PA MEDICAL MALPRACTICE AND RISK MANAGEMENT MEDICNE MEETS LAW

1. PA MEDICAL MALPRACTICEAND RISK MANAGEMENTMEDICNE MEETS LAW  Jeffrey G. Nicholson, Ph.D., PA-C, DFAAPA WAPA Spring Conference and MU PAP, 2009

2. GENERAL OBJECTIVES What is PA malpractice? What are my chances of being sued? What do I do if I get sued? What steps can I take to reduce my risk? What type of insurance do I need?

3. REMEMBER THAT PRACTICING MEDICINE AS A PHYSICIAN ASSISTANT CAN BE A REAL BEAR AT TIMES. AND YOU NEED DON’T ALWAYS HAVE TO GIVE YOUR PATIENTS A TWINKIE OR A REASON FOR THEM TO COME AFTER YOU. SOMETIMES THEY JUST WANT THE TWINKIE AND SOMETIMES THEY WANT YOU AND THE TWINKIEREMEMBER THAT PRACTICING MEDICINE AS A PHYSICIAN ASSISTANT CAN BE A REAL BEAR AT TIMES. AND YOU NEED DON’T ALWAYS HAVE TO GIVE YOUR PATIENTS A TWINKIE OR A REASON FOR THEM TO COME AFTER YOU. SOMETIMES THEY JUST WANT THE TWINKIE AND SOMETIMES THEY WANT YOU AND THE TWINKIE

4. TALK TOPICS I. MEDICAL MALPRACTICE DEFINED II. PROCESS OF A MALPRACTICE CASE III. HOW PAS COMPARE TO MDs, NPS REDUCING YOUR RISK INSURANCE NEEDS VI. RESOURCES

5. I.WHAT IS MEDICAL MALPRACTICE?

6. MORE THAN LIKELY IT WILL BE THE INCIDENT THAT DID NOT RAISE ANY RED FLAGS THAT WILL SUDDENLY APPEAR. THE SHARK THAT CAME OUT OF NOWHERE. HERE IS A PHYSICIAN ASSISTANT AND EITHER A PLAINTIFF, WHICH IS YOUR PATIENT, OR THE PLAINTIFF’S ATTORNEY THAT JUST FILED THE MEDICAL MALPRACTICE ALLEGATION AGAINST YOU. MORE THAN LIKELY IT WILL BE THE INCIDENT THAT DID NOT RAISE ANY RED FLAGS THAT WILL SUDDENLY APPEAR. THE SHARK THAT CAME OUT OF NOWHERE. HERE IS A PHYSICIAN ASSISTANT AND EITHER A PLAINTIFF, WHICH IS YOUR PATIENT, OR THE PLAINTIFF’S ATTORNEY THAT JUST FILED THE MEDICAL MALPRACTICE ALLEGATION AGAINST YOU.

7. MEDICAL MALPRCTICE DEFINED Medical Malpractice is generally defined as Negligence on the part of the Physician, Allied Healthcare Provider or Hospital which causes Physical or Emotional Damage to the patient.

8. NEGLIENCE REQUIRES… Duty Breach Causation Injury - Damages

9. DUTY Provider – Patient Relationship Implied Contract

10. BREACH Standards of Care External / Internal / Discipline EXTERNAL “Standards of Care” my by what the state or federal government has set up.. IE: PA’s not writing for narcotic medications because they do not have a DEA Number. INTERNAL “Standards of Care” are the office, clinic or hospitals protocols for Allied Health Care Providers. Can also be our job descriptions as well. DISCIPLINE SPECIFIC: THIS IS WHAT “PA EXPERT WITNESSES” ATTEST TO EXTERNAL “Standards of Care” my by what the state or federal government has set up.. IE: PA’s not writing for narcotic medications because they do not have a DEA Number. INTERNAL “Standards of Care” are the office, clinic or hospitals protocols for Allied Health Care Providers. Can also be our job descriptions as well. DISCIPLINE SPECIFIC: THIS IS WHAT “PA EXPERT WITNESSES” ATTEST TO

11. CAUSATION Cause In Fact – The provider’s negligence caused the injury Or a reasonable close connection existed between the provider’s conduct and the patient’s injury Must prove that the provider was the “Cause-In-Fact” of the patient’s injury

