The team performed well
In the case of C.S., the physicians, by nature and by intent, were attentive to the human needs of this grieving family. Here is what we did well:
- The same residents provided care through both labor and delivery and during postpartum care
- The attending physician (me) was present through all clinical milestones
- All members of the team openly expressed their sorrow to the family
- I visited with the patient daily—providing honest answers to the family’s questions and acknowledging gaps in the medical team’s understanding of what had happened
- A follow-up plan was established to provide autopsy results to the family
So what went wrong? Why did the family—and the members of the care team—have to suffer the ordeal of litigation?
Critical lapse uncovered
Note the last bulleted item, above. This was the critical lapse: I did not call the family to relay the results of the autopsy. Why not? I knew better, after all, and prided myself on my commitment to all dimensions of the care I provided. As with most lapses in medical care, failure was multifactorial—part system design, part human failing.
At the tertiary-care institution in question, maternal transport high-risk pregnancies are managed with a group of attending obstetricians on a week-by-week rotational schedule. This provides continuity of care through the calendar week but, by its very nature, relieves the attending of the previous week from clinical responsibilities. By happenstance, the monthly rotation of residents coincided with this patient’s hospitalization. Thus, no member of her care team had continuing direct responsibility for the OB service.
To complicate matters, I left town after the delivery for a conference, with vacation tacked on afterwards. When I returned to the office 10 days later, my head was refreshed but my memory had been purged, and I failed to follow through on my promise to contact the family.
About 3 months after the delivery, I overheard a secretary trying to calm a frustrated patient on the telephone. When I heard the secretary say, “I’m sorry, ma’am, but we just don’t have the autopsy results, maybe you should call pathology,” I realized which patient it was and took over the conversation. Abjectly apologetic, I promised to get the information for her within hours. The patient was reserved but accepted my offer.
The autopsy revealed a polymorphonuclear leukocyte infiltration throughout the body, but no organisms could be identified by culture or on histologic examination. The final pathologist’s report provided no definitive explanation of the sequence of events that led to fetal death. When I explained this to the patient during a telephone call, her demeanor turned icy and she hung up. Several months later, the lawsuit was served.
Averting disaster: 4 ways to ensure adequate follow-up
1. Build a solid foundation. We all know communication is important, but many of us fail to take the extra steps necessary to standardize communication so that the entire care team is apprised of the goals for a given patient—as well as exactly how much progress has been made toward those goals. Various systems have been designed to accomplish this aim, many of them derived from the aviation industry. A small investment in time can reap big rewards. A few examples:
- “Time-out”—A pause before an invasive procedure to confirm that you have the correct patient and will be performing the appropriate procedure.
- “Snapshot”—An overview of cases within a defined time period, including identification of the team’s priorities. For example: “This morning we have 3 patients scheduled for surgery, beginning with Mrs. ‘A,’ whose hysterectomy for a large myomatous uterus will likely be time-consuming.”
- “Turn-over”—A synopsis of cases at the time they are handed over to another team member or a different team. The information provided should include outstanding tasks and tests.
- “De-brief”—Time set aside after a case to discuss what happened, what could have been handled differently, and what the next steps are. These sessions provide immediate feedback to the team and influence the care of future patients.
2. Don’t leave warmth and caring to your staff. The evidence is in: Physicians who interact in a positive manner with their patients are less likely to be sued than those who fail to communicate warmth and concern. Given the competing demands on our time, it is all too easy to rush through patient visits or other aspects of care without attending to the human component. Take a few minutes to greet each patient by name, inquire about her family and any concerns she may have about her condition, and listen attentively to her response. Then document any important details that arise during this discussion, so the rest of your team knows about them, too.
3. Offer and follow through on an evidence-based explanation of events. At times of tragedy, pay attention to the needs of grieving patients—and their families. This begins with an acknowledgment of the shock and sorrow they are experiencing and includes reassurance that the reasons for the adverse event will be explored and reported. This should not be an empty promise. It is important that the physician offers as full an explanation of an event as possible—as soon as all the facts are in—and that this explanation is voluntary, not something the patient has to ask for repeatedly.
4. Implement an effective tracking system. The case of C.S. illustrates the need for a more comprehensive tracking system. In that case, my failure to relay the need for autopsy results to other team members, and my subsequent absence from the scene, allowed a critical detail to slip through the cracks.
Because patient files tend to be forgotten once they are stored away, a tickle file or similar system is a simple way to keep track of tests and communications that have not yet been performed.