Major Topics
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Yale-New Haven Hospital and Yale School of Medicine comprise one
of the preeminent medical centers in the nation. The institutions
undertake to train medical professionals, advance medical science and
improve the delivery of health care. In addition, the hospital is
committed to providing the best quality of care possible, as well as
the continuous assessment and improvement of the quality of care and
services rendered to our patients. The risk management program at the
hospital plays a crucial role in fulfilling these commitments.
The goals of the overall risk management program are to identify
areas of actual or potential risk, prevent, as much as possible,
injuries to patients, visitors and employees, and to prevent or limit
financial loss to the hospital and its staff. Financial loss can
occur in a number of ways. From a risk management perspective, the
primary concerns are those financial losses associated with the
inherent risks that exist in providing health care services, which
can result in a patient instituting a medical malpractice claim or
lawsuit against the hospital and/or a health care provider. The key
element in the success of the risk management program in preventing
and reducing these particular claims and associated financial losses,
is the participation of physicians, nurses, other health care
providers and hospital employees in implementing effective risk
management strategies. Each individual must be committed to reducing
risks.
The purpose of this handbook is two-fold: 1) to provide information
that addresses a number of the medical-legal and risk management
issues encountered by physicians and other health care providers; and
2) to serve as an easily referenced resource for such information,
supplementing additional information also contained in some of the
hospital's administrative policy and procedure manuals. The intent in
highlighting these issues is to make all health care providers more
aware of important opportunities they have to reduce the risks of
injury to patients and others, reduce the risks of financial loss to
the hospital and staff, and improve the quality of care. Since these
issues and related procedures may change over time, the hospital
intends to periodically update this handbook.
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Risk management is a planned and systematic process to reduce
and/or eliminate the probability that losses will occur in a specific
setting. It consists of three distinct, yet interrelated areas: 1)
risk identification and loss prevention; 2) loss reduction; and 3)
risk financing. To be most effective in the hospital setting, risk
management involves a multidisciplinary and proactive approach.
The first component involves those activities related to risk
identification and loss prevention. Generally, these activities
include the identification and correction of situations or problems
which may give rise to events or incidents of potential liability for
the hospital, its employees, physicians and other health care
providers. These activities are vital to successful risk management
since in most cases, the cost of preventing a liability claim is far
less than the cost of resolving the claim after it occurs. Loss
prevention activities also consist of the planning and presentation
of regular educational programs to clinical and administrative
departments which includes:
The second component involves loss reduction activities. Loss
reduction includes those steps which are taken after an event or
incident occurs that are aimed at minimizing the adverse impact,
financial or otherwise, of such an event or incident on the patient,
the hospital and its staff. These loss reduction activities are
multifaceted and, depending on the facts and circumstances of the
particular occurrence, include involvement and input from a number of
the medical and administrative staff throughout the hospital. The
foundation of an effective loss reduction program includes procedures
that identify and respond as soon as reasonably possible to incidents
which occur. In this way any adverse impact potentially resulting
from the incident can be best minimized. These activities include the
hospital's management of professional and general liability claims
reported under its insurance program.
The third component is risk financing, which involves the mechanisms
utilized to ensure that there are adequate financial resources
available to cover any potential liability situations, and includes
the procurement of adequate liability insurance coverage at
reasonable premiums to cover such losses. To respond to this need,
the medical center has developed a professional and general liability
insurance program which provides coverage for "medical malpractice"
and other types of negligence claims. Risk financing also involves
the effective negotiation and use of indemnity provisions in hospital
contracts to transfer liability risks to other parties whenever
possible.
The hospital's risk management program primarily is administered by
the Office of Legal Affairs in the areas of loss reduction and loss
prevention. However, risk management at the hospital is a coordinated
effort integrating many administrative and clinical departments
throughout the hospital. In particular, the hospital's Patient
Relations and its Quality Assurance Departments work closely with the
Office of Legal Affairs in the hospital's overall risk management
effort.
The risk management program at all Yale-New Haven Hospital
("YNHH") facilities is coordinated through the Office of Legal
Affairs and Risk Management, which is located in the Clinic Building,
Room 230, Ext. 5-2291.
The Director of Legal Affairs is responsible for the activities the
department and the YNHH risk management program. The department has a
staff of three attorneys who handle a wide range of issues on behalf
of YNHH including answering questions about patient consents, DNR
orders, withdrawal of treatment issues, business transactions,
contract negotiations, leases and regulatory matters. The attorneys
are available to speak at inservices, at Grand Rounds and other
educational programs on topics of interest to departments.
The Office of Legal Affairs is responsible for managing and
investigating the professional and general liability claims that are
made against the medical center facilities, its employees and insured
physicians. Members of the office staff are available for individual
consultation on risk management and liability issues.
The Office of Legal Affairs is also responsible for managing certain
insurance policies that have been secured by YNHH and its insured
physicians. Staff members assist physicians and others with questions
concerning insurance coverage, premium payments and proof of
insurance.
The attorneys in the department are available via telephone to answer
hospital/patient related legal questions Monday through Friday, 8:30
a.m. to 5:00 p.m. An attorney from the department is always on-call
after hours and on weekends and can be reached by beeper through the
YNHH page operator, at 5-3111.
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In 1978, several other major teaching hospitals formed an
insurance company (the "Company") chartered in Bermuda to underwrite
medical professional liability insurance, commonly referred to as
medical malpractice insurance, and general liability insurance for
the participating hospitals and schools of medicine, physicians and
dentists closely affiliated with each hospital, and the physician and
non-physician employees of each hospital. Yale-New Haven Hospital and
Yale School of Medicine joined the Company in 1979.
The hospitals and their affiliated universities who participate in
the insurance program (and who are the principal Named Insureds)
are:
In addition to the primary coverage provided through the program,
the participating institutions purchase excess insurance from some of
the largest and most reputable insurance companies issuing policies
covering health care related risks in the United States.
The policy is written on a claims made basis, which means it covers
claims or adverse medical incidents actually reported to the insurer
during the policy year resulting from services rendered during the
policy year or after inception of an insured's coverage under this
program (the retroactive date), whichever is earlier. Claims related
to services rendered prior to an insured physician's or dentist's
coverage under this program should be covered by the insurance
carried by that insured at the time the service was rendered.
The scope of the malpractice coverage provided by the insurance
program's policy generally parallels that customarily included in
medical professional liability policies. This generally includes
coverage for such allegations as negligence, breach of patient
confidentiality and lack of informed consent, for example. Coverage
is extended for professional service of a medical nature performed
anywhere in the world, provided suit is brought in the USA, its
territories or Canada. Interns, residents and fellows are insured
solely for activities performed within the scope of their formal
program and approved affiliations. This does not exclude coverage for
"good samaritan" activities, but does exclude coverage for
"moonlighting". Non-physician employees, including nurses,
therapists, social workers, and psychologists are automatically
covered under the policy but only while acting within the scope of
their employment.
The general liability insurance provided under the program is limited
to acts and conditions arising out of activities on behalf of the
hospital (or Named Insured) and does not provide coverage in homes or
private offices, except where such offices are located in a facility
owned or controlled by a participating institution.
