Emergency Department Directors Academy Phase III Spring 2020 Implementing a Risk Management Program DESCRIPTION Time, expectations, communication, errors, etc. all conspire against us to create dissatisfaction and poor outcomes. We and our colleagues all experience situations leading to less than optimal care. How are you as the director going to raise quality and decrease errors? How do you raise awareness and implement programmatic changes. This course will teach the teachers (you) how to create an effective risk management program. OBJECTIVES

• Implement operational procedures to reduce risk, such as protocols for change of shift (sign-out) and return visits.

• Implement clinical procedures for reviewing and improving care for presentations, such as chest pain, pediatric fever, recheck of abnormal vital signs.

• Implement procedures decrease exposure to particularly high risk situations, such as AMA, and transfers.

• Develop review procedures (templates) and use documentation recommendations. 2/6/2020, 8:00 AM - 9:30 AM; 9:45 AM - 12:15 PM FACULTY: Daniel J. Sullivan, MD, JD, FACEP DISCLOSURE: (+) No significant financial relationships to disclose

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ACEP MEDICAL DIRECTOR’S ACADEMY - 2020 IMPLEMENTING A RISK MANAGEMENT PROGRAM Daniel J. Sullivan, MD, JD, FACEP Outline

1. Foundational ED structure is a prerequisite to a successful risk and safety program.

2. The Peer Review Opportunity 3. Break-Out Discussions – The Spectrum of ED Risk 4. The Failure to Diagnose – The Highest ED Risks, Create a Program 5. The Cognitive Disposition to Respond 6. Break-Out Discussions – Malpractice Case Review

I. ED Structure & Function The following recommendations address some of the basic fundamentals of operating an emergency department, including ED Structure, the process of peer review. Emergency Department Structure

1. Department of Emergency Medicine. The bar (higher standard) is that the hospital should have a Department of Emergency Medicine with a voting representative on the facility Medical Executive Committee. Some hospitals have elected to create emergency divisions or sections of the medical staff without an independent emergency medicine committee structure. The threshold is that the ED should have a department structure as described below.

2. ED Committee Structure. Whether the emergency service is a

department, division, or section, there should be an ED committee structure. Whether this is accomplished through one or more committees is left to the individual ED or hospital group.

3. Administrative Support. This committee structure should be

supported by administration and minutes should be taken. Minutes should be maintained in a manner consistent with the hospitals policy on performance or quality improvement documentation.

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4. Operational Impact. The committee/s should address items that relate to the clinical and administrative operations of the department, including but not limited to:

a. Quality b. Process c. Operations d. Performance Improvement e. EMTALA / Transfers f. Patient satisfaction g. Metrics and statistics h. Core measures i. Interdepartmental Issues (Lab, Rad, etc.) j. Review of Complaints k. EMS Issues

5. Leadership. The threshold is committee leadership by the ED Physician Director or the ED Nursing Director. The bar is co-chairmanship by ED physician and nursing leadership.

6. Department Meeting Frequency: This committee(s) will meet at a

threshold of every other month, but the recommended bar is monthly meetings.

7. Department Meeting Attendance. In general, the following

individuals or departments should participate in the committee structure:

a. ED Medical Director b. ED Nursing Director c. ED Physicians d. ED APs e. Administrative Leadership f. Ancillary Services (i.e. Laboratory & Radiology) g. Case Manager h. ED Nursing Educator i. Others with a role in ED process and operations as needed

8. Frequency of Physician / AP Attendance Recommendation. All the full-time ED Physicians and Advanced Practitioners are required to attend 50% of the Department meetings as a threshold, with a bar of 75+ % participation. For the purpose of this recommendation define full time as an average of 6 or more shifts per month.

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Any emergency physician group ‘business’ meeting, unrelated to the clinical, process, and operations of the emergency department will be handled separately from this committee structure.

Department Communication. It is critical that department personnel are kept apprised of decision-making by the committee structure. Communication is key. As the complexity of emergency departments continues to increase, the importance of careful communication becomes all the more important. As a threshold there should be a mechanism in place for communication of important clinical practice, process, and operational issues to the entire ED team. Conducting Physician Peer Review

II. Emergency Department Peer Review. Emergency Departments should

conduct peer review as outlined below.

The Process of Peer Review.

a. Peer review is conducted during a meeting of the physicians and allied health practitioners (AHPs).

b. The meeting should be supported by administration and minutes should be taken.

c. The emergency department physicians and AHPs should actively participate in case review.

d. Any cases that are addressed by the peer review committee should be rated according to a system devised by the medical staff and articulated in the medical staff bylaws. Each hospital should have a standardized method for measurement of peer review events.

e. Cases should be tracked and trended by provider for frequency and severity as a threshold. The minutes should contain evidence of this process.

f. The method of documentation of cases may be influenced by local state law and specifically by the issue of discoverability of the cases reviewed.

g. In all cases peer review should be conducted in strict accord with the hospital bylaws and the local administrative rules or laws relating to discovery.

h. Peer review should be approached as a patient advocacy event. i. Peer Review should be conducted at the hospital. In some states

the medical regulatory body formally recognizes emergency medical groups as ‘peer review organizations.’ In these few instances, peer review may be conducted as part of the business meeting of the emergency medical group in strict accord with the state rules protecting peer review documents from discovery. In all other cases peer review must be conducted at the hospital.

j. If Peer Review is done outside of the ED Department Committee Structure (i.e. by another department, other hospital committee)

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then as a threshold there must be a mechanism for sharing the results or lessons from the peer review meeting with the physician and allied health practitioners in the Emergency Department.

k. If Peer Review is done outside of the ED Department Committee Structure (i.e. by the emergency medical group outside of the hospital) then as a threshold there must be hospital/administrative oversight and the same process of peer review should be followed.