12. YOU CAN BE SURE SOMEONE WIL BE LOOKING FOR THE CAUSE OF THIS LITIGATION THAT IS ABOUT TO OCCURYOU CAN BE SURE SOMEONE WIL BE LOOKING FOR THE CAUSE OF THIS LITIGATION THAT IS ABOUT TO OCCUR

13. INJURY & DAMAGES Death – Disability – Deformity – Severe Pain Special – Lost Wages – Out-of-Pocket Expenses

14. II. PROCESS OF LITIGATION

15. THE LITIGATION PROCESS CAN BE COMPLEX DRAWN OUT ANXIETY PROVOKING OCCURS IN PHASES

16. FIRST QUESTION ASKED How would a reasonable, careful and prudent doctor, allied health care professional or hospital behave in the same or similar circumstances?

17. SECOND QUESTION Did the doctor, allied healthcare professional or hospital breach the Standard of Care in this specific situation?

18. THIRD QUESTION Was the unreasonable, careless, or inappropriate behavior on the part of the doctor, allied healthcare professional or hospital the proximate cause of the injury to the patient?

19. LITIGATION TIMELINE Almost 2 years (22 months) to be reported and filed – on average 3.5 – 4 years for the claim to be resolved (paid or dismissed) Total of 5-6 years from filing to settlement (NPDB Data)

20. THE LITIGATION PROCESS PHASES Put on notice Discovery Deposition Preparation for trial Conclusion of the case

21. BEING PUT ON NOTICE Someone has named you in a case Share this information with your risk management office or insurer right away. Don’t panic, resources are available - in house, and externally - that is what your premiums are for!

22. HERE IS SOMEONE HELPING YOU TO AVOID THE ALLEGATIONS OF MALPRACTICE THAT COME BARRELING DOWN ON YOUHERE IS SOMEONE HELPING YOU TO AVOID THE ALLEGATIONS OF MALPRACTICE THAT COME BARRELING DOWN ON YOU

23. DISCOVERY What really happened? Who all was involved? Are all the criteria for a malpractice claim met? duty, negligence, contract, breach, causation, harm? Defense lawyers are hired, Experts are consulted.

24. DEPOSITION You will be questioned about your documentation and your memory of the incident(s) by the attorney for the plaintiff over several hours. PA Experts on both sides will also be deposed.

25. PREPARATION FOR TRIAL Your attorney or attorney team will work with you, advise and counsel you about how to act and what to say and NOT say They also will prep you in the same way for your deposition, all communication between you and your attorney is privileged

26. CASE CONCLUSION Settlement vs. Trial Nobody wants a trial by jury Only 6% of cases go to trial (NPDB). You may never take the stand. 62% cases are dismissed or dropped (NPDB) Plaintiffs win only 32% of the time (NPDB) Your insurance company will pay attorney fees, experts fees, court costs

27. IMPLICATIONS You may be listed in the NPDB You will need to report the case in your credentialing applications Your insurance rates may increase If you are successfully sued more than once, you may not be able to acquire insurance in the future You may become bitter and leave practice

29. PHYSICIAN ASSISTANT MEDICAL PRACTICE IN THE HEALTH CARE WORKFORCE: A RETROSPECTIVE STUDY OF MEDICAL MALPRACTICE AND SAFETY COMPARING PHYSICIAN ASSISTANTS TO PHYSICIANS AND ADVANCED PRACTICE NURSES Jeffrey G. Nicholson, MEd, MPAS, PA-C Dissertation Defense June 25, 2008

30. QUESTION Is the practice of medicine by PAs as safe as the practice of medicine by physicians?

32. And also… Does the average cost of PA malpractice offset cost effectiveness? Is the rate and ratio of malpractice claims per provider the same for PAs as for physicians and APNs? Are the reasons for disciplinary action the same for PAs, physicians, and APNs?