Physicians and other insureds who terminate their insurance
voluntarily, or who retire or leave a participating institution will
continue to be covered for claims made subsequent to their departure
but arising out of professional services rendered during the period
of their participation in the program. This insurance coverage will
be provided as part of the institution's policy in future years. The
program will provide departing insureds this so-called
"tail-coverage" for future unreported claims at no additional premium
charge, as long as the insured's sponsoring institution remains a
participant in the program. In the event an institution no longer
participates in the program, it will be the possible for that
institution to buy "tail coverage" for itself as well as current and
prior staff. No coverage is provided for any claim arising out of
services rendered after an individual terminates participation in the
program.
To be covered under the insurance program, physicians and dentists
must participate under the sponsorship of a Named Insured
institution, meet the eligibility criteria of the Company and be
subject to and comply with the hospital's credentialing and
reappointment process and requirements. Coverage may be withheld or
terminated if a physician or dentist does not meet the required
eligibility or underwriting standards of the Company. Insured
physicians, dentists and other health care providers are required to
participate in regularly scheduled risk management and quality
assurance education programs either conducted or sponsored by the
institution.
Since the policy is written with a common aggregate limit of
liability, each participating institution is listed as a "Named
Insured" on the policy. Individual physicians and dentists are
additional insureds and do not have an "individual" policy. Premiums
are determined each year in the aggregate at a level deemed
sufficient to cover anticipated claims and necessary reserves, plus
certain costs such as reinsurance premium and administrative
expenses.
The institutions who comprise the Company have established procedures
for the management and resolution of claims brought against the
hospital, the School of Medicine or its insured physicians or
employees. The participating institutions have engaged a company with
expertise in the management of medical professional liability claims
to assure adherence to these agreed upon claims management
procedures. All insured physicians, dentists and other health care
providers are have a duty under the policy to cooperate with the
hospital's representatives, the Company and its agents, and to assist
in the investigation, defense and resolution of claims. Insured
physicians and dentists can obtain further information regarding the
insurance program by contacting the Office of Legal Affairs.
The policy requires that, in order to minimize costs and to insure
the efficient handling of claims, physicians and other insureds
promptly report the following circumstances:
All such reports should be made to the Office of Legal Affairs,
which administers the claims management program at the hospital and
School of Medicine. Written communications to the Legal Office should
be so addressed and marked privileged and confidential. Copies of
this correspondence should not be directed to others outside the
Legal Office.
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In the current health care environment, an increasing number of
patients who believe they have sustained physical or psychological
harm (a "bodily injury") as a result of the hospital's or a health
care provider's negligence bring claims or lawsuits to recover
damages. A number of factors are felt to contribute to patients'
decision to sue, such as the experiencing of an unexpected or less
than perfect result, or a feeling that they have been treated in an
uncaring, rude, unsympathetic and/or less than professional manner.
Many believe the most important factor that causes a patient to
resort to litigation is a breakdown in the patient-physician
relationship. Although some patients have legitimate reasons to bring
a claim or lawsuit, much of the increase in litigation is
attributable to our living in a society which commonly uses
litigation to address any perceived injustice.
Generally, hospitals and health care providers need to be concerned
about two types of negligence claims, professional liability
(commonly referred to as "medical malpractice") and general
liability.
Professional liability, or medical malpractice claims, generally
concern allegations of negligence regarding the rendering of
professional services which result in bodily injury to the patient.
Negligence, in the professional liability setting, is defined as a
departure, either by the acts or omissions of a health care provider,
from the accepted standards of care.
General liability, or general "negligence" claims, usually concern
allegations of negligence regarding the maintenance of the hospital's
or a health care provider's buildings and/or property resulting in
bodily injury or property damage to a visitor, or less commonly, to a
patient. Negligence, in the general liability setting, is defined as
the failure to exercise a reasonable degree of care which the law
requires to protect others from a foreseeable or unreasonable risk of
harm. In a physician's office or the common areas of the hospital
(rather than a specific patient room), a number of factors may give
rise to a claim for general liability. Most often, general liability
claims involve "slips and falls". However, a number of other
occurrences can give rise to these types of claims.
Medical malpractice and negligence lawsuits are brought in the
civil court system, usually under state, but occasionally under
federal law. This body of law, the statutory part of which is
periodically amended by legislative bodies and all of which is
subject to interpretation by the courts, is ever subject to change,
expansion and reinterpretation.
In these lawsuits, the person bringing the claim (the plaintiff) must
establish the following four elements:
A legal duty is established when a hospital or health care
provider undertakes the care and treatment of a patient, whether it
be to treat only a certain ailment or injury, at a certain place and
for a specified time, or for ongoing care and treatment. The breach
of the standard must be established by expert testimony. The relevant
standard is the one in effect at the time of the incident, not when
the claim is made. Causation is the connection between the failure to
meet a duty owed and the event (the injury) which occurred. This is
often times referred to as "proximate cause." The damages are the
injuries and as a practical matter are defined as the estimated
monetary equivalent to compensate the injured person for the loss or
injury sustained.
In order to become familiar with issues and chronological events of a
medical malpractice or negligence lawsuit, the following specific
areas will be discussed:
The statute of limitation defines the time within which a
plaintiff must commence a lawsuit by complying with certain
prescribed procedures. The statutes of limitation for civil actions,
which differ depending upon the type of action, are usually state
laws. These time periods allow a plaintiff or his or her authorized
representative a reasonable time to discover and investigate whether
he or she was injured as a result of a defendant's negligence. In
Connecticut, personal injury lawsuits, which include medical
malpractice and non-medical malpractice actions (general liability),
must be commenced by the patient (the plaintiff) against the hospital
or a health care provider (the defendant) within two (2) years from
either the date or discovery of the act or omission from which the
injury is alleged to have been caused, but in no event more than
three (3) years from the date of the act or omission complained of.
In Connecticut, there is no extension of this statute even if the
injury occurred to a minor. Due to a recent statute change, a
plaintiff may get an automatic three month extension to the two year
statute if application is made to the court prior to the two year
period; therefore, some suits may be brought two years and three
months after the incident.
While a letter of representation from an attorney may be the
initial indication of a claim or potential lawsuit, it is the filing
and service of specific legal pleadings known as the Summons and
Complaint, which initiate the formal litigation process. A Summons,
which notes the plaintiff(s), defendant(s) and jurisdiction of the
lawsuit, generally gives little indication of the specific
allegations which form the basis of the lawsuit. The Complaint
describes, with more or less specificity, the dates and allegations
of negligence against each defendant, and the injury and damages
allegedly sustained by the plaintiff. These materials must be served
on the defendant(s) and filed in court. Service may be in person, in
which case the Summons and Complaint should immediately be sent to
the Legal Office; service may also be accepted in the Legal Office,
if coverage is confirmed and the defendant has not moved out of the
area. The Complaint allegations will be answered later in the
litigation.
This second aspect of the litigation process involves the
investigative phase of the lawsuit. Both the plaintiff(s) and
defendant(s) seek to discover information by obtaining witness
testimony, medical records, expert opinions, documents, etc. The
period of time for discovery varies depending upon the complexity of
the case and the number of parties involved but, in general, it will
encompass a minimum of 2 years, and can extend for as long as 5-7
years.