3. Content of Peer Review. The following should be the threshold

items to be included in the Peer Review meeting:

a. Return visits that are admitted b. Any event which has resulted in an unanticipated death or major

permanent loss of function, not related to the natural course of the patient’s illness or underlying condition

c. Suicide of any patient receiving care, treatment and services in a staffed around the clock setting within 72 hours of discharge

d. Abduction of a patient receiving care, treatment or services e. Hemolytic transfusion reactions involving the administration of

blood or blood components f. Mortality review – Practitioners may determine which mortalities

should be reviewed. Not all codes require review. For example, patients presenting in asystole and remaining in asystole may not be appropriate for committee review. Choose mortality cases that demonstrate potential errors, system issues, or a learning opportunity for the staff.

g. Radiology Discrepancies h. Response to complaints and grievances i. Any other care concerns and complaints

III. Break Out Group Discussion – The Spectrum of ED Risk

Scenario # 1 Acute Coronary Syndrome Case. Medical Malpractice Risk. The hospital administration and the medical staff are up in arms regarding the hospital’s door to balloon times in patients with acute coronary syndrome. Yours is THE go-to hospital for interventional care. The finger is pointing to the ED. The average door to ECG is over 30 minutes (AHA/ACC past guidelines are 10 min). The average ‘time to order’ of troponin is 45 minutes. There is a chest pain protocol that allows nurses to initiate lab orders but most of the physicians will not allow them to initiate without seeing the patient.

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There have been several poor outcomes, with related litigation. In fact, this represents a current trend in emergency medicine nationally. The failure to diagnose STEMI is dropping. The new ACS litigation focus is on timing and ‘loss of opportunity’. The hospital, the physicians, and most importantly your patients are at risk. What steps will you take to address these issues? Scenario # 2 Waiting Room / Triage risk. There have been three recent adverse outcomes in your ED waiting room over the last two months. A 14-year-old presented to the triage area complaining of a painful scrotum. The triage nurse did not recognize the importance of the presentation and the mother and teenager sat in the waiting room for 4 hours. The mother was irate and went to another hospital. At the second hospital the young man was in surgery within 30 minutes of arrival. A 65-year-old male presented with a complaint of slurred speech and weakness in the right arm that started approximately an hour and a half prior to presentation. His triage vital signs were normal, and the nurse did not detect any weakness in the arm. He was asked to have a seat in the waiting room. After 55 minutes his wife knocked on the triage window after she noted that her husband was unable to move the right side of his body. A 45-year-old patient with chest pain sat in a wheelchair holding his chest until he collapsed on the floor. This was all picked up on security videotape. The clock was running on the tape, he had been in the waiting room for 28 minutes before he collapsed. The VP risk has contacted you, the medical director. She is asking for an action plan for resolution of the problem. She is looking at the possibility of three lawsuits and possibly worse. The states attorney is threatening to bring a charge of homicide related to the videotaped death of the chest pain patient. Scenario # 3 Fraud and Abuse Risk Your physicians are heavily incentivized through an RVU reimbursement program. The quality department has just brought an issue to your attention. There are three emergency physicians who have been having patients return to

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the ED for continuing IV therapy. Quality is concerned regarding possible over utilization. Case # 1 involves a patient who developed cellulitis after a cat scratch. The chart indicates cellulitis, patient was given Rocephin and discharged on Augmentin. She was asked to return for IV antibiotics the following day. In total, the patient returned for 17 days for various antibiotic regimens including Rocephin, Imipenim, and Vancomycin.

Case # 2 is a dog bite who was treated for a cellulitis on the leg for eight days with IV Rocephin in the emergency department. Case # 3 is a patient who developed a skin infection following a laceration. The patient was initially treated with Keflex. The infection worsened. The patient was given a dose of Rocephin IV and discharged on Augmentin. He returned for 4 days and was treated with IV Rocephin. The patient became septic and was admitted to the hospital. He ultimately needed debridement of area around the initial laceration and has filed suit. The quality department has asked you to look into the issue. What steps will you take? Scenario # 4 EMTALA Risk You are the medical director of an ED in a tertiary care hospital. Surrounding hospitals have been having serious problems with their on-call schedules. As a result, the number of transfers to your facility have been increasing dramatically. Transfers come to your ED. Transferring hospitals routinely call your ED. The medical staff at your hospital is up in arms over the reverse dumping situation. Two of your ED physicians have refused transfers in the past 24 hours. The first is a patient who had fallen off a horse and suffered an intracranial bleed. The second a patient for cardiac cath. The ED was extremely busy, but not on bypass in both instances. The hospital had to self-report both cases to CMS. The state agency representing CMS will be visiting your hospital tomorrow. What immediate steps can you take? What additional steps can you take to resolve this potentially dangerous situation?