33. Safety Defined as avoidance of harm to patients or the public Markers of safety include number and amount of medical malpractice payments, board and state licensure actions, hospital privilege actions, federal program participation restrictions, DEA actions, professional society membership actions

34. Data Source National Practitioner Data Bank Federally mandated depository of malpractice claims and payments, and disciplinary actions against health care providers. Health Care Quality Improvement Act 1986 Sample 324,285 cases (physicians, PAs, APNs) logged between Jan. 1, 1991 - Dec. 31, 2007 17 year sample EXPLAIN THIS WELL REASON FOR ITS EXISTENCEEXPLAIN THIS WELL REASON FOR ITS EXISTENCE

35. THE GOOD NEWS PAs Fare Well by Comparison

36. CONCLUSIONS Based on malpractice incidence, malpractice payments and required reporting elements of adverse actions, PAs are safe providers of medical care when compared with physicians

37. CONCLUSIONS PAs do not negate their cost effectiveness through the costs of malpractice – they may add cost savings over physicians The rate of malpractice incidence is at the same trajectory for PAs and physicians and at a lower trajectory than APNs

38. CONCLUSIONS The ratio of malpractice claims per provider is much less for PAs and APNs than physicians. The reasons for disciplinary action are similar for physicians, PAs and APNs for required reporting elements.

39. THE BAD NEWS The COST to the health care system and to you and I as insured providers was over $74 BILLION from 1991-2007, an average of $4.4 billion/year.

40. THE DETAILS

41. Data Summary

42. Number of Physician Malpractice Reports

44. Number of PA Malpractice Reports

45. Number of APN Malpractice Reports

46. Average Annual Payments by Type

47. Malpractice Payments Adjusted ($’08) MEAN MEDIAN MD $301,150, $150,821 APN $350,540, $190,898 PA $173,128, $80,003 17 Year Total $74.5 Billion !

48. 1991-2007Average Payment UNADJUSTED DOLLARSUNADJUSTED DOLLARS

49. 1991-2007 Median Payment

50. There are approximately 140 accredited PA programs in the United States. And 12-thousand students will be enrolled in PA programs in this calendar year.There are approximately 140 accredited PA programs in the United States. And 12-thousand students will be enrolled in PA programs in this calendar year.

51. 17 Year Malpractice Payment Incidence Ratio Ratio of payment to providers calculated as total payments in last 17 year per average number of providers over the 17 years. “17 year likelihood” Physician 1:2.7 37% PA 1:32.5* 3.1% APN** 1:65.8 1.52% *12 times less than physicians **APN data includes active and non-active providers

52. Rank of Reasons for Payment IF YOU TAKE AWAY ANESTHESIA AND OBSTETRICS, APN REASONS FOR PAYMENT ARE SIMILAR TO MD AND PA.IF YOU TAKE AWAY ANESTHESIA AND OBSTETRICS, APN REASONS FOR PAYMENT ARE SIMILAR TO MD AND PA.

53. 2006 NPDB StatisticsPhysician Assistants 113 Payments for 2006 Average = $234,635.02 65 Diagnosis related 33 Treatment related 4 Medication 4 Surgery 3 Monitoring 2 Anesthesia 1 Obstetrics 1 Miscellaneous

54. Unexpected Findings More malpractice payments were recorded from female patient lawsuits suggesting that female patients may litigate more frequently than male patients or…? Female practitioners have higher malpractice payments on average than male practitioners

55. Unexpected Findings The number of adverse actions against all three provider types has been declining since 2003, especially for physicians and PAs Some states have disproportionate adverse actions to malpractice payments suggesting that some states are better than others at sanctioning unsafe providers There is a significant difference in the ratio of malpractice payments to provider by state, suggesting that some states are less litigious than others (New Paper – Wisconsin Ranks low)

56. IV.SO LET’S REDUCE OUR RISK !!

57. THERE ARE MANY UNRECOGNIZED PITFALLS THAT COULD TRIGGER A MEDICAL MALPRACTICE LAWSUIT HIDDING OUT THERE IN THE DAILY PRACTICE OF MEDICINE YOU WILL LEARN THAT YOU CAN NOT PREDICT WHICH CASE WILL COME BACK AND BITE YOU YOU WILL FIND THAT IT ISN’T THE CASE IN WHICH YOU THINK YOU MISSED SOMETHING OR THAT THERE WAS A PATIENT MISUNDERSTANDING. THERE ARE MANY UNRECOGNIZED PITFALLS THAT COULD TRIGGER A MEDICAL MALPRACTICE LAWSUIT HIDDING OUT THERE IN THE DAILY PRACTICE OF MEDICINE YOU WILL LEARN THAT YOU CAN NOT PREDICT WHICH CASE WILL COME BACK AND BITE YOU YOU WILL FIND THAT IT ISN’T THE CASE IN WHICH YOU THINK YOU MISSED SOMETHING OR THAT THERE WAS A PATIENT MISUNDERSTANDING.