Depositions and interrogatories are often the most important part
of the discovery process, especially for an individual defendant. A
deposition is a formal legal process whereby oral testimony is taken,
under oath, in the presence of a court reporter. Depositions may take
place in an attorney's office or in an appropriate room in the
medical center, with the attorneys representing all parties involved
in the litigation present. Generally, all of the parties in the
lawsuit will be deposed, and on occasion, the deposition of non-party
fact witnesses and experts will be taken.
Any physician, nurse, other health care provider and medical center
current or former employee scheduled to be deposed will meet with
defense attorneys prior to testifying. At this meeting, your attorney
will discuss the case, the medical records, and the procedural rules
of the deposition.
Remember, a deposition is an adversarial procedure that is in the
area of expertise of lawyers, not health care professionals.
Attorneys who specialize in the medical malpractice field have an
excellent working knowledge of medicine, with some having extensive
expertise in certain specialties. Therefore, although some questions
posed may appear to be innocuous, they may be phrased ambiguously or
duplicitously to elicit extremely damaging admissions. Always
remember that the goal of the plaintiff's attorney is to gain
admissions and/or inconsistencies in the testimony to support
allegations that an accepted standard of care was breached. Your
attorney will prepare you for the type of questions that may be asked
and the best way to answer such questions.
Some guidelines to remember when testifying include:
Following your deposition, the court reporter will send a written
record of your testimony, called a transcript, to your attorney. It
is unusual for a court reporter to record the testimony of a witness
without some errors or omissions. Your attorney will provide you with
a copy and ask you to review it in order to note any errors or
inaccuracies which should be corrected. It is important that you
carefully review the transcript since once you verify that it is an
accurate version of your testimony, it functions as your sworn
testimony. The testimony of a witness at a deposition can be
introduced as evidence at the time of trial, and, if the testimony of
a witness during trial differs from that given at deposition, the
opposing party will use such discrepancies to impeach the credibility
of the witness.
Interrogatories are a series of written questions propounded by one
party upon another to obtain factual information. Answers to the
interrogatories are prepared, in writing, and when sworn to, the
written responses may be used as evidence at trial. Counsel
representing the plaintiff(s) and defendant(s) will consult with the
client and prepare the answers to the interrogatories.
Interrogatories are commonly used in Connecticut and can be a
valuable tool in fact gathering during the discovery process.
If the defendant(s) decides not to settle the case and the
plaintiff decides not to voluntarily withdraw the lawsuit, the case
will be scheduled for a trial. When the case is tried, the plaintiff
is required to present his or her case first followed by the
defendant(s). The trial proceeds in the following chronological
order:
The role of the judge is not to decide whether a defendant is
negligent, but to see that the trial is conducted in a fair and
impartial manner and to rule on matters of law. It is the
responsibility of the jury, after considering the evidence, which
consists of the witness testimony, medical records and any other
exhibits allowed into evidence by the judge, to render a verdict
either in favor of the defendant(s) or plaintiff. The civil jury in
Connecticut State Court is comprised of six jurors and usually two
alternates.
During opening statements, the attorneys representing the plaintiff
and defendant(s) will provide the jury with an overview of the case
and the facts they intend to prove or disprove during the trial. The
plaintiff, by law, has the burden of proving that a defendant
departed from accepted standards of care and that this departure was
the proximate cause of an injury. The plaintiff will present his or
her proof first, usually by the testimony of witnesses and experts,
as well as the introduction of records and documents into evidence.
Following the direct examination of a witness by an attorney,
opposing counsel is entitled to cross-examine the witness.
During closing statements, the attorneys representing the parties
have the opportunity to summarize to the jury the evidence they have
offered to prove their case or rebut that offered by the opposing
side. Like the opening statements, the plaintiff is the first to
present arguments to the jury, followed by the defendant(s), with the
plaintiff having a final rebuttal opportunity. During the closing
arguments, it is common for the attorneys to comment on the
credibility of the fact and expert witness testimony the jury has
heard, and to suggest to the jury which witnesses they should find to
be the most credible and convincing.
Following closing statements, the judge will instruct the jury on the
law and how they should apply it to the evidence they have heard and
seen. This is commonly referred to as "charging" the jury. Following
being charged by the judge, the jury will be sent out to deliberate.
Often, a number of questions will be presented to the jury on a
written verdict sheet, and they will be asked to render a verdict on
each question. All six jurors must agree in order for a verdict to be
reached. If a jury renders a verdict in favor of the plaintiff, they
will also be instructed to award monetary damages, and when there are
multiple defendants, apportion the damages among them. Should the
jury find in favor of the defendant(s), unless the plaintiff appeals,
the lawsuit has ended. The judge may overturn a plaintiff's verdict
or reduce the amount awarded. A defendant has the right to appeal
when a verdict in favor of the plaintiff is rendered.
The conduct of hospitals, physicians and other health care
providers, has come under increasing scrutiny by federal and state
regulatory agencies. Some agencies are responsible for collecting and
maintaining data regarding medical malpractice settlements and
disciplinary actions taken against licensed health care
professionals, while others are charged with the responsibility for
investigating patient complaints regarding medical treatment. The
activities described above usually occur outside the civil legal
system, but are closely related to it.
The establishment of the National Practitioner Data Bank ("NPDB") was
mandated by the Health Care Quality Improvement Act of 1986 ("HCQIA")
and responsibility for its implementation and management resides with
the U.S. Department of Health and Human Services. The act was passed
by Congress to encourage good faith professional review activities
and restrict the ability of incompetent physicians and licensed
health professionals to avoid discovery of prior substandard or
unprofessional conduct by mandating the reporting of specific
information. The HCQIA requires: 1) health care entities and State
Boards of Medical Examiners to report certain information to the
NPDB, and 2) hospitals and health care entities to request
information from the data bank in various situations.
Some of the information which must be reported to the NPDB
includes:
Some of the information which must be requested from the NPDB
includes:
The Connecticut Department of Public Health and Addiction Services
is responsible for investigating complaints by patients and others
regarding medical treatment rendered by both health care entities and
individual physicians, nurses and other licensed health care
professionals. Any individual receiving a notice from the state
indicating it is investigating a complaint should treat it with the
utmost seriousness, since an investigation with adverse findings
could affect the status of a practitioner's license. Should you
receive such a notice, you may wish to consult with the Office of
Legal Affairs for advice on how to handle the matter.
If any health care provider or hospital employee learns of an
incident or complaint that may lead to legal action against the
hospital or a staff member, that person should immediately notify the
Office of Legal Affairs. The person reporting the potential action
may be subsequently contacted by a representative from the Office of
Legal Affairs regarding the matter.
Hospital personnel should not speak with attorneys or investigators
who are not affiliated with the hospital regarding any matter
involving the hospital unless specifically authorized by the Office
of Legal Affairs. Questions as to whether a person is a hospital
representative or for other guidance should be directed to Office of
Legal Affairs.
The hospital is required by law to report to the Department of
Public Health the termination or restriction of staff privileges of
any licensed physician. In addition, physicians and hospitals are
required by law to report to the Board of Medical Examiners any
information which appears to show that a physician is or may be
unable to practice medicine with reasonable skill and safety. The
Board will then make its own investigation. While this reporting may
be prescribed by law, it should also be considered by such
practitioners as a moral and ethical obligation. Should you become
aware of information regarding the professional misconduct of a
physician, contact the Office of Legal Affairs.