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Scenario # 5 Intentional Tort Risk An anesthesiologist was a member of a medical group. He was found to be abusing Demerol. The hospital would not allow him to continue practice and the medical practice fired him. The termination letter stated “you have reported to work in an impaired physical, mental and emotional state. Your impaired condition has prevented you from properly performing your duties and puts your patients at significant risk.” The anesthesiologist applied for a job at a facility in another state. The facility initiated a background check, including examining referral letters from the prior medical practice and Hospital where the primary doctor previously practiced. Letters from 2 partners stated that the doctor “was in excellent anesthesiologist”. And “recommend him highly” and that he is sure to be “an asset to the facilities anesthesia service.” The hospitals response was brief: “Our records indicate that he was on the active medical staff… in the field of anesthesiology from (date)... (date). The facility hired the physician. A short time later one of the doctor’s patients was severely injured. He admitted that he had been diverting and using Demerol and that he had become addicted. The injured patient’s family sued the doctor and the facility in cases that were settled. The facility and its insurer then filed suit against the doctor’s former medical practice and the hospital charging “intentional misrepresentation, negligent misrepresentation, and general negligence.” A jury awarded the facility and the insurer $8.24 million. A US appeals Court found the hospital was justified in providing “name, rank and serial number in its reference letter. It exonerated the hospital because it had no affirmative duty to disclose negative information about the doctor. However, the Court upheld the decision against the medical practice. “The defendant showed a duty to avoid affirmative misrepresentation in the referral letters.” The Court also said, “although a party may keep absolute silence and violate no rule of law or adequately… if he volunteers to speak and to convey information which may influence the conduct of another party, he is bound to disclose the whole truth.” Kadlec Medical Center v. Lakeview Anesthesia Associates and Lakeview Medical Center. US Ct of Appeals (5th Circuit) No. 06-30745

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Scenario # 6 Employment Law Risk The charge nurse notified you that 3 nurses are concerned because the physician is administering narcotics to patients. The physician orders meds; she tells the nurse to give her the meds and she will administer to patients. A nurse advises you that one of her patients told her that he only got one of the 2 meds ordered for him. What do you do? Call counsel. Conduct a chart review to review physician history of prescribing narcotics. Put physician billing on hold, potential fraud and abuse issue. After results, meet with the physician with 2 people from your team. Review performance and reiterate policy that physicians do not administer narcotics to patients. Document the meeting. Get the physician to sign it. Continue to monitor and evaluate. You receive 2 more notes from nurses regarding your providers continued request for narcotics to administer directly to patients. What do you do? Another meeting, again with 2 people present from your team. Advise regarding the nurses’ concerns, reiterate earlier meeting and policy on physicians administering narcotics. Express concern regarding substance abuse dependency issue. If willing to disclose up, offer to get her help. In this case she denied. You receive a patient complaint complaining that the same physician took 3 Percocet pills out of the patient’s pill bottle without consent. The patient reported the incident to the nurse and the hospital is investigating. What you do? Call physician and advise of the allegation again with 2 people. Give the physician an opportunity to respond to the allegation. Take the physician off the schedule until the investigation is concluded. Once the hospital and ED group concludes the investigation, meet again with 2 people and advise as to the decision. In this particular case it was termination with cause unless she wanted to resign effective immediately and writing; the emergency physician group agreed to waive the notice. Can you think of a better approach to this case?

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IV. The Failure to Diagnose (slide presentation)

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VI. Cognitive Disposition to Respond

This is another learning tool to use in evaluation of adverse outcomes, threatened litigation, or other problem cases.

Failed Heuristic/ CDR / Bias

Synonyms Description

Anchoring or Diagnostic Anchoring

Tram lining, first impression, jumping to conclusions

Anchoring is the tendency to fixate on specific features of a presentation too early in the diagnostic process, and to base the likelihood of a particular event on information available at the outset (i.e., the first impression gained on first exposure, the initial approximate judgment). This may be an effective strategy, but it exerts an overly powerful influence in some people who fail to amend it in the light of later information. Anchoring can be particularly devastating when combined with confirmation bias (see below). Anchoring is particularly prevalent in perispinal abscess cases.

Ascertainment bias

Response bias, seeing what you expect to find.

Ascertainment bias occurs when the physician’s thinking is pre-shaped by expectations or by what the physician specifically hopes to find. Thus, a physician is more likely to find evidence of congestive heart failure in a patient who relates that he or she has recently been noncompliant with his or her diuretic medication, or more likely to be dismissive of a patient’s complaint if he or she has already been labeled as a “frequent flyer” or “drug-seeking.” In this course, you will see that a history of chronic back pain causes an ascertainment bias that resulted in a failure to consider other possibilities. Gratuitous or judgmental comments at hand-off rounds and other times can help seal a patient’s fate. Stereotyping and gender biases are examples of ascertainment biases. Any prejudgment of patients is dangerous and may result in underassessment or over-assessment of their conditions.

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Cognitive Disposition to Respond Examples

Confirmation Bias

Belief bias, following hunches, relevance bias

This is a powerful bias, which may seriously confound problem-solving and clinical decision-making. When a hypothesis is developed on relatively weak or ambiguous data, it may later interfere with superior and more plentiful data—such subsequent data might not be treated objectively and may be ignored. Confirmation bias is reflected in a tendency to look for confirming evidence to support the hypothesis, rather than to look for disconfirming evidence to refute it. For example, diarrhea is confirming evidence leading to a common and inappropriate diagnosis of gastroenteritis. However, without anorexia, nausea, or vomiting, the gastro portion of that diagnosis simply does not exist. Thus, confirmation bias may suggest gastroenteritis and stop a critical thought process as to the cause of isolated enteritis. In difficult cases, confirming evidence feels good, whereas disconfirming evidence undermines the hypothesis and means that the thinking process may need to be re-started (i.e. looks like more work, more mental effort, and more time.) This bias leads to the preservation of hypotheses and diagnoses that were weak in the first place. The bias may result in a lot of wasted time and effort and may completely miss the correct diagnosis.