58. Common Sense Risk Management Strategies

59. WHY INCORPORATE RISK MANAGEMENT IN YOUR PRACTICE? Reduce your own liability, chances of being successfully sued To provide better, safer care for our patients

60. PA PITFALLS IN THE NPDB Inadequate Supervision Inadequate Examination Untimely Referral Failure to Correctly Diagnose Lack of Documentation Poor Communication

61. PA PITFALLS Inadequate Examination Always confirm & expand on the Chief Complaint. Do not take some else's triage, but compare it with you own. You must always perform a complete physical examination for the history taken.

62. PA PITFALLS Untimely Referrals All providers must ensure timely referrals Not sending the patient to the supervising physician, Emergency Room, other medical specialties.

63. PA PITFALLS Failure to Diagnose Uncertain about the assessment of a patient. Patients condition does not follow the anticipated course. Not ordering appropriate diagnostic tests. Not correctly interpreting lab/diagnostic results and reports. 51.4% medical malpractice suits are Failure to Diagnose.

64. PA PITFALLS Lack of Documentation Five years from now, if someone reads your record on a patient you saw today, will they get an accurate picture of your care or will what is missing in the record speak louder than what you charted?

66. PA PITFALLS COMMUNICATION Although you will not find POOR COMMUNICATION listed anywhere as an official cause of MEDICAL MALPRACTICE CLAIMS, it underlies almost every malpractice action. Contributing factor is 80%.

67. GET ORGANIZED! PERSONAL RISK Get back to patients, don’t let results sit INSTITUTIONAL RISK Look at the process of diagnostic studies and who communicates results Who is responsible for making sure the study is done in a timely fashion and that results are communicated back to the patient in a timely fashion – YOU ARE! Heart Murmur Case CURRENT CASE – ECHOCARDIOGRAM FOR A NEWLY DIAGNOSED GRADE II HEART MURMUR, THE ECHO WASN’T ORDERED FOR A FULL MONTH, THE TECH DIDN’T VIST THE CLINIC FOR ANOTHER THREE WEEKS, THE SIGNIFICANT RESULT (SHOWING A 20% EJECTION FRACTION) WAS NOT REPORTED TO THE MD FOR ANOTHER TWO WEEKS BECAUSE IT HAD TO BE READ BY A CARDIOLOGIST, THEN THE RESULT WAS NOT REPORTED TO THE PATIENT – SHE MISSED HER APPOINTMENT, AND DIED A FEW DAYS LATER – TAKING MULTIPLE COLD MEDICATIONS INCLUDING SUDAFED THAT PUT A STRAIN ON HER HEART. INSTITUTIONAL NEGLIGENCE – NEGLIGENCE IN THE PROCESS OF DIAGNOSTIC TESTING AND REPORTING – MANY, MANY CASES INVOLVE A DELAY IN DIAGNOSIS OR TREATMENT. Example of untimely lab test, process malfunction, provider malfunction, PA had the opportunity to speak with Echotech in the office and echo tech had opportunity to give the heads up to the PA in the office the day of the test. PA HAD THE DUTY TO GET THE RESULT BACK TO THE PATIENT IN TIMELY FASION AND EITHER WARN AND TREAT OR REFER.CURRENT CASE – ECHOCARDIOGRAM FOR A NEWLY DIAGNOSED GRADE II HEART MURMUR, THE ECHO WASN’T ORDERED FOR A FULL MONTH, THE TECH DIDN’T VIST THE CLINIC FOR ANOTHER THREE WEEKS, THE SIGNIFICANT RESULT (SHOWING A 20% EJECTION FRACTION) WAS NOT REPORTED TO THE MD FOR ANOTHER TWO WEEKS BECAUSE IT HAD TO BE READ BY A CARDIOLOGIST, THEN THE RESULT WAS NOT REPORTED TO THE PATIENT – SHE MISSED HER APPOINTMENT, AND DIED A FEW DAYS LATER – TAKING MULTIPLE COLD MEDICATIONS INCLUDING SUDAFED THAT PUT A STRAIN ON HER HEART. INSTITUTIONAL NEGLIGENCE – NEGLIGENCE IN THE PROCESS OF DIAGNOSTIC TESTING AND REPORTING – MANY, MANY CASES INVOLVE A DELAY IN DIAGNOSIS OR TREATMENT. Example of untimely lab test, process malfunction, provider malfunction, PA had the opportunity to speak with Echotech in the office and echo tech had opportunity to give the heads up to the PA in the office the day of the test. PA HAD THE DUTY TO GET THE RESULT BACK TO THE PATIENT IN TIMELY FASION AND EITHER WARN AND TREAT OR REFER.