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The medical record serves many purposes but its primary function
is to plan for patient care and provide for continuity in information
about the patient's medical treatment. As a permanent record, the
patient's medical record informs other health care providers both
inside and outside the hospital about the medical history of the
patient. In addition, the medical record:
From the risk management perspective, the medical record is a
crucial element in preventing and minimizing the potential adverse
consequences of malpractice litigation. Ultimately, it serves as the
basis for the defense of malpractice claims and lawsuits. Medical
records which are poorly maintained, incomplete, inaccurate,
illegible or altered, create questions of fact regarding the
treatment given to a patient. Patient's attorneys often institute
malpractice lawsuits when they believe the questions of fact created
by incomplete and poorly documented medical records will cause a jury
to find liability against a hospital and/or health care provider.
Proper documentation in the medical record creates a legal document
which accurately and completely reflects the care provided to a
patient and, in a courtroom setting, it may be likened to a witness
whose memory is never lost. It serves to correlate, for all involved,
important patient information regarding the treatment rendered and
the patient's treatment plan, and is the means by which a level of
communication is achieved among all health care providers involved in
the patient's care.
Each and every page of a patient record should be clearly labeled
with the patient's complete name and medical record number.
Individuals making entries in a patient's chart should do so only
through a password electronic system, or on hospital approved medical
record forms and then only with pen rather than pencil, which might
fade and become illegible, or felt tips which might bleed through the
page. Include the complete date of the entry with the month, day,
year and time of day. Use only hospital accepted medical
abbreviations and terminology. Associated records and tests such as
EKG's, EEG's, fetal monitoring tracings, etc., should all be properly
labeled with patient's name and medical record number, and when
appropriate, the date and time performed.
All entries in the medical record should be dated, include an
indication of the time the note was written and be signed by the
person making the entries. Attending physicians may be required to
review and countersign progress notes by interns and residents.
Progress notes by junior residents should include reference to the
fact that a specific aspect of the patient's condition or treatment
plan was discussed with a senior resident or attending physician.
All examinations of the patient should be documented in the record.
Progress notes should indicate that the patient was kept informed of
his or her condition, as well as the treatment plan. Document all
instances of patient non-compliance or refusal of recommended
treatment and that the patient was informed of potential
consequences.
Patient records should never be altered. One should not erase,
obliterate or attempt to edit notes previously written. All
corrections, late entries, entries made out of time sequence, and
addenda should be clearly marked as such in the record, and should be
dated and timed on the day they are written and signed. Draw a single
line through any erroneous chart entry and write "error" with the
date and time, as well as your initials. The following diagram is
representative of the manner in which charting errors should be
corrected:
Health care providers should only document factual and objective
information from their own treatment and/or observation of the
patient. When documenting information derived from other sources, for
example, other health care providers, other medical records, or
entries in the same medical record, be sure to reference the source
of that information. Subjective documentation is far less clinically
useful than objective information. Examples of objective/subjective
charting include:
OBJECTIVE STATEMENTS SUBJECTIVE
1. Half of breakfast eaten 1. Diet taken fairly
2. No complaints of pain 2. Had a good day
3. Surgical incision healing - no sign of infection 3. Wound okay
4. Thrashing in bed 4. Appears restless
5. IV site clear and infusing at 40 drops per minute 5. IV running
well
A means by which health care providers can document factual and
relevant information is by specifically charting information based
upon what is:
When a patient is discharged, it is good medical practice to write
a final note commenting on the stability of the patient by noting the
patient's vital signs, the status of recovery from the condition on
admission, or for an elective admission, the status of recovery from
the elective treatment/surgery. The note should completely document
the discharge instructions given to the patient and/or the patient's
family members.
Following a patient's discharge, health care providers should
promptly complete the medical record in accordance with hospital
requirements to enable the medical record department to secure the
patient record expeditiously and safely.
Avoid the use of words that subjectively categorize a patient's
treatment or condition, such as unintentionally, inadvertently,
unexplainably, accidentally and unfortunately. Do not leave loose
ends in the chart. Follow-up on diagnostic tests ordered with results
not yet received, and/or abnormal test results.
The medical record should never be used as a forum for remarks to
"cover" yourself. Never make statements in the record which criticize
or cast blame upon others, or are intended to serve as gratuitous
remarks. Do not engage in battles in the chart over treatment
decisions. When disagreements regarding a patient's treatment plan
occur, a case conference should be called to resolve them. This
advice, however, is not intended to preclude using the medical record
to list differential diagnoses and the process of excluding potential
diagnoses.
Incidents and unanticipated patient outcomes should be promptly,
clearly and objectively documented in the medical record. Because
these occurrences may form a basis for litigation even when there has
been no negligence, the best defense is a record which contains
timely, accurate and properly charted information.
Assign a member of the treatment team with first-hand knowledge of
the event to record the event. Entries regarding an incident should
include the date and time of the incident, a brief factual and
objective description of what was seen and heard, using exact quotes
when possible of the patient's description of the event, along with
the findings of any physical examination and follow-up care. When
there is no apparent injury as a result of the incident, this should
be clearly documented in the record. Avoid writing information
unrelated to the medical care of the patient. The record should not
make reference to the preparation of an incident report and/or
notification of the hospital's Office of Legal Affairs.
When unanticipated patient outcomes occur, documentation of the
complication(s) should also be accurately recorded. Entries should
include information regarding the complication in an objective
fashion without judgment as to whether the complication is
acceptable, unacceptable or anyone is to blame. The entry should
indicate that the patient was informed of the complication and its
consequences, as well as any change in his or her treatment plan,
should it be necessary.
Question:
How should a physician respond to a letter from a patient's attorney
requesting medical information?
Answer:
Be sure the request contains an original dated written authorization
from the patient, or the parent or guardian of a child, or when the
patient is deceased, the appropriate legal representative of the
patient's estate. If the release is more than one year old, it is
prudent to request a more recent one. Forward a complete copy of the
patient's record, or only specifically requested items if they have
been detailed. You may request a reasonable fee for photocopies and
processing the request; by statute in Connecticut a hospital may
charge 65cents per page plus 1st class postage; a physician's office
may charge 45cents plus postage. You should not prepare a written
summary of the patient's care and treatment.
Because specific laws and regulations impose liability and monetary
penalties for the unauthorized disclosure of patient information
regarding HIV status, alcohol or drug treatment and psychiatric
treatment, without specific written authorization from the patient, a
release form for this information must explicitly authorize its
release.
It is strongly recommended that you notify the Office of Legal
Affairs of any record request by an attorney or dissatisfied patient
so that individual consultation and advice regarding the request can
be provided.
Question:
What do I do if I disagree with a note that someone wrote in the
chart?
Answer:
It is not uncommon for members of the health care team to disagree
occasionally among themselves or with a consultant's recommendations.
Usually, these disagreements can be resolved by discussing them at
case conferences and do not need to be documented in the record.
However, when a health care provider believes the patient's care is
affected, the disagreement should be discreetly, factually and
objectively documented, always expressing a tone of concern for the
patient's well-being, rather than hostility among the members of the
team.
Example:
Dr. Doe's recommendation that the patient be started on Streptomycin
is noted. Due to the patient's prior history of being sensitive to
this medication, the patient will be continued on his current
antibiotic regimen and will be followed with daily blood
cultures.