Diagnosis Momentum

Diagnostic Creep

Diagnosis momentum refers to the tendency for a particular diagnosis to become established without adequate evidence. Typically, the process starts with an opinion of what the source of the patient’s symptoms might be. A patient may suggest that chest pain is just “gas.” As this is passed from person to person, the diagnosis gathers momentum to the point that it may appear almost certain at a point in time. A diagnosis that gathers momentum tends to suppress further thinking, sometimes with disastrous outcomes. This is common when an emergency physician documents a diagnosis in the medical record and communicates that diagnosis to the primary physician prior to admission. While the patient may have obvious symptoms of some other condition, days may pass before the primary physician engages in an objective re-evaluation.

Diagnoses may gather momentum without gathering verification. Delayed or missed diagnoses lead to the highest disabilities and are the most costly. Allowing the wrong label to stay on a patient may seal his or her fate.

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Cognitive Disposition to Respond Examples

Gender Bias

Sex Discrimination

Gender bias leads to the gender of the patient exerting an influence on clinical decision-making when gender is known not to be relevant in the etiology of the disease. Or the opposite. Where there are differences in gender and should be a bias, but this is not considered in clinical decision-making.

Premature Closure

Counting chickens before they are hatched

This is a powerful bias. Physicians typically generate several diagnoses early in their encounter with a clinical problem. Premature closure occurs when one of these diagnoses is accepted before it has been fully verified. The tendency to apply closure to the problem-solving process can result from vivid presenting features that may be convincing for a particular diagnosis, or by anchoring on to salient features early in the presentation. Attaching a diagnosis to a patient provides a convenient, shorthand description. It may also reflect some laziness of thought and a desire to achieve completion, especially under conditions of fatigue or circadian dysynchronicity. Premature closure tends to stop further thinking.

Search Satisficing

Bounded rationality, keyhole viewing

Search satisficing is the tendency to call off a search once something is found. Most searches in everyday life are initiated because a single known thing has been lost and, consequently, the search will be called off once it has been found. However, it's a different process in the ED. There is often more than one "thing" to be found, we are not always sure what it looks like, we do not always know where to look, and we often do not find anything. When a fracture of the C-Spine is found, the literature strongly suggests the possibility of a second or even a third fracture. In self-poisonings, there may be co-ingestants; there may be more than one foreign body in a wound. Patients may have more than one diagnosis, especially if the patient has a psychiatric diagnosis. In all of these cases, satisfying oneself that the search is over once something has been found will often be erroneous. Finding something may be satisfactory, but not finding everything is suboptimal. Calling off the search once something has been found can lead to significant further findings being missed.

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Cognitive Disposition to Respond Examples

Triage Cueing

Geography is destiny

Triage cueing results from an abbreviated assessment that is known to be imperfect. It may miss, under assess, or over assess the acuity or severity of a patient’s condition and misdirect the patient within the ED. The consequence of triage-cueing is that bias applied at the outset may propagate within the ED. It may lead to delayed or missed diagnoses, or over utilization of resources.

Yin-Yang Out

Serum rhubarb (UK), standing stool velocities (Canada)

The assumption underlying the yin-yang out is that because the patient has been “worked up the yin-yang” for a pre-existing condition prior to presenting to the ED, it is unlikely that further effort will be productive, and this lets the ED out. In the UK, exhaustive workups are said to have covered all possibilities or having included the measurement of serum rhubarb levels, and in Canada, the ultimate workup includes measures of "standing stool velocities."

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VII. Break Out Group Discussion – Malpractice Case Review Case # 1 Page 1 A 14-year-old child presented to the emergency department at 1315 on Monday with her mother. The child complained of vomiting for 1 day, fever, and a rash. Triage Triage Time: 1330 Tetanus: Up to Date Allergies: No Known Allergies Temp. 101.8°F Pulse 160 Resp. 20 BP 130/70 Vomiting X 1 day, fever, rash. Triage Category 3 (1 – 5 scale) Nursing Assessment The child’s medical record contains a primary nursing evaluation on a templated “Nurse Assessment/Data Base” form. Ventilation: Respirations regular Circulation: Skin warm and dry. Nailbeds pink. Left and right radial pulses palpable. Neurologic: Glasgow Coma Scale Score 15, cooperative. Mobility/Comfort: Fever, rash. Nutritional Status: Vomiting for 1 day. Physician history and Physical Exam The physician’s history and physical was dictated. Mode of transportation: Private vehicle Chief Complaint: Vomiting History of Chief Complaint: This is a 14-year-old female who presents with a history of vomiting and fever for the past 24 hours. She denies any cough or shortness of breath, no sputum production. She has no diarrhea. Review of Systems: Unremarkable except for above.

