residents
Clinical Pediatrics 2014, Vol. 53(5) 479–485 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814527500 cpj.sagepub.com
Jaime K. Otillio, MD, FAAP1, Daniel B. Park, MD2, Kathryn M. Hewett, MD2, and Joseph D. Losek, MD, FAAP, FACEP2
Abstract Objective. To determine the effectiveness of a medicolegal lecture on risk-reduction documentation by residents in a pediatric emergency department. Design/Methods. Pediatric residents at an academic children’s hospital were offered a 1-hour lecture on reducing medicolegal risks. Residents in attendance made up the intervention group (IG) and nonattendants were the control group (CG). The primary outcome was risk-reduction documentation (RRD) using patients with chief complaints of abdominal pain, extremity fractures, and lacerations with potential foreign body. Results. For abdominal pain patients, RRD by IG improved 6.1% compared with 15.1% for the CG. For fracture patients, RRD by IG improved 20% compared with 26.5% decrease by CG. For laceration patients, RRD by IG decreased 20.8% compared with 30.6% decrease by CG. Although none reached statistical significance, the postintervention IG rates were greater. Conclusions. We showed a trend toward improvement in the rate of riskreduction medical record documentation. Keywords medicolegal education, risk management, risk-reduction, documentation, resident curriculum
Introduction Continued periodic surveys conducted by the American Academy of Pediatrics (AAP) find that approximately 30% of pediatricians are sued during their career, and 10% of the occurrences leading to suit occur in residency.1,2 Yet recent AAP surveys of graduating residents have shown that 57% reported receiving no instruction in medical malpractice litigation, 54% reported receiving no instruction on medical liability insurance, and 50% reported no instruction in risk management and loss prevention.2 The AAP has recently recommended that residency programs incorporate this education into their curricula.3 Good risk management is a solid basis, not only for reduction of the risk of lawsuits but also for improvement in patient safety and care quality.2 Most residents are also not fully aware of their personal liability when it comes to medical malpractice. This is unfortunate because litigation involving residents is not a rare occurrence. It has been estimated that residents are named in approximately 22% of lawsuits as co-defendants in addition to attendings and hospitals.4 While it is impossible to completely remove the risk of lawsuit from oneself, there are numerous suggested strategies aimed at prevention. These suggestions
include keeping up with current clinical practice guidelines, establishing professional patient–physician relationships, close follow-up of studies and laboratory tests ordered, and making sure that documentation is thorough and complete.5 Though specific medical diagnoses underlying most pediatric lawsuits has not been systematically analyzed, certain diagnoses have led to successful legal claims historically and are likely to lead to similar claims in the future. Knowledge about the medical conditions producing successful lawsuits is a starting block for development of improved patient safety, as well as risk-reduction techniques, especially with documentation practices.6 Evaluation of prior deficiencies in documentation can lead to improvements in the future. When care is closely analyzed for litigation purposes, the chart becomes essential in determining the details of the encounter and 1
Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, TN, USA 2 Medical University of South Carolina, Charleston, SC, USA Corresponding Author: Jaime K. Otillio, Monroe Carell Jr Children’s Hospital at Vanderbilt, 2020 Children’s Way, 1014 VCH, Nashville, TN 37232, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at Bobst Library, New York University on June 4, 2015
480
Clinical Pediatrics 53(5)
can be a friend or foe in a physician’s defense during a trial. Though the medical chart conveys only a skeleton of the patient–physician encounter, clear documentation of relevant physical exam findings may be helpful in defense or even dissuade a plaintiff’s attorney from pursuing the case.7 A recent analysis highlighting specific medical conditions associated with lawsuits against pediatricians found that12% of meningitis claims made to the Physician Insurers Association of America (PIAA) involved problems with the medical chart or inadequate charting, including failure to record pertinent negative findings and nonrecorded reassessment of patient status.6 PIAA analysis has also identified meningitis, appendicitis, long-bone fractures, lacerations, and testicular torsion as the most common diagnoses involved in lawsuits originating in the pediatric emergency department (PED).8 The purpose of this study was to analyze whether a simple educational intervention on medical liability can, not only increase the pediatric residents’ awareness and knowledge of this topic but also affect risk-reduction through better documentation. It has not previously been determined whether or not a 1-hour lecture can make a significant impact on the documentation practice of pediatric residents.