Question:
How long must I retain a medical record on a patient whom I have not
seen in sometime?
Answer:
In Connecticut, a hospital must retain a patient record for at least
25 years. Licensed health care providers must retain office records
for 7 years from the date of last treatment or 3 years from the death
of the patient.
Question:
Who owns the medical record?
Answer:
The health care provider or facility that created the records owns
the original. A patient is entitled to a copy of the record but not
the original.
Question:
What do I do if a patient demands to see his or her record while he
or she is hospitalized, before it is complete, or in the office?
Answer:
Generally the patient has the right to a copy of the hospital record
after the patient is discharged and after it is completed (e.g.,
operative notes and discharge summary dictated and signed). However,
there may be times when, to defuse a situation, you may decide to let
the patient read the original. When this occurs, a staff member must
be present to maintain the integrity of the record, prevent the
patient from adding comments or crossing out notes, and possibly to
answer questions about the notes.
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The hospital's risk management program employs a number of systems
to identify and provide notification of incidents or events that have
occurred involving patients, visitors, staff, equipment, facilities
or grounds which are likely to give rise to potential liability,
affect the quality of patient care or affect safety in the hospital.
The early identification of such occurrences allows the hospital to
immediately investigate the circumstances of the incident, and if
necessary, institute corrective action to prevent similar occurrences
in the future. One of the systems used to identify and report patient
and visitor related occurrences is the hospital's incident report
system.
Health care providers and other hospital employees are required to
report and complete a Report of Incident form (F-877) regarding any
patient or visitor who, while within hospital jurisdiction and/or
while on hospital premises, is involved in an occurrence which has
caused or has the potential to cause injury or loss or damage to
their personal property. This includes incidents where the
possibility of injury existed although no injury was actually
incurred and those incidents which are inconsistent with the routine
care of a particular patient or routine operation of the
hospital.
The following are some examples of reportable incidents:
All health care providers should be familiar with the complete
hospital incident reporting procedures which can be found in the Yale
New Haven Hospital Administrative Policy and Procedure Manual, I-3.
The following is a brief discussion of the procedures involved in
incident reporting.
For incidents involving patients, the person completing the Report of
Incident form should be the individual who witnessed, first
discovered, or is most familiar with the incident. Each section of
the form must be completed according to the directions on the form.
The report must then be immediately presented to the reporter's
supervisor who must then investigate and recommend corrective action.
The description of the incident should be a brief narrative which
should consist of an objective description of the facts. It should
not include the writer's judgment as to the cause of the event.
Quotes should be used where applicable with unwitnessed incidents,
e.g., "Patient states..." The name of any witnesses should be
included on this report. The name of the employee directly involved
in the incident can be recorded in the witness space as well, if the
employee is not the reporter. The patient must be examined by an
appropriate physician, who should complete the appropriate section on
the form regarding his or her findings. The Report of Incident form
should be completed no later than the end of the shift during which
the incident occurred or was discovered to have occurred and must be
forwarded to the Central Nursing Office within 24 hours and the
Office of Legal Affairs within 48 hours.
All incidents involving visitors must be reported to the supervisor
in the area where the incident occurred. A visitor who has sustained
an injury while in the hospital should be escorted by a staff member
to the Emergency Service for medical attention. If the injured person
refuses medical attention, this must be noted on the Report of
Incident form.
The Report of Incident form is an administrative document, not part
of the medical record. The fact that an Report of Incident form has
been completed should not be reflected in the medical record, nor
should the report be placed in the medical record. In addition, no
copies of the Report of Incident form may be made. An objective
description of the incident should be recorded in the medical record
by both the medical and nursing staff along with any follow-up
observations, diagnostic studies and results, and/or related
treatment.
Whenever a patient or visitor incident is of an unusual or serious
nature, the Office of Legal Affairs must be called immediately.
If a medical device is involved (caused or contributed to death of,
serious injury to, or serious illness of a patient):
Report of Incident forms and other significant incidents are
reviewed on an ongoing basis by a number of departments and
committees in the hospital. This review process allows for:
Each service reviews and analyzes all reported incidents on an
ongoing basis and reports trends and corrective actions taken as part
of the periodic QA/QI reports.
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Physicians who carefully listen to patients and comfortably share
medical information with them have discovered the cornerstone of the
art of medicine. A healthy physician-patient relationship can make a
difficult diagnosis more bearable for the patient. It can help a
resistant patient understand the need for a procedure or medication,
and allow the physician to develop a realistic plan for continuing
care. When a physician's relationship with a patient is marked by
mutual trust and open communication, he or she has taken a major step
towards the assurance of patient satisfaction.
Evidence shows that a clear, two-way conversation is a key element in
the prevention of patient dissatisfaction and malpractice claims. In
fact, many episodes of patient dissatisfaction triggered by an
iatrogenic injury or other "adverse outcome" can be defused by a
reasonable explanation from the physician who has established a good
basis for communication.
On the other hand, inadequate communication and misunderstanding are
often the inciting agent that transform a poor medical outcome into a
legal action against a physician, even when quality care was
delivered. Most studies show that a significant percentage of
malpractice lawsuits are ultimately resolved without any payment to
the patient. Many risk managers believe that a large number of these
malpractice cases could be avoided if physicians listened more
attentively to patients who experienced less than optimal or
unexpected treatment outcomes. Techniques for increasing patient
satisfaction through improved communication are now widely
recommended for malpractice claims prevention.
Risk management begins the moment a professional relationship is
established with a patient. The understanding by, compliance by and
satisfaction of any patient ultimately depend on oral and written
communication. The following general points will be helpful as you
build each physician-patient relationship. The result should be a
mutually rewarding experience for both the physician and patient.
Question:
When a patient is difficult, non-compliant or otherwise incompatible,
and a physician believes that he or she cannot continue to provide
care within these constraints, what is the best way to go about
terminating the physician-patient relationship?
Answer:
The instances of the patient's non-compliance and difficult or
disruptive behavior should have been noted contemporaneously with
their occurrence in the patient's medical record. Once a physician
has made the decision that the relationship will be terminated, the
reasons for the decision should also be noted in the medical recor\.
Always attempt to meet with or speak with the patient (and family
members, if appropriate) to inform them of your decision, explain the
reasons for it, and to answer any questions the patient may have.
It is recommended that you notify the patient in writing, both by
certified and regular mail, of your decision and the specific
professional reasons for terminating the relationship. This should be
done even if you have met with the patient. The following should be
included in the letter:
Since the circumstances involved with each patient are unique, you
may wish to contact the Office of Legal Affairs for specific
advice.
Question:
If the patient has not paid my bill for professional services, may I
terminate the relationship?
Answer:
Yes. Use the principles noted above for notifying the patient.
However, the law does not permit the refusal to forward medical
records even though a bill has not been paid.
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Many physicians feel that informed consent is merely a formality
necessary to obtain the patient's signature on a form in order to
allow a specific procedure or treatment to be performed on the
patient. Rather, informed consent should be thought of as a
communication process through which a patient, with the advice and
support of his or her physician, makes decisions concerning the
treatment he or she will receive. The process assists in developing
the critical element of trust between the physician and patient, and
is often the most important discussion a physician will have with his
or her patient.