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Case # 1 Page 2 Past Medical History: Negative Medications: None other than acetaminophen. Vomits after taking acetaminophen. Allergies: No known allergies. Physical Examination: Blood pressure is 130/70. Pulse rate is 140 beats/min per the nursing notes, respiratory rate 20, and temperature 101.8°F. Constitutional: Child alert and in no distress. HEENT: Normocephalic, atraumatic. Eye examination normal. Tympanic membranes intact, good light reflex bilaterally. Tongue and uvula were midline. The pharynx is red. There is no purulent material noted on the tonsils. There are no oral lesions. No lymphadenopathy. Heart: Rate and rhythm are regular, no murmurs, clicks or rubs. Lungs: Clear to auscultation. Abdomen: Soft, nontender, bowel sounds present. Extremities: There is no cyanosis, clubbing, or edema. Laboratory and X-Ray: None performed. ED Course The physician ordered Phenergan 20 mg IM at 1430. The physician also ordered an oral fluid challenge after the administration of the Phenergan. The emergency physician wrote the following at 1445: “No further nausea or vomiting.” The nurse rechecked the vital signs at 1500. Temperature 102°F; Pulse rate 136 beats/min; Respiratory rate 18; Blood pressure 100/64. The physician noted “Diagnosis: 1) Pharyngitis; 2) Gastroenteritis” Physician Disposition: Discharged on Phenergan suppositories. Ampicillin 250 mg PO TID for 10 days. Rest and drink plenty of fluids for the next 2 days. Follow up with primary care physician in 2 to 3 days and return for fever over 103.5°F, nausea or vomiting, or shortness of breath. The nurse documented gastroenteritis and pharyngitis on the patient’s discharge form and listed the physician’s instructions. The child was discharged at 1515.

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Case # 1 Page 3 Parent Call Back On Monday (same day as the ED visit) evening at approximately 9 PM, the patient’s mother called the emergency department because the child was acting strangely. There was some confusion about the facts at this point, because nothing about this call was documented in the medical record. A clerk testified that she remembered the call, but no nurses on the PM shift remembered speaking with the family. The mother testified that she was told that it takes some time for medications to take effect and not to worry. She testified that the individual she spoke with did not speak with a physician during this telephone call. Outcome At 0900 on Tuesday, the child’s parents called 911 because the child had an altered mental status and difficulty breathing. The paramedics arrived at 0915 and documented the following vital signs: blood pressure 150/70; pulse rate 160 beats/min; respiratory rate 24. Skin was warm and dry. The mother told the paramedics that the child had a sore throat for 3 days, vomiting for 2 days, and then she noticed multiple small spots on the arms and legs, so she took the child to the emergency department on Monday. The EMTs documented that the child was unresponsive to verbal commands. Neck examination was normal. Chest was wet sounding. Abdomen was soft. Upper and lower extremities had small red blotches in large numbers. The EMTs started oxygen and transported the child to the closest emergency department. On arrival at the emergency department, the child had a decreased level of consciousness, pulse rate of 170 beats/min, respiratory rate of 30. Soon after arrival, she had a seizure. After the seizure, the child remained unresponsive, and her pupils were fixed and dilated. She had a petechial rash on the lower extremities and agonal respirations. She was intubated. The computed tomography (CT) scan was normal. The child was diagnosed with meningococcemia. She was started on antibiotics, admitted to the hospital, but died soon afterward.

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Case # 2 Page 1 EMS Run Report The following information was obtained directly from the EMS run report: History: 62 yr. old female with diarrhea and chest pain. Chest pain lasted 10 minutes. She then got lower back pain, abdominal cramps and numbness in her left leg. In route to the hospital she had severe abdominal pains. Exam: BP 130/70 P 68 R 28 Pulse ox 97% Oriented. Diaphoretic. Lungs clear. Pupils equal. Treatment: Monitor – sinus rhythm. O2 applied. Aspirin 325 mg given. IV lock established. 12-lead EKG done. “Patient was pain free” upon arrival to hospital. Nurse Evaluation Upon arrival to the crowded ED, Ms. Roberts was placed in a hall bed and assessed by the nursing staff. History: 62-year-old female, complains of left leg pain and numbness. Change in mental status. Nausea, diarrhea. Past medical history: Rheumatoid arthritis, left hip surgery. Medications: Azulfidine, estrogen, progesterone Exam: BP 147/87, P 66, R 24, T 94.4 Abdomen distended and firm. Lungs clear. Left leg assessment included “numbness and decreased range of motion”. Skin, cardiac, and neurologic assessments were not recorded. Physician History The emergency physician recorded a detailed history. Some of the history was supplemented by Ms. Roberts’ adult children, who accompanied her to the ED. They indicated that their mother was stoic and rarely complained. By this time, she had been moved from a hall bed into a monitored private room in the ED. Chief complaint: Left leg pain History: Sore throat and tiredness earlier today. Had sudden onset of severe abdominal pain, left leg pain and numbness, and diarrhea. Her daughters note a

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Case # 2 Page 2 change in mental status, described as “yelling out and writhing in pain” intermittently. No complaint of chest pain was noted. Social history: Nondrinker, nonsmoker, lives alone, employed in a bank. No foreign travel. Allergies: Allergic reaction from IV contrast dye in past, consisting of “swelling up”. Physician Exam The chart reflected the physician’s impression that Ms. Roberts was seriously ill. The physician exam showed several pertinent positive findings: General appearance: VS are noted. Awake, alert, obviously severely ill, groaning in pain and intermittently confused. Lungs and heart: Lungs were clear, and cardiac exam showed no murmurs. Abdomen: Distended, with diffuse tenderness and guarding. No rebound or rigidity. No masses, no pulsatile mass. Extremities: Absent left leg pulses including femoral and dorsalis pedis. Left leg is cool with diminished sensation, but she can lift the left leg off of the bed. Right leg pulses are intact. Radial pulses strong and equal. Rectal: Frequent loose stools which are visibly bloody. Diagnostic Test Results The initial urinalysis and INR were normal. The potassium was 3.0, BUN 20, and creatinine 1.5. Hemoglobin 12.8, hematocrit 37, platelets 248,000. WBC was 11,400 with a differential of 74 segs, 4 bands, 19 lymphs. Arterial blood gases revealed ph 7.57, pCO2 17, bicarb 15, pO2 137, and O2 saturation 97%. EKG showed sinus rhythm, rate 55, with diffuse non-specific ST&T wave abnormalities. A second EKG performed 2 hours later was unchanged. Cardiac markers were sent late during the ED stay. Portable AP chest x-ray was normal. After discussion with the radiologist regarding Ms. Roberts’ prior reaction to IV contrast, a non-contrast CT of the abdomen was performed. It was interpreted as normal by the radiologist. Cultures of blood and stool were collected.