68. COMMUNICATION It is the combination of long wait times and a short visit with the physician that yields the most negative results on patient satisfaction Patients who have short wait times and adequate patient-doctor exam room time are the most satisfied patients

69. DOCUMENTATION “The witness whose memory never fades.” Critical, must be legible, thorough Includes emails Document all phone calls and emails Initial and date all documents you have reviewed – such as lab reports

70. DOCUMENATION (3 Purposes)… Reminds you of what you did and what you were thinking Tells other providers what you did and what you were thinking Serves as a legal record in case of litigation – USE IT TO PROTECT YOU not the other way around!! Appendicitis Case e.g. APPENDICITIS CASE There was no belly pain, therefore a CT to r/o appendicitis was not required by the standard of care. Now I’ll have to argue that there was belly pain and the PA missed it – the triage nurse note said patient was complaining of belly pain -APPENDICITIS CASE There was no belly pain, therefore a CT to r/o appendicitis was not required by the standard of care. Now I’ll have to argue that there was belly pain and the PA missed it – the triage nurse note said patient was complaining of belly pain -

71. DOCUMENATION Establish a Consistent Method Write a FULL note – positives and especially negatives Do not use abbreviations Be consistent with nurses and triage notes Never say “dictated but not reviewed” – it is your responsibility to review – strange things may be written! APPENDICITIS CASE There was no belly pain, therefore a CT to r/o appendicitis was not required by the standard of care. Now I’ll have to argue that there was belly pain and the PA missed it – the triage nurse note said patient was complaining of belly pain -APPENDICITIS CASE There was no belly pain, therefore a CT to r/o appendicitis was not required by the standard of care. Now I’ll have to argue that there was belly pain and the PA missed it – the triage nurse note said patient was complaining of belly pain -

73. DOCUMENTATION Must be Legible – MD and Pharmacist each blamed each other - both paid $225,000 each Dictation is the best form of documentation, most complete, most informative – even more than EMR, checkboxes , 175 vs. 87 words Reduces risk of a communication being overlooked if you make it a habit to dictate everything. Allows you to describe WHY you did what you did. Less work than writing, 175 words vs 87 wordsAllows you to describe WHY you did what you did. Less work than writing, 175 words vs 87 words

74. DOCUMENTATION DO NOT ALTER THE MEDICAL RECORD If an error is made, SLIDE it! Single Line through the words Initial it Date it Write “Error” next to it

75. RECORD TAMPERING WILL CAUSE YOU TO LOOSE/SETTLE Missing Medical Records Records Conflict With Patients Testimony Different Ink on Single Entry Different Handwriting Late Entries Long entries when normally short Handwriting too neat Late entry or out of sequence Additions to the chart Erased – Obliterated – Whited Out ADD HOW PROVIDERS MAKE AN EXCESSIVELY LONG NOTE WHEN THEY SCREWED UP OR TRY TO ASSESS BLAME ON SOMEONE ELSE.ADD HOW PROVIDERS MAKE AN EXCESSIVELY LONG NOTE WHEN THEY SCREWED UP OR TRY TO ASSESS BLAME ON SOMEONE ELSE.