Patients may bring a claim or lawsuit against the hospital and/or a
physician predicated solely on the allegation that they did not give
their consent; this is called a battery. A second more common claim
is that the consent given was not based upon proper and adequate
information; this is known as a claim for "lack of informed consent."
This type of claim is usually found as part of the typical
malpractice or negligence action. Because of this type of potential
claim, from a risk management perspective, the informed consent
process plays a crucial role in minimizing the exposure of both the
hospital and physicians to medical malpractice claims and
lawsuits.
Informed consent is a three part process in which there is an
exchange of information between the physician and patient. The first
part is the disclosure and explanation to the patient, in language
that the patient can understand, of the nature of a proposed
procedure or treatment, its potential risks and benefits, and
reasonable alternatives which may be available. The second part of
the process involves: 1) ensuring that the patient understands what
has been explained to him or her (to the best of the patient's
intellectual capacity); 2) the patient accepting the risks; and 3)
the patient giving his or her consent to undergo the procedure or
treatment. Finally, the process must be documented.
In the process noted above, in many instances, the patient will be
asked to sign a form acknowledging that he or she has received
sufficient information upon which informed consent can be given for
the procedure or treatment, and has given his or her voluntary
permission to undergo it. Also, the physician who had the discussion
with the patient must document the details of the discussion in the
patient's medical record.
Physicians are responsible for obtaining informed consent. The
physician who will perform the proposed procedure or treatment should
engage in this process with the patient. It is acceptable for a
physician to delegate the task of obtaining the patient's signature
on the necessary consent form to another member of the health care
team. However, this should occur only after the discussions necessary
for a patient to give his or her informed consent have occurred.
Where possible, it is desirable for the informed consent
discussion to occur a sufficient period of time before the proposed
procedure or treatment in order to allow the patient time to consider
the information and ask questions. During the discussion, it is
recommended that the physician use language the patient can
understand and avoid the use of "medical jargon." The informed
consent discussion may take place in the physician's office prior the
patient's hospital admission, in the patient's hospital room, and in
emergent situations, in the emergency room or other
procedure/treatment areas of the hospital.
A patient must have capacity in order to give informed consent. This
requires that the patient understand the proposed procedure or
treatment and be able to voluntarily give or withhold his or her
consent after making an informed decision. Informed consent may be
given by adult patients with capacity, the parent or legal guardian
of a minor, emancipated minors under specific circumstances or a
court or patient designated surrogate of a patient without capacity.
In some instances, a family surrogate may give consent.
The following information should be discussed with the patient and
documented in the medical record:
As a general rule, a physician is required to disclose information
to a patient that a reasonably prudent person under similar
circumstances would want to know. A physician need not disclose all
of the risks or complications which may occur, but should discuss: 1)
those commonly associated with the procedure or treatment and having
a reasonable chance of occurring; and 2) those which have a small
chance of occurring, but which have grave consequences. Less common
or remote risks/complications should be discussed with the patient if
they are significant to that patient.
The informed consent process is documented in two separate ways in
the medical record. The first way is by obtaining the patient's
signature on an appropriate consent form following the necessary
disclosure of information upon which a patient can give his or her
informed consent. The second way is by documenting the informed
consent process in the patient's medical record. This can be an entry
in the office records maintained by a physician or by a progress note
in the hospital record.
State law and hospital policies and procedures require that
written informed consent must be given by all patients before any
non-emergency operation, invasive procedure or treatment, regardless
of whether that procedure takes place in the operating room, a
treatment room or office. The hospital has developed a consent form
for surgical operations and diagnostic or other therapeutic
procedures, which must be signed by all patients and the responsible
physician. These consent forms can be found on all patient units.
When questions arise regarding the need for or use of these forms,
the Office of Legal Affairs should be consulted.
The contemporaneous documentation of the informed consent process
serves as the foundation for the defense of any subsequent claim by a
patient for lack of informed consent. The signature of the patient on
a consent form alone is not legally determinative evidence that the
patient has given informed consent. Poor or absent documentation will
force a physician to testify from recollection about an event which
occurred several years previously, which will undermine his or her
credibility. In addition, poor or absent documentation may be a
significant factor in a patient's attorney's decision to institute a
legal action.
To reiterate, the physician who had the discussion with the patient
must document the details of the discussion in the patient's medical
record. The entry in the medical record regarding the informed
consent process should describe the information disclosed to the
patient. Avoid the use of summary statements such as "The patient was
advised of the potential risks/complications of the operation and
alternatives" and instead, note at least some of the actual risks,
complications and alternatives discussed with the patient. For
example, the entry could state that "information regarding the risks,
complications and alternatives were discussed with the patient and/or
family, including but not limited to ...", followed by the specific
information discussed. Note whether the patient was given any
booklets or written material regarding the procedure or treatment. It
is also important to document any questions asked by the patient and
the answers given.
In certain situations, the patient's informed consent is not
required before a physician may proceed with the delivery of medical
care. In each of these situations, the hospital has developed
specific policies and procedures to follow with which all physicians
and other health care providers should be familiar. The Office of
Legal Affairs should be contacted to answer questions regarding these
procedures or provide advice on how to deal with specific situations.
These situations include:
1) Emergency treatment - Often a physician will determine that a
patient is in immediate need of medical treatment but is unable to
give consent because of a physical or mental impairment. Medical
treatment can be instituted under these circumstances once it is
determined that: a) a delay in treatment would be life threatening or
cause the patient serious harm; b) no close family member or
surrogate is available to give consent on behalf of the patient; and
c) the physician has no evidence that would suggest that the patient
would oppose the treatment. The physician should document in the
medical record the emergency circumstances under which the medical
treatment without consent was rendered. This emergency exception
should be narrowly construed.
2) Therapeutic privilege - This is the term used to describe the
withholding of certain information from the patient by the physician
based upon his or her judgment that disclosure of the information
would have a harmful effect on the patient. When a physician invokes
such a privilege, it is imperative that the objective justification
for it be documented in the patient's medical record. This should
include the reason why information was withheld, and both the
information that was disclosed and not disclosed. It is not
acceptable to use this privilege because the patient would be
"anxious" or "upset" by the information, or the family does not want
the patient told. The use of therapeutic privilege should be
carefully considered and used infrequently.
3) Lack of Capacity - This is a situation in which a person lacks the
legal capacity to make certain decisions regarding his or her care.
Often, it may be possible to obtain family or surrogate consent; in
other cases it may be necessary to have a court make such a
determination in a special proceeding. When questions regarding the
capacity of a patient arise, you may wish to consult with the Office
of Legal Affairs for advice.
The Federal Patient Self-Determination Act requires hospitals to
develop policies and procedures that recognize a patient's right to
accept or refuse medical treatment and to formulate advance
directives in accordance with state law.
The regulations require that adult patients be given written
information at the time of admission regarding state law concerning
advance planning for their medical treatment. In addition, a summary
of the hospital's policy regarding these rights must be supplied; and
the verbal and written information given to the patient must be
documented in the medical record. All physicians and other health
care providers should be familiar with this information and the
hospital's policy and procedures regarding these subjects. Every
physician has an important responsibility for ensuring that patients
understand their right to plan in advance for their medical
treatment.
It is important to note that both written (e.g., living wills and
health care proxies) and oral advance directives (e.g., statements
made orally to a physician, witnessed by a third party and documented
in the chart) are recognized under state law.