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Case # 2 Page 3 Emergency Department Course Ms. Roberts received IV fluids, morphine for abdominal and leg pain, and Phenergan and Zofran for nausea and vomiting. When a Foley catheter was placed, the urine was noted to be turning pink with blood. The emergency physician documented his medical reasoning in the following paragraph. “This is a patient with sudden onset of abdominal pain, distention, bloody diarrhea, hematuria, and a pulseless, painful left leg. My concern was to rule out abdominal aortic aneurysm or dissection, despite no evidence of these on her CT scan. I am still concerned about left leg acute arterial insufficiency, infectious diarrhea, and mesenteric ischemia. The hematuria is concerning. I have contacted vascular surgery and the internist on call for her primary care physician. Both will be coming to evaluate the patient due to her severe and sudden presentation with an uncertain diagnosis”. Ms. Roberts was admitted to the ICU, with the diagnoses of: 1. Severe abdominal pain, rule out ischemic bowel. 2. Bloody diarrhea, rule out infection. 3. Hematuria, uncertain cause 4. Left leg pain and pulselessness, rule out ischemia. The Consultants While waiting in the ED for admission, Troponin returned elevated mildly elevated. The vascular surgeon responded promptly to evaluate Ms. Roberts in the ED. He recorded a one-day history of vague abdominal pain, confusion, and left leg pain. He spoke with the radiologist who assured him that “he could 100% exclude aortic disease with the non-contrast CT.” The option of MRI was also discussed, and the radiologist related that it was not an emergency test and if needed, could wait until morning. Since Ms. Roberts now had a faint left femoral pulse, the opinion of the vascular surgeon was that she had “no evidence of acute ischemia of the left leg. She most likely has chronic ischemic changes. Her main problem now is myocardial infarction.” The admitting internist also came to the ED and elicited a somewhat different history from Ms. Roberts. He learned that in addition to her abdominal and left leg pain, she had non-radiating substernal chest pressure for hours that persisted until her arrival in the ED. He also learned that she had hypertension controlled

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Case # 2 Page 4 with Maxzide. His exam showed a grade II/VI holosystolic murmur heard “everywhere”. He noted that the noncontrast abdominal CT showed no aortic dissection. Telephone consultation with cardiology was obtained, and it was agreed that the presentation was highly suspicious for acute MI. The internist, cardiologist, and vascular surgeon were in agreement that Ms. Roberts be heparinized and treated conservatively overnight. The Hospital Course and Outcome In the ICU that night, Ms. Roberts continued to have abdominal pain, hematuria, hematochezia, and occasional confusion. Early the next morning she was noted to have slurred speech, lethargy, and left hemiparesis. The admitting physician and consultants conferred, and for the next 5 hours Ms. Roberts underwent a series of diagnostic tests. A transthoracic echocardiogram showed aortic insufficiency, a dilated aortic root, and suspected dissection of the proximal aorta. MRI of the chest showed dissection of the aorta from the aortic root down to the entire visible portion of the aorta, including the proximal abdominal aorta. MRI of the brain demonstrated an evolving acute right MCA infarct, with near complete occlusion of the right internal carotid artery. Ms. Roberts and her family were apprised of the diagnosis and poor prognosis. It was elected to transfer her to a tertiary care facility for attempted surgical repair. She expired during the operation. The case underwent a review process at the hospital. Despite an inquiry by the family, no claim or legal action was ever initiated.

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Case # 3 Page 1 A 55-year-old female presented to the emergency department at 1115 with a complaint of nausea, vomiting and diarrhea for 4 days. Triage Evaluation: Complaint of nausea, vomiting fever and diarrhea for 4 days. Vital signs: Temperature: 100.1 Pulse: 106 Resp.: 34 BP: 140/80 Primary Nurse Evaluation: The primary nurse noted that the patient was alert and oriented X 3. She made check marks on the primary assessment form indicating that the patient was in mild distress. She described the patient’s color as normal. Later she described the patient as “flushed.” Patient was obese. HEENT was normal. Lungs were clear with a respiratory rate 34 which was normal. Heart exam normal. Abdomen unremarkable and extremities normal. Physician History and Physical Examination: The physician noted that the patient was oriented X 3. There was a complaint of nausea, vomiting and occasional diarrhea. He noted that there was no chest pain, sweating or cyanosis. He noted that she was in moderate distress. On physical exam, he reiterated the nursing vital signs. Normal mental status. HEENT was WNL. Neck supple. Chest clear. Breath sounds normal, without distress. Cardiac exam Normal S1, S2, no murmurs. Back exam normal. Abdomen benign. Extremities normal. No focal neurologic deficits. The physician ordered a CBC and a chemistry panel and a chest x-ray. Emergency Department Course: The labs returned within normal limits. There was no elevation of the white blood cell count, no electrolyte abnormalities and no indication of dehydration. The x-ray was never done. The physician ordered 4 liters of 0.9 NS IV over 4 hours. Five hours after arrival the IV was discontinued. The patient stated that she felt better, and the physician prepared the medical record for discharge.

