High Risk Specialty
Although patient injury may occur in any area of medical practice, certain specialties, especially obstetrics, orthopedics, neurosurgery and emergency medicine constitute a disproportionately larger percentage of claims. This is almost certainly reflects the magnitude of injuries sustained and, to some degree, the expectations of patients. ELM courses address risk avoidance and patient safety in these specialties with emphasis on provider education, appropriate consultation and referral and utilization of and attention to established protocols.
Failures of care, on occasion, are simply lack of clinical competence, but more often injuries result from system failures such as; failure to follow established protocols, lack of preparation for foreseeable emergencies, failure of adequate supervision or provider intimidation and chain of command issues. By using court cases with current clinical situations, ELM places the provider into the events of an actual case as they unfold. ELM courses focus not on directly teaching clinical medicine, nor on who happened to prevail in the lawsuit, but rather on how understanding the medical legal issues can help in avoiding these system failures. The cases demonstrate by example how patient injury, and therefore provider liability, can be reduced.
Obstetrics
In obstetrics practice, certain events and injuries are recurrent. Most providers are aware for example, of the appropriate clinical management of shoulder dystocia. ELM cases emphasize the importance of anticipation of the potential for its occurrence, routine review of the necessary steps to manage the event in advance by all involved providers, the need for supervision of trainees by senior staff and the need for proper contemporaneous documentation of steps taken to attend to the patient and avoid injury.
Likewise, lack of response to non-reassuring fetal heart rate patterns and injudicious use of oxytocin are common allegations, and ELM cases remind all providers by case example of the need for labor and delivery staff to maintain constant vigilance to developing problems before there is injury to the mother or fetus. Although there may be disagreement among individual providers as to the physiologic basis for a particular fetal monitoring pattern, ELM cases focus on appropriate documentation of thought process, preparation for possible deterioration in fetal well-being and consultation when appropriate. Most obstetrical services have established protocols for example, for oxytocin administration; ELM cases teach the potential hazard in failure to follow these procedures.
ELM provides basic courses in risk avoidance for all of the labor and delivery team, specialty specific courses for physicians, courses exploring the respective roles of supervisors and trainees and a weekly program of obstetric clinical-legal cases, covering the spectrum of possible complications in prenatal care, labor, delivery and the post-partum period, all offering ACCME Category 1 AMA/PRA credit.
Course Recommendations
YEAR ONE:
Communication: Bedside Manner I
Supervision & Control I
Scope of Practice I
YEAR TWO:
Communication: Disclosure I
Consultation & Referral I
Risk & Safety Issues in Obstetrics I
YEAR THREE:
Managing Labs & Test Results
Duties to Non-Patients I
Provider Interaction I
Orthopedics/Neurosurgery
Orthopedic and neurologic surgeons, even when proficient in their surgical technique, may fail to attend to intervening medical issues or suggestions from other providers. They may become distracted by the urgency of the injury or illness they are treating and fail to respond to equally urgent issues also putting the patient in danger. ELM courses remind them of the need to consider the whole patient, to be responsive to information from the nursing staff and to seek consultation for complications better addressed by other medical specialties.
Surgery involving the spinal column always carries a risk of nerve injury. ELM cases point out the care required in matching the procedure anticipated to the training and experience of the surgeon, the balance between resident training and risks to the patient and the need for appropriate pro-operative discussion in obtaining consent.
At times the surgical arena may generate tension, especially when a complication arises. ELM courses address the potential harm which can result from disruptive conduct, even if the actual medical care provided is satisfactory.
Course Recommendations
YEAR ONE:
Informed Consent I
Patient Safety I
Supervision & Control I
YEAR TWO:
Provider Interaction I
Documentation I
The Disruptive Provider
YEAR THREE:
Scope of Practice I
Communication: Disclosure I
Office Practice: Coding Fraud & Abuse
Emergency Medicine
As emergency departments expand their role beyond their intended usage, emergency department providers may believe that they must be all things to all patients. ELM courses emphasize the need for adequate collection of relevant historical data, appropriate consultation for unusual or complicated injury or illness and clear explanation of necessary follow-up as required.
ELM cases demonstrate the potential injury which can result from late arriving laboratory results, revised imaging study reports and failure to timely consult or to refer the patient as indicated. ELM cases emphasize the need to promptly evaluate patients in emergency situations, the extent to which intermediate level providers can be utilized to accomplish this goal and those circumstances where an experienced senior level provider should personally attend to the patient.
ELM courses are available to address basic risk issues and issues for all providers. Statutory provisions such as HIPPA and EMTALA are addressed with actual case examples. Specialty specific courses are available for physician providers addressing other issues unique to the emergency department.
Course Recommendations
YEAR ONE:
EMTALA
Supervision & Control I
Scope of Practice I
YEAR TWO:
Provider Interaction I
Managing Labs & Test Result
Minor Consent I
YEAR THREE:
Patient Conduct I
Consultation & Referral I
Duties to Non-Patients I