76. LESSONS FROM CASES communicate – say you are sorry - be organized - don’t be rushed - keep your cool - be polite and professional no matter what - be aware of shift changes, ER “pneumonia” case - again take your time, do not discharge with abnormal vitals signs – Saw II “torticollis” case Pneumonia case: Some wheezing, SOB, PA diagnosed as probable pneumonia to the MD who was leaving shift in ten minutes. He never looked at xray, he passed it on to MD who took over for him, he never looked at xray because patient was to be admitted for SOB, low pulse ox. Hospitalist came down also assumed pt had pneumonia. She sat in ER all night long waiting for a bed. Nurses didn’t do hourly checks and vitals. She became more and more tachycardic and tachypneic and coded on the way to CT to r/o PE. She had post partum cardiomyopathy. Se died. Director of Saw II: woke up with neck pain - torticollis – quick rudimentary exam. The usual IM Dilaudad and Torodol. They snowed him in the ER for neck pain – presuming musculoskeletal. Vicodin and flexeril RX. They masked his symptoms and sent him home. He did not get better, saw a chiropractor. Ended up becoming septic for missed strep throat. He went into septic shock, cardio-respiratory failure and died. Huge Hollywood settlement. High income potential. Pneumonia case: Some wheezing, SOB, PA diagnosed as probable pneumonia to the MD who was leaving shift in ten minutes. He never looked at xray, he passed it on to MD who took over for him, he never looked at xray because patient was to be admitted for SOB, low pulse ox. Hospitalist came down also assumed pt had pneumonia. She sat in ER all night long waiting for a bed. Nurses didn’t do hourly checks and vitals. She became more and more tachycardic and tachypneic and coded on the way to CT to r/o PE. She had post partum cardiomyopathy. Se died. Director of Saw II: woke up with neck pain - torticollis – quick rudimentary exam. The usual IM Dilaudad and Torodol. They snowed him in the ER for neck pain – presuming musculoskeletal. Vicodin and flexeril RX. They masked his symptoms and sent him home. He did not get better, saw a chiropractor. Ended up becoming septic for missed strep throat. He went into septic shock, cardio-respiratory failure and died. Huge Hollywood settlement. High income potential.

77. LESSONS FROM CASES communicate with your supervising physician - insist on supervision and involvement when you are in over your head or uncomfortable – refer, refer, refer, Back Surgery Case, UC Strep Throat case – choose a good supervising physician and know their credentials Kansas D.O. Case -- document well - keep documentation professional - quote the patient – be sure your notes and the triage or nurse assessments are similar Back Surgery: ripped dura that became infected – supervising MD refused to see patient. PA hung out to dry. PA should have sent the patient to another MD in the practice. Strep throat in a child with an inflammatory kidney disease. Some type of glomerulonephritis, on imuron and prednisone long term. Under the care of a nephrologist. Immunosupressants. PA treated her like any other child,. Positive strep – amoxil. She died of sepsis. No call to nephrologist, no call to PMD. Kansas D.O. Narcotic mill. No specialiszed training in pain management. PAs did not know the lack of credentials of the D.O who held himself out to be a pain mangemnet specialist. They thought he was FP – turns out he was known in the community for supplying huge numbers of narcotic pain meds for his chronic pain patients – not try PT – no coordination with anesthisiologists, pain management specialists. Many of his patient’s OD’d. He and his wife sit in jail. 3 PAs, all fairly new grads, await trial. KNOW YOUR SUPERVISING MD’s credentials. Do not do anything you are uncomfortable doing. Back Surgery: ripped dura that became infected – supervising MD refused to see patient. PA hung out to dry. PA should have sent the patient to another MD in the practice. Strep throat in a child with an inflammatory kidney disease. Some type of glomerulonephritis, on imuron and prednisone long term. Under the care of a nephrologist. Immunosupressants. PA treated her like any other child,. Positive strep – amoxil. She died of sepsis. No call to nephrologist, no call to PMD. Kansas D.O. Narcotic mill. No specialiszed training in pain management. PAs did not know the lack of credentials of the D.O who held himself out to be a pain mangemnet specialist. They thought he was FP – turns out he was known in the community for supplying huge numbers of narcotic pain meds for his chronic pain patients – not try PT – no coordination with anesthisiologists, pain management specialists. Many of his patient’s OD’d. He and his wife sit in jail. 3 PAs, all fairly new grads, await trial. KNOW YOUR SUPERVISING MD’s credentials. Do not do anything you are uncomfortable doing.

78. LESSONS FROM CASES A $4 antibiotic may prevent a $300K settlement, post surgical knee case, hip case, MRSA – document patient instructions and especially follow up instructions – exude a caring and compassionate attitude at all times – take frequent breaks – take care of yourself Post op MRSA infections.Post op MRSA infections.