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Case # 3 Page 2 The nurse assisted the patient to the bathroom via wheelchair. The patient got up out of the wheelchair and went to the bathroom without assistance. The nurse then documented that the patient had increased shortness of breath upon exertion. She did not report this to the physician. At that time, she also noted that the vital signs were unchanged with a temperature of 100; a pulse of 104; a respiratory rate of 30 and a BP of 150/90. The patient was discharged from the emergency department with discharge instructions for gastroenteritis and a follow up with her primary physician within 1 to 2 days. Post-Discharge Events The patient left the emergency department with her mother at 1230. The mother prepared to drive home from the ED parking lot. Moments later the mother came running back into the department for assistance stating that her daughter appeared pale and was having a hard time breathing. The nurse ran to the car and the patient was, in fact, in respiratory distress. She called for assistance and the patient was returned to the ED on a stretcher, 10 minutes post discharge at 1240. Continuing Treatment in the ED On return to the ED her respiratory rate was 40 with a pulse of 160. Pulse oximetry was 70% on room air. The physician ordered oxygen administration 2 liters per minute per nasal canula at 1340. One hour after the patient’s return he ordered 40 mg of Lasix IV push. He also called for a stat portable chest x-ray and attempted to contact the patient’s primary physician. The chest x-ray did not demonstrate any obvious abnormality according to the emergency physician’s reading or the ultimate reading by the radiologist. Ninety minutes after her return the physician ordered C-Pap which provided some relief. At 1445 the physician ordered an arterial blood gas, which demonstrated a pO2 of 84 and a metabolic acidosis. After seeing the blood gas results, he ordered a CT scan of the chest. Case Outcome The physician received the results of the CT scan at 1510, which showed probable pulmonary emboli in both lungs. The radiologist read the study as high probability for pulmonary embolism.

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Case # 3 Page 3 At 1615, the patient was seen by her primary physician. The primary physician documented an examination, which included a statement that the patient appeared short of breath. The physician documented a significant past medical history of pulmonary embolism with the placement of a Greenfield filter 6 years prior to this visit. The patient’s condition deteriorated, and she was intubated at 1637. The plan at that time was to admit to the intensive care unit and start her on heparin. At 1730 the patient was still in the ED and heparin had not been started. A pulmonologist arrived to consult on the patient. During his exam the patient became cyanotic and went into cardiopulmonary arrest. After appropriate ACLS measures, she could not be resuscitated.

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Case # 4 Page 1 September 10th Day 1 The patient was a 54-year-old female who presented to the emergency department complaining of back pain. Nurse Evaluation Triage Vitals: Temp. 98.8�F; Pulse 102; Resp. 16; Pain 9/10 Chief Complaint: Dull but severe pain from neck to knees posteriorly. No known recent injury. Nurse Assessment: Moderate distress. Temp with chills and sweats. Physician History of Present Illness: 54-year-old female complains of back pain. History of chronic back pain, sciatica and right hip bursitis. She states that today’s pain is different than usual. She usually has lower back discomfort. Today she has pain all the way from her shoulder blades down to and including the back of her legs. She states the pain is excruciating. She sees a psychiatrist and is on several psychiatric medications. Has been running a low-grade fever at home between 99.5 F and 100.9 F. She has been waking up sweaty and soaking wet in the middle of the night for several days. She is asking why the pain is different than her usual back pain. Past Medical History: Negative other than the psychiatric history as above. Social History: Negative Review of Systems: Fever, sweaty episodes. Feels weak and tired. Rest of the review of systems is negative. Physical Exam: Vital Signs: Temp. 98.7�F; Pulse 105; Resp. 18; BP 117/77.

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Case # 4 Page 2 General: Alert and responsive. Not toxic or ill appearing. Does not appear to be in severe pain. She rates pain as a 10/10. HEENT: Normal Neck: [No documented examination] Chest: Clear to auscultation. No abnormal breath sounds. No respiratory distress. Heart: S1 and S2 normal. No murmur. Elevated heart rate. Abdomen: Soft, non-tender. Bowel sounds normal. No organomegaly. No guarding or rebound. Back: Diffuse pain to palpation in her mid-back, low back, sciatic grooves, and posterior thighs. No point tenderness. Straight leg raise negative. Gait: Ambulates without difficulty. Neurologic: [There was no documented neurologic examination.] ED Course The physician ordered 25mg of Phenergan and 10 mg of morphine IVP. On re-evaluation the patient remained in severe pain. The physician ordered a second dose of 10mg of morphine IVP. Following the second dose of morphine, the nurse documented that the patient had partial relief of her pain. The electrolytes were all within normal limits. The Complete Blood Count (CBC) was normal including a white blood cell (WBC) count of 9.3. The urinalysis was normal. Physician re-evaluation: Pain less. Will treat outpatient with pain medication and follow-up with her private physician. Impression: Exacerbation of chronic back pain. Discharge Plan: “Patient requested an MRI. I gave her a prescription for an MRI of the lumbar spine, which she will schedule as an outpatient. No urgency for this. No evidence by history, examination of an acute neurologic problem.” The nurse gave the patient instructions for back pain. The physician did not request that the patient return to a private physician or the emergency room for follow-up. There was no patient signature on the discharge form.