Unless there is a Do Not Resuscitate (DNR) order in the medical
record, all patients suffering cardiac or respiratory arrest will
receive appropriate cardiopulmonary resuscitation (CPR). Physicians
and other health care providers should be familiar with the
hospital's Limiting Life Support Treatment policy. The responsible
attending physician must discuss the DNR order with patient, family
members and/or surrogate, and this physician must write the DNR
order. No specific medical pre-condition is required for the entry of
a DNR order consented to by a competent adult patient, and this
written or oral consent must be obtained prior to writing the order,
unless it is determined that the patient would suffer immediate and
severe injury from a discussion of such an order. A DNR order may be
written for an incompetent patient if the patient had, prior to
losing capacity, consented to a DNR order.
Before giving consent to a DNR order, a patient or the patient's
surrogate, must be advised by the responsible attending physician of
the patient's diagnosis and prognosis, the reasonable foreseeable
risks and benefits of CPR, and the consequences of a DNR order.
The patient's attending physician must document the medical record
regarding discussions about DNR orders and the decisions made by the
patient or the patient's surrogate.
Question:
May a patient revoke his or her consent for a procedure or treatment
once it is given?
Answer:
Yes. A patient has the right to revoke his or her consent either
verbally or in writing at any time. When this situation occurs, the
patient's physician should be notified immediately. A patient has the
right to revoke his or her consent during a procedure or treatment.
If this occurs, the procedure or treatment should be terminated at
the earliest (and safest) time possible. The patient's revocation of
consent must be documented in the medical record.
Question:
Is it acceptable to obtain consent over the telephone by a parent,
legal guardian, or surrogate, when they are unable to come to the
hospital?
Answer:
Yes, but consent should only be obtained in this manner in emergency
situations or when it is determined by a physician that the delay in
treating the patient, while waiting for the arrival of the parent,
legal guardian, or surrogate, would cause greater harm to the
patient. The physician should disclose the same information as under
normal circumstances. The substance of the telephone conversation and
the name and telephone number of the person giving the consent must
be documented in the medical record. Also, the telephone conversation
should be witnessed by another professional staff member who should
countersign the note in the medical record.
Question:
Consent forms are often signed in the office prior to admission for
surgery. How long is the form to be considered valid?
Answer:
At Yale-New Haven Hospital, a surgical consent form is valid for up
to 30 days, unless the surgeon has evidence that the patient has
revoked consent.
Question:
Are faxed consent forms valid?
Answer:
Usually the health care facility is required to maintain original
evidence of consent in its record. Faxed consent forms may be
considered acceptable in unusual circumstances, but must be followed
by the original form (brought from the office) immediately.
Question:
My patient has been premedicated but has not signed the consent form.
May surgery proceed?
Answer:
It is much preferable to obtain documentation of the consent prior to
premedication. However, presuming that the physician has discussed
the surgery with the patient prior to premedication, documentation by
the responsible physician of that discussion in the medical record
may be acceptable under hospital policy. If the patient signs a form
after premedication, the physician must document that fact and that
the patient was awake, alert and aware of the circumstances.
Question:
My patient did not sign a consent form prior to surgery. Now that the
surgery has taken place, should I get the form signed?
Answer:
No, this should never be done. Either no consent was necessary
(because the surgery was an emergency), or consent was documented by
the surgeon prior to surgery in a progress note. "Retrospective"
consent is ineffective.
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The ability of the hospital to control infectious disease is an
important element of its overall risk management efforts. All health
care providers must comply with federal, state and municipal rules
and regulations, in addition to the hospital's policies and
procedures regarding the control of infectious disease. Some of the
aspects of infectious disease control which you should familiarize
yourself with include:
States and often, cities, require all physicians and hospitals to
report cases, carriers or persons infected with specified
communicable diseases. Several of the more common diseases include
botulism, chicken pox, dysentery, encephalitis, rubella, gonorrhea,
Hepatitis (A, B, Non-A, Non-B), Lyme disease, meningitis, rabies,
Streptococcal sore throat, syphilis, tuberculosis, and whooping
cough. Reporting procedures will vary somewhat as between the states.
Patients need not consent to this reporting and in fact, may not
refuse. There are penalties for the failure to report. Questions
about assistance with infectious disease reporting may be directed to
the hospital Department of Epidemiology and Infection Control.
Since a medical history, examination or laboratory testing cannot
reliably identify all patients infected with HIV, Hepatitis B or
other blood borne pathogens, health care providers must utilize
universal blood and body fluid precautions in caring for all
patients. These precautions include, but are not limited to:
1) Hands must be washed before and after contact with patients, even
when gloves have been used. If hands, or other parts of the body,
come in contact with blood, body fluids or human tissue, they should
be immediately washed with soap and water.
2) Gloves must be worn when contact with blood, body fluids or
contaminated surfaces is anticipated.
3) Gowns or plastic aprons are indicated if blood splattering is
likely. Masks and protective goggles must be worn if aerosolization
or splattering is likely to occur, such as in certain dental and
surgical procedures, wound irrigations, post mortem examinations and
bronchoscopy.
4) To minimize the need for emergency mouth to mouth resuscitation,
mouth pieces, resuscitation bags or other ventilation devices must be
available for use in areas where the need for resuscitation is
predictable.
5) Sharp objects, such as needles and glass, must be handled in a
manner to prevent accidental cuts or punctures. Used needles should
not be bent, broken, reinserted into their original sheaths,
recapped, or unnecessarily handled. Immediately after use, they must
be discarded intact in puncture resistant needle disposal containers.
All needle stick accidents, mucosal splashes or contamination of open
wounds must be reported immediately to Personnel Health Services.
6) Blood spills should be cleaned up promptly with a disinfectant
solution such as 1:10 dilution of bleach.
7) All patient specimens should be considered bio-hazardous and
bagged for transport to laboratories.
These precautions may minimize transmission of disease from patient
to health care provider and decrease the likelihood that other more
easily transmitted organisms are transmitted to other patients.
Occupational exposure to, and the transmission of, Hepatitis B (HBV)
and human immunodeficiency virus (HIV) are of the utmost importance
from a risk management standpoint because of the need to protect
health care workers, patients and visitors from these viruses.
Needlestick injuries are the largest source from which occupational
exposures to these agents arise in the hospital workplace. Since all
hospital workers are at risk of needlestick injury, adherence to the
following practices is useful in preventing needlesticks:
1) Avoid rushing when handling needles.
2) Avoid pulling hard when encountering resistance in withdrawing
needles from patients.
3) Seek assistance when using a needle in caring for an uncooperative
patient.
4) Avoid recapping under all circumstances, but never recap a needle
that has been used on a patient.
5) Dispose of needles properly in puncture resistant containers.
Never leave needles on beds, stretchers, or bedside tables since they
may injure staff, patients, or visitors. Do not throw them into
regular garbage containers where they may injure housekeeping
staff.
6) Never put needles in your pocket.
7) Never try to remove anything from a needle container or force
needles into a full container.
8) Pick up improperly discarded needles with care and dispose of them
in a puncture-resistant container.
In the event a needlestick does occur, promptly wash the area with
soap and water, record the patient's name and hospital number,
prepare an incident form and report the event to Personnel Health.