Methods Study Design and Setting This was an experimental study of risk-reduction documentation by pediatric residents from an Accreditation Council for Graduate Medical Education (AGCME) accredited resident education program (48 residents) at an urban, academic children’s hospital PED with an annual census of 22 000. This study was conducted over a 26-month period (January 1, 2011 to March 1, 2013). Approval for this study was granted by the hospital’s institutional review board with a waiver of consent because care was not altered and no patient identifiers were collected. The intervention was a 1-hour lecture given during the pediatric resident’s protected conference time. The lecture was prepared and presented by authorOtillio, a -second year pediatric emergency medicine fellow at the time of the lecture. The lecture focused on various medicolegal issues, including procedural aspects of how a lawsuit develops, medical liability insurance coverage, and risk-reduction through careful documentation. The lecture was designed using information from AAPgenerated literature, most specifically Medicolegal Issues in Pediatrics, 7th edition.9 Prior litigation from
common diagnoses involved in pediatric lawsuits were discussed, including fractures with poor neurovascular status, lacerations with retained foreign bodies, and abdominal pain leading to missed appendicitis. Specific recommendations for reduction of risk through documentation were provided. Categorical pediatric residents in the postgraduate year (PGY)-I and PGY-II classes (2011-2012) were included in the study. The lecture was given in June 2012, therefore all graduating PGY III residents as well as residents who did not have rotations scheduled in the PED within the study period were excluded from the risk-reduction documentation analysis portion of the study. Intervention group participants were both in attendance at the lecture and had the required rotation time in the PED. Control group participants had the required rotation time but were not in attendance at the lecture. Prior to the lecture intervention, the residents in attendance completed a questionnaire and pretest. The questionnaire of 18 items was used to collect basic demographic data as well as to assess for any previous medicolegal training and experience. A 5-point Likerttype scale was used for self-assessment of knowledge about medicolegal issues, ability to define standard of care, and fear of malpractice lawsuits affecting practice. Questions requiring only an affirmative or negative response included previous involvement in malpractice cases, previous employment in a legal environment, familiarity with liability insurance, and opinions about the value of medicolegal education in residency training. The pretest contained 9 items used to assess prior knowledge of topics to be covered in the lecture intervention (Appendix A). Immediately following this lecture, to assess for improvement in knowledge, a posttest with the same nine items as the pretest was distributed. Topics on both versions included medical record alteration, communication as a catalyst for lawsuit, general malpractice insurance coverage, and individual responsibility in litigation. Additional questions were asked at the end of the post-test inquiring if the resident believed the lecture would have an immediate and/or lasting effect on their documentation practice, and if they perceived lectures on medicolegal risk to be beneficial to their future career (Appendix B). Pilot testing for clarity and face validity was performed using graduating residents who were not part of the study population. Pediatric emergency department encounters with chief complaints or diagnoses of abdominal pain, fracture, or laceration were selected through a query of the PED tracking board system. A list of encounters was generated by searching for chief complaints or
Downloaded from cpj.sagepub.com at Bobst Library, New York University on June 4, 2015
481
Otillio et al diagnoses, including “lac,” “fracture,” or “abdom.” Encounters were included if assigned via the tracking board to a participating pediatric resident. Further exclusion criteria for charts of patients with abdominal pain included recent traumatic events, dysuria, history of inflammatory bowel disease, pregnancy, history of sickle cell disease, or age less than 1 year. Fracture charts were excluded if involving nonextremity fractures or reinjury of a recent fracture. Laceration charts were excluded if the injury was nonforeign body related in addition to all head or facial lacerations, intra-oral lacerations, eye injury, penile or perineal lacerations, self-inflicted injury, or animal bites. A chart review to assess for content was performed using a blinded, 2-reviewer system. The reviewers received an orientation, including discussion of the standard form created for collection of data and exclusion criteria for the study. For abdominal pain patients, the documentation of presence or absence of right lower quadrant tenderness was recorded. For fracture patients, the documentation of neurovascular status of the extremity distal to the fracture was recorded. For laceration patients, the documentation of need for imaging studies among those with potential foreign body involvement was recorded. Reviewers were instructed to eliminate patient encounters in which the principal investigator was involved. The reviewers were not informed of the goals of the study. Data from the standard form were entered into a Microsoft Excel (Microsoft Corp, Redmond, WA) spreadsheet. Categorical data were reported as numbers and proportions and analyzed as 95% confidence intervals (CIs) for differences in proportions. Continuous data were reported as means, standard deviation, median, and ranges and analyzed as 95% CI for differences in means. A P value