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Case # 4 Page 3 September 13 Day 3 The patient presented to the emergency department again on September 13 after her lumbar MRI. Nursing Note Patient moved from MRI to the emergency room. Needs pain relief. Sharp pain in mid and lower back. Vitals: Temp. 97.0�F; Pulse 78; Resp. 18; BP 117/68. Triage level 3. Physician Evaluation Chief Complaint: Low back pain. History of Present Illness: 54-year-old female in for MRI today. Finished the exam but afterward was very uncomfortable. MR tech brought her to the ER. Patient states she has increasing pain in the back; it is “very excruciating.” Long history of back pain with multiple physician referrals. Apparently was a surgical candidate but she declined lumbar disc surgery, opting for conservative treatment. No loss of bowel or bladder function. No weakness of her extremities but is having some pain down the posterior aspect of her right leg to her foot and recently down the anterior aspect. No fevers or chills. Ambulatory. Review of Systems: Otherwise negative Physical Examination General: Alert but appears sedated Extremities: Clear Back: Tender over lumbar area of her back. Neurologic: DTRs are grossly intact. There are no sensory or motor deficits. ED Course The physician ordered 2 mg of IV Dilaudid, and 25 mg of Phenergan. He noted that the “MRI revealed broad based disc herniation at L5-S1 with some facet degeneration. No impingement on the spine.” Discharge Plan: Discharge home. To be seen by private physician here, Dr. Smith. Will prescribe prednisone 60 mg PO q AM for 5 days. Patient to return for increased pain or progression of pain.

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Case # 4 Page 4 Diagnosis: Exacerbation of chronic back pain. The nurse gave the patient herniated disc instructions. She gave the patient a discharge instruction form that stated “See doctor when you get home. May also see Dr. Smith.” There was no time frame for the follow-up visit. The nurse noted that pain on discharge was 10/10. September 18 Day 8 The patient presented to the same ED for a third time on September 18. Chief Complaint: Low back pain. History of Present Illness: 54-year-old with low back pain. Seen initially by Dr. White who ordered pain medication. Ongoing back pain and body aches. Patient has an L4-L5 disc herniation on MRI. She has an appointment with Dr. Black but unable to wait. Not doing well at home and requesting admission to hospital. ED Course The physician ordered Dilaudid 2mg and Phenergan 12.5 mg IVP. Admit to private physician and consult neurosurgeon. Attending Admit Note Chief Complaint: Severe back pain with radicular pain down the leg. History of Present Illness: History of low back pain and degenerative disc disease of 18 years. No surgery. Trouble on and off with back pain. On and off narcotics for this. Increasing difficulty with back pain this past week and seen in the emergency department on two prior occasions. This morning was her third visit. She says she always leaves the ER doped up but with 10 over 10 back pain. I didn’t know if this lumber MR is a new change, there are no comparison films. She has been on a PCA pump since admission. She wants to get better enough to get back to her regular physicians. Past Medical History: Low back pain but a lot of psych issues, depression and anxiety.

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Case # 4 Page 5 Attending Physical Examination All OK except musculoskeletal. She does not move and anytime she does move it sends spasms through her back, even up to the mid back. She does get electrical-feeling moving down both right and left legs. Previously had problems primarily with right leg, but now symptoms in right leg and increased and different than before and has never had symptoms before in the left leg. Symmetric DTRS, but the exam is difficult as patient says any type of range of motion is exquisitely painful. Impression: Intractable back pain, lumbar disc disease, radiculopathy. Plan: Admit for observation. Control pain. Neurosurgical evaluation. Get her pain better so she can return to her hometown and see her regular physicians. The primary physician did not document motor, sensory, cauda equina evaluation, and no mention of bowel or bladder function. Hospital Course This patient was seen by an orthopedic consultant on September 21, now day 11 in the overall sequence of events; the dictation made it into the chart on the September 22. Orthopedic Consultation Impression: Strange constellation of symptoms which is migratory and not adequately explained by MRI scan of the lumbar spine. Swelling of right lower extremity, possible deep vein thrombosis. Plan: Difficult case, patient emotionally labile, no specific symptoms. Overly emotional, visibly magnifying her symptoms. Scheduled for MR today which will likely not give explanation for her intermittent symptoms of her upper extremity. September 22, Day 12 Infectious Disease Consultation This consultant documented the same historical events as the orthopedic consultant but with some significant additions.

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Case # 4 Page 5 On September 8, started to shiver and felt a freezing and burning sensation. Downward slide continued and had an MR on September 13. Admitted September 18. Fever yesterday was cultured and cultures growing methicillin resistant staph. I was called. Patient with profound weakness in her lower extremities and upper extremities. Had back pain but no longer because she has no feeling in her back or lower extremities. Problems moving her arms and grasping. Discussed with private physician and neurosurgeon. Sent for MR for abscess. Found to have abscess at C6 – C7 region. Taken to neurosurgery. Started on antibiotics. Impression: Bacteremia and spinal epidural abscess. Surgical Report: Epidural abscess C6 – C7 and L5 – S1. Purulent material found in both places. Patient Outcome The patient ultimately sustained complete permanent paralysis in her lower extremities.