Attempts to "milk" the wound to express contaminants are ineffective
and only damage tissues further. Personnel Health will provide you
with information about or appropriate testing for hepatitis and HIV
along with any recommended prophylaxis.
The improper disposal of medical waste not only has the potential to
cause injury to health care workers, patients and visitors, but can
have widespread public health effects. A number of federal, state and
local regulatory agencies, in addition to hospitals, have promulgated
regulations and policies governing medical waste disposal with which
all health care workers should familiarize themselves. Improper
disposal of medical waste could expose the hospital to significant
penalties, including fines and the suspension of services.
The following guidelines will be of assistance in complying with the
rules and regulations governing the disposal of medical waste.
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Patients have the right to expect that all communications and
records pertaining to their care will be treated as confidential, and
that their rights to privacy will be protected. Therefore, all health
care providers must treat patient related information in a
confidential manner, and guard against the indiscriminant and/or
unauthorized release of such information. Although such an act may
occur unintentionally, the hospital, physicians and other health care
providers may be found liable for the unauthorized or improper
disclosure of medical information.
Discussion of patient related information should be conducted only in
locations where confidentiality can be maintained. Health care
providers should refrain from such discussions in elevators,
hallways, dining areas and other public areas. Health care providers
should use discretion when discussing medical information concerning
a patient in front of visitors or family members, and should first
determine whether the patient wishes to have this information
discussed in the presence of such persons. In addition, the patient's
permission should be obtained prior to leaving a message containing
confidential medical information on a telephone answering machine, or
with family and/or household members. Health care providers should
not disclose patient related information when asked by unidentified
or unknown persons, or in response to telephone inquiries, other than
providing hospital approved condition reports, e.g., critical,
stable, etc. In such situations, the requesting party should be
referred to the patient's attending physician for further
information.
Patients' medical records should be guarded at all times in areas
where entries to the record are made to prevent unauthorized access.
Medical records should be stored and protected according to hospital
policy, preventing passers-by from viewing the record. Access to
patient information via electronic systems should also be protected
according to hospital policy, with access code and password security
maintained.
In order to maintain the peer review privilege and patient
confidentiality, staff meetings to discuss patients and M & M
reviews should be conducted in appropriate locations. Materials
distributed should be collected and not left for members of the
general public to find.
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The hospital is committed to ensuring that the individual rights
of all patients are respected during their hospital stay. Most
importantly, all patients have the right to expect to be treated with
dignity and respect. It is important for all health care providers to
be familiar with patients' rights under state law and hospital policy
and observe them at all times. Patients afforded these basic
considerations are usually more satisfied with their hospital
experience, and from a risk management perspective, it makes them
less likely to make a complaint, which could ultimately result in a
claim or lawsuit.
The hospital is obligated to provide appropriate assistance,
including the use of an interpreter, to ensure that patients
understand their rights. All individuals are entitled to receive
emergency care and/or treatment without discrimination due to race,
color, religion, sex, national origin, disability, sexual
orientation, or source of payment. Patients are entitled to be
informed of the identity and role of all physicians and support staff
involved in their care, and have the right to refuse treatment or
examination by them. Patients have the right to privacy while in the
hospital and to expect all information and records regarding their
care will be kept confidential.
Patients must be given all the information they need to give informed
consent regarding treatment and refusal of treatment. Under most
circumstances patients are entitled to review, and should they so
desire, obtain a copy of their medical records (after discharge if
the record is a hospital record). A patient may refuse to take part
in research and should be able, without fear of reprisals, to
complain about the care and services they have received.
Patients, or appropriate family members, should be informed about
unexpected and/or negative outcomes promptly. This should include the
nature and cause of the event, if known, as well as the manner in
which the event will affect the patient's prognosis and treatment
plan. Failing to disclose, or disclosing only partial information
regarding such occurrences, is perhaps the most common cause of
patient dissatisfaction. Often, this dissatisfaction results in
malpractice claims and lawsuits. Regardless of how difficult it may
be for patients, it is legally unwise to speculate on the cause of an
untoward event.
Patients should also be made aware that in order for the health care
team to render good care, patients have certain responsibilities. The
most important of these is to provide, to the best of their
knowledge, accurate and complete information about their present
complaints, past illnesses, hospitalizations, medications and other
matters relating to their health. Patients are responsible both for
following the treatment plan recommended by the members of the health
care team, and for the consequences should they refuse treatment or
not follow recommended instructions.
While trying to treat all patients with dignity and respect,
occasionally, the use of physical restraints must be employed to
protect and avoid harm to the patient or those surrounding the
patient. In almost all circumstances, prior to the use of restraints,
the written order of a physician who has examined the patient must be
obtained. In emergency situations, a registered nurse may order
restraints but the physician must be contacted immediately. It is
imperative that the patient's medical record be documented regarding
the need for, use of, and termination of restraints. Hospital
policies are in compliance with the JCAHO policies on restraints and
will generally provide a sound procedural approach.
Competent adult patients have the right to refuse treatment. Since
this refusal may be subsequently disputed or denied by the patient,
it is important that all health care providers document these
occurrences in the patient's medical record. When a patient refuses
treatment, it is important that his or her physician disclose the
risks and consequences associated with the decision. The treatment
being proposed and refused by the patient should be documented in the
medical record, as well as the fact that the potential adverse
consequences have been discussed with the patient (and when
appropriate, family members).
Similarly, adult patients may not be detained in the hospital should
they wish to leave against medical advice, except under extreme
circumstances prescribed by law. Again, the patient's medical record
should be documented regarding his or her voluntary decision to be
prematurely discharged, noting the potential adverse consequences
that have been discussed and that the patient understands them. The
record should also note that further care has been recommended, as
well as where and when the patient intends to obtain this care. In
addition, most hospitals require that the patient be asked to sign a
form indicating he or she is being discharged against medical advice.
The patient's refusal to sign this form, which often occurs, should
be documented in the record.
The hospital has a patient representative to serve as a liaison
between the patient and his or her family, and the medical and
administrative staff of the hospital. The patient representative acts
as advocate, ombudsman and agent for the patient and enhances patient
care by assuring the identification, investigation and amicable
resolution of patient complaints and problems. In addition to
resolving patient complaints, the patient representative can explain
hospital policy and procedures for the patient and/or family and
handle lost property claims.
From a risk management perspective, the patient representative plays
a critical role in preventing patient complaints which, without their
early intervention, could evolve into malpractice claims and lawsuits
against the hospital and/or health care providers. All health care
providers are encouraged to contact the patient representative for
assistance.
Footnotes:
A medical device is an instrument, apparatus, contrivance, implant,
in vitro reagent, or other similar or related article, including any
component, part or accessory (e.g., catheters, infusion pumps, suture
materials, syringes, defibrillators, pacemakers, hospital beds,
patient restraints, wheelchairs, tampons, in vitro diagnostics,
etc.).
Permanent impairment of a body function or permanent damage to a body
structure.
Necessitates immediate medical or surgical intervention to preclude
permanent impairment of a body function or permanent damage to a body
structure.
Note, however, that the physician-patient relationship generally
cannot be terminated during a medical emergency, labor or any other
acute event.
Handbook Contents Page | Risk Managment Home Page
January, 1997.
Copyright 1997, Yale-New Haven Hospital and Yale University. All rights reserved.