research-article2014
CPJXXX10.1177/0009922814527500Clinical PediatricsOtillio et al
Article
Effectiveness of a Medicolegal Lecture on Risk-Reduction Medical Record Documentation by Pediatric Residents
Clinical Pediatrics 2014, Vol. 53(5) 479–485 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814527500 cpj.sagepub.com
Jaime K. Otillio, MD, FAAP1, Daniel B. Park, MD2, Kathryn M. Hewett, MD2, and Joseph D. Losek, MD, FAAP, FACEP2
Abstract Objective. To determine the effectiveness of a medicolegal lecture on risk-reduction documentation by residents in a pediatric emergency department. Design/Methods. Pediatric residents at an academic children’s hospital were offered a 1-hour lecture on reducing medicolegal risks. Residents in attendance made up the intervention group (IG) and nonattendants were the control group (CG). The primary outcome was risk-reduction documentation (RRD) using patients with chief complaints of abdominal pain, extremity fractures, and lacerations with potential foreign body. Results. For abdominal pain patients, RRD by IG improved 6.1% compared with 15.1% for the CG. For fracture patients, RRD by IG improved 20% compared with 26.5% decrease by CG. For laceration patients, RRD by IG decreased 20.8% compared with 30.6% decrease by CG. Although none reached statistical significance, the postintervention IG rates were greater. Conclusions. We showed a trend toward improvement in the rate of riskreduction medical record documentation. Keywords medicolegal education, risk management, risk-reduction, documentation, resident curriculum
Introduction Continued periodic surveys conducted by the American Academy of Pediatrics (AAP) find that approximately 30% of pediatricians are sued during their career, and 10% of the occurrences leading to suit occur in residency.1,2 Yet recent AAP surveys of graduating residents have shown that 57% reported receiving no instruction in medical malpractice litigation, 54% reported receiving no instruction on medical liability insurance, and 50% reported no instruction in risk management and loss prevention.2 The AAP has recently recommended that residency programs incorporate this education into their curricula.3 Good risk management is a solid basis, not only for reduction of the risk of lawsuits but also for improvement in patient safety and care quality.2 Most residents are also not fully aware of their personal liability when it comes to medical malpractice. This is unfortunate because litigation involving residents is not a rare occurrence. It has been estimated that residents are named in approximately 22% of lawsuits as co-defendants in addition to attendings and hospitals.4 While it is impossible to completely remove the risk of lawsuit from oneself, there are numerous suggested strategies aimed at prevention. These suggestions
include keeping up with current clinical practice guidelines, establishing professional patient–physician relationships, close follow-up of studies and laboratory tests ordered, and making sure that documentation is thorough and complete.5 Though specific medical diagnoses underlying most pediatric lawsuits has not been systematically analyzed, certain diagnoses have led to successful legal claims historically and are likely to lead to similar claims in the future. Knowledge about the medical conditions producing successful lawsuits is a starting block for development of improved patient safety, as well as risk-reduction techniques, especially with documentation practices.6 Evaluation of prior deficiencies in documentation can lead to improvements in the future. When care is closely analyzed for litigation purposes, the chart becomes essential in determining the details of the encounter and 1
Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, TN, USA 2 Medical University of South Carolina, Charleston, SC, USA Corresponding Author: Jaime K. Otillio, Monroe Carell Jr Children’s Hospital at Vanderbilt, 2020 Children’s Way, 1014 VCH, Nashville, TN 37232, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at Bobst Library, New York University on June 4, 2015
480
Clinical Pediatrics 53(5)
can be a friend or foe in a physician’s defense during a trial. Though the medical chart conveys only a skeleton of the patient–physician encounter, clear documentation of relevant physical exam findings may be helpful in defense or even dissuade a plaintiff’s attorney from pursuing the case.7 A recent analysis highlighting specific medical conditions associated with lawsuits against pediatricians found that12% of meningitis claims made to the Physician Insurers Association of America (PIAA) involved problems with the medical chart or inadequate charting, including failure to record pertinent negative findings and nonrecorded reassessment of patient status.6 PIAA analysis has also identified meningitis, appendicitis, long-bone fractures, lacerations, and testicular torsion as the most common diagnoses involved in lawsuits originating in the pediatric emergency department (PED).8 The purpose of this study was to analyze whether a simple educational intervention on medical liability can, not only increase the pediatric residents’ awareness and knowledge of this topic but also affect risk-reduction through better documentation. It has not previously been determined whether or not a 1-hour lecture can make a significant impact on the documentation practice of pediatric residents.