79. WHY PATIENTS DON’T SUE They know you care You kept them informed You were honest You apologized - “Sorry Works” They view their provider as a friend It’s been too long (seven years) It’s too much trouble

81. RECOMMENDATIONS Sign and date when you review diagnostic tests, labs, radiology reports etc. Chart and time all discussions with supervising physicians and specialists, record what they recommended Chart transfer of care and time to the next shift PA or the supervising MD or the admitting physicians Always read the triage nurse assessment and note agreement or disagreement with them

82. RECOMMENDATIONS Never discharge a patient with abnormal vitals signs without a good reason Always document that explicit follow up instructions were provided to the patient When you order tests, it is your duty to follow through on them in a timely fashion Insist on adequate supervision from your staffing MD Know you supervising MDs credentials and experience. Leave bad situations promptly

83. RECOMMENDATIONS If you are uncomfortable with your supervising MDs judgment or supervision, get a second opinion Don’t contradict your supervising MDs orders (Knee rehab case) Don’t make the patient decide their best course of treatment Don’t get in over your head – consult with and refer to specialists

84. RECOMMENDATIONS If you are uncomfortable with your supervising MDs judgment or supervision, get a second opinion Don’t contradict your supervising MDs orders (Knee rehab case) Don’t make the patient decide their best course of treatment Don’t get in over your head – consult with and refer to specialists

85. RECOMMENDATIONS Don’t pretend to be an expert without proof of additional training. Be honest with patients about your limitations, offer to research their question and get back to them if you don’t know Above all, treat everyone with respect and show them that you care Saying sorry without admitting blame does work

86. What to have MD Review? DON’T BE A HOTSHOT All ECGs (multiple missed MIs) Abdominal films (ileus case) Chest films (post partum cardiomyopathy) MUST BE REVIEWED BY SUPERVISING MD OR RADIOLOGIST IN A TIMELY FASHION

87. V.INSURANCE

88. Ins and Outs of Liability Insurance PAs are responsible for their own negligent acts PAs are sued Insurance companies provide a defense attorney Insurance covers claims, legal fees, and court costs up to the policy limit

89. What is at Risk? Your good name Your license Your career Your income potential Your personal assets – home included in many states – asset protection important for PAs – AAPALM

90. Malpractice Awards Compensatory Financial compensation to “restore patient to prior injury state” Punitive Deter future wrongful conduct

92. Imputed Liability Non-negligent party held liable for the actions of another based on their relationship. Vicarious Liability Employers held responsible (MD/PA) Apparent Agency Agency held responsible for employees Physician Liability Liability for supervisors (respondeat superior)

93. Malpractice InsuranceWhat do PAs need? Employer provided Umbrella Coverage Cost Patient Compensation Fund Cost (~$300 annually – physicians pay this) Individual (own) policy Cost ($2000-3000 annually-AAPA, HPSO) Depends on type of practiceDepends on type of practice

94. AAPA Insurance Services AAPA benefits financially Information on web site is slanted One size does not fit all “All or Nothing” Wisconsin has the Patient Compensation Fund for claims exceeding $1 mil/3 mil Wisconsin has a cap ($750,000) on suffer Moonlighting/Volunteering

95. Complexities of Malpractice Insurance Shopping for insurance –AAPA, HPSO Cost and who pays premiums What affects Premiums Scope/type of practice Hospital privileges History of lawsuit or claim Deductible – not common

96. State Laws Required coverage (MD, CRNA, APNP) Limits ($1 million-3 million) Patient Compensation Fund Cap ($750,000 on non-economic damages)

97. Types of Coverage “Occurrence” “Claims Made” “Tail” “Nose”/Prior Acts “Umbrella” “Separate Limits”

98. Insurance Policy ElementsDICE Declarations (Limits, Costs in Excess) Insuring Agreement Conditions (Duty to Report-Timely Manner) Exclusions

99. Occurrence (forever) Covers claims made during and after the policy period. Broadest protection available More $ “Nose”/prior acts coverage

101. Claims Made Coverage Only covers claims made and reported during the policy period Less costly “Tail” coverage needed Or “Prior acts” coverage needed on new policy.

102. Employment Agreements Employer will provide liability insurance Continuous Coverage Certificate of Insurance Know the type of insurance before you sign a contract – be sure you have tail coverage – its not if you leave but when you leave

103. VI.RESOURCES

104. MORE INFORAMTION PA Malpractice and Legal Medicine: www.AAPALM.org Quality and Risk Management Issues and Insurance: www.aapa.org/gandp/qandr.html My Consulting LLC, Dissertation, Articles etc: www.PAexperts.com

105. MAY YOUR CAREER BE PEACEFUL AND FREE OF SHARKS, BEARS AND TWINKIES LIKE THIS PHOTO - THANK YOUMAY YOUR CAREER BE PEACEFUL AND FREE OF SHARKS, BEARS AND TWINKIES LIKE THIS PHOTO - THANK YOU