Methods Study Design and Setting This was an experimental study of risk-reduction documentation by pediatric residents from an Accreditation Council for Graduate Medical Education (AGCME) accredited resident education program (48 residents) at an urban, academic children’s hospital PED with an annual census of 22 000. This study was conducted over a 26-month period (January 1, 2011 to March 1, 2013). Approval for this study was granted by the hospital’s institutional review board with a waiver of consent because care was not altered and no patient identifiers were collected. The intervention was a 1-hour lecture given during the pediatric resident’s protected conference time. The lecture was prepared and presented by authorOtillio, a -second year pediatric emergency medicine fellow at the time of the lecture. The lecture focused on various medicolegal issues, including procedural aspects of how a lawsuit develops, medical liability insurance coverage, and risk-reduction through careful documentation. The lecture was designed using information from AAPgenerated literature, most specifically Medicolegal Issues in Pediatrics, 7th edition.9 Prior litigation from
common diagnoses involved in pediatric lawsuits were discussed, including fractures with poor neurovascular status, lacerations with retained foreign bodies, and abdominal pain leading to missed appendicitis. Specific recommendations for reduction of risk through documentation were provided. Categorical pediatric residents in the postgraduate year (PGY)-I and PGY-II classes (2011-2012) were included in the study. The lecture was given in June 2012, therefore all graduating PGY III residents as well as residents who did not have rotations scheduled in the PED within the study period were excluded from the risk-reduction documentation analysis portion of the study. Intervention group participants were both in attendance at the lecture and had the required rotation time in the PED. Control group participants had the required rotation time but were not in attendance at the lecture. Prior to the lecture intervention, the residents in attendance completed a questionnaire and pretest. The questionnaire of 18 items was used to collect basic demographic data as well as to assess for any previous medicolegal training and experience. A 5-point Likerttype scale was used for self-assessment of knowledge about medicolegal issues, ability to define standard of care, and fear of malpractice lawsuits affecting practice. Questions requiring only an affirmative or negative response included previous involvement in malpractice cases, previous employment in a legal environment, familiarity with liability insurance, and opinions about the value of medicolegal education in residency training. The pretest contained 9 items used to assess prior knowledge of topics to be covered in the lecture intervention (Appendix A). Immediately following this lecture, to assess for improvement in knowledge, a posttest with the same nine items as the pretest was distributed. Topics on both versions included medical record alteration, communication as a catalyst for lawsuit, general malpractice insurance coverage, and individual responsibility in litigation. Additional questions were asked at the end of the post-test inquiring if the resident believed the lecture would have an immediate and/or lasting effect on their documentation practice, and if they perceived lectures on medicolegal risk to be beneficial to their future career (Appendix B). Pilot testing for clarity and face validity was performed using graduating residents who were not part of the study population. Pediatric emergency department encounters with chief complaints or diagnoses of abdominal pain, fracture, or laceration were selected through a query of the PED tracking board system. A list of encounters was generated by searching for chief complaints or
Downloaded from cpj.sagepub.com at Bobst Library, New York University on June 4, 2015
481
Otillio et al diagnoses, including “lac,” “fracture,” or “abdom.” Encounters were included if assigned via the tracking board to a participating pediatric resident. Further exclusion criteria for charts of patients with abdominal pain included recent traumatic events, dysuria, history of inflammatory bowel disease, pregnancy, history of sickle cell disease, or age less than 1 year. Fracture charts were excluded if involving nonextremity fractures or reinjury of a recent fracture. Laceration charts were excluded if the injury was nonforeign body related in addition to all head or facial lacerations, intra-oral lacerations, eye injury, penile or perineal lacerations, self-inflicted injury, or animal bites. A chart review to assess for content was performed using a blinded, 2-reviewer system. The reviewers received an orientation, including discussion of the standard form created for collection of data and exclusion criteria for the study. For abdominal pain patients, the documentation of presence or absence of right lower quadrant tenderness was recorded. For fracture patients, the documentation of neurovascular status of the extremity distal to the fracture was recorded. For laceration patients, the documentation of need for imaging studies among those with potential foreign body involvement was recorded. Reviewers were instructed to eliminate patient encounters in which the principal investigator was involved. The reviewers were not informed of the goals of the study. Data from the standard form were entered into a Microsoft Excel (Microsoft Corp, Redmond, WA) spreadsheet. Categorical data were reported as numbers and proportions and analyzed as 95% confidence intervals (CIs) for differences in proportions. Continuous data were reported as means, standard deviation, median, and ranges and analyzed as 95% CI for differences in means. A P value
