Physical medicine and rehabilitation physicians, also known as physiatrists, manage medical conditions resulting from disease or injury that alter a patient’s function and performance. Emphasis is placed on a comprehensive patient-centered treatment plan that optimizes function through the combined use of medications, procedures, and physical modalities.
The Doctors Company analyzed 111 claims against physiatrists that closed between 2008 and 2018. The study revealed that the most common patient allegations were improper performance of treatment or procedure (22 percent), related to diagnosis (failure, delay, or wrong) (19 percent), improper management of treatment (15 percent), and improper medication management (11 percent). Consider the following case examples and discussions regarding the most common patient allegations.
Improper Performance of Treatment or Procedure and Failure to Diagnose a Complication
A patient who was referred to a physiatrist for a trigger point injection signed a generic consent form before receiving the injection. Afterward, while still in the office, the patient complained of difficulty breathing and chest discomfort. The physician, believing that the symptoms were secondary to muscle spasms, treated the patient with a Lidoderm patch and recommended calling 911 for emergency assistance.
The patient refused the physician’s recommended treatment plan to call for emergency services, choosing instead to drive himself to the nearest hospital emergency department. Upon admission, a chest x-ray indicated a right-sided pneumothorax that necessitated the placement of a chest tube. Subsequently, the patient’s pneumothorax completely resolved, but he sued, alleging improper performance of the trigger point injection, lack of informed consent, and failure to diagnose the pneumothorax, causing a delay in care.
The defense expert testified that a pneumothorax is a well-known risk of the procedure. The expert was, however, critical regarding the physician’s failure to recognize this complication when it occurred. In addition, the risk of a pneumothorax should have been addressed in the consent form, and the discussion between the physician and patient should have been documented.
Although informed consent cannot eliminate malpractice claims, it provides the patient with realistic expectations regarding a procedure, treatment, test, medication, or even the overall treatment plan. An exchange of information between the patient and physician allows the patient to make a reasonable decision while preventing surprise, disappointment, and anger. When the discussion takes place, complete a procedure-specific form detailing the risks involved. The form should be signed by the patient and the physician and placed in the medical record. For more information, refer to our article, “Informed Consent: Substance and Signature.”
Patient factors can cause a delay in the provision of care or affect the outcome of care and contribute to patient injury. The most common patient factors include nonadherence or refusing to follow the recommended treatment plan and failure to follow up with appointments for tests, labs, or consultations. In the case example above, the patient refused to follow the physician’s recommendation to call for emergency services. If you are unable to change the patient’s willingness to accept and follow your recommendations, document your discussions and education thoroughly and use a refusal-to-consent form. For further guidance, see our article, “Informed Refusal,” and the form on our Informed Consent Sample Forms page.
Improper Management of Treatment
An elderly male who was scheduled for a lumbar epidural steroid injection for low back pain informed the physiatrist he was taking a “blood thinner.” After the procedure, the patient was discharged home and later called 911 due to leg weakness and urine incontinence. A subsequent MRI of the lumbar spine at the hospital indicated a lumbar epidural hematoma requiring emergency decompression. The patient filed a lawsuit as a result of his residual paralysis. During his deposition, the physiatrist admitted he neglected to look at the patient’s health history or review the patient’s current medications before performing the procedure.
Patient harm and claims occur when providers fail to review the information available in the medical record. Prior to any procedure, allow time to review the patient’s history and physical, medications, laboratory tests, diagnostic studies, and consultations.
Communication and collaboration are also essential components in providing patient care in accordance with the individualized care plan. Ensure that everyone on the team is crosschecking critical information before carrying out a procedure or a prescribed treatment plan. This includes checking for allergies or contraindicated medications such as anticoagulants.
Improper Medication Management
A 48-year-old male patient with a history of chronic pain, anxiety, and depression was found dead at home from a suspected overdose of medications. This patient had previously sustained injuries in a motor vehicle accident and had received treatment that included pain medications, surgery, interventional nerve blocks, and a trial of spinal cord stimulation.
The coroner’s report cited the cause of death as the combined effect of MS Contin, Ambien, Norco, and clonazepam. The expert opined that the group of treating physiatrists had not collaborated when prescribing medications and the patient’s mental illness had not been adequately addressed.
Physiatrists are responsible for prescribing medications, including those for acute pain control or long-term chronic pain management. Successful pain management, however, requires a collaborative approach among all treating physicians. In addition, obtaining a specialty consultation would have been appropriate in this situation due to the patient’s mental health history. After this tragic outcome, changes were implemented to improve collaboration, assessment, and documentation in patient care.
Analyzing closed physical medicine and rehabilitation claims can provide insights into what motivates allegations of injury. By understanding the allegations and causes of patient injury, physicians can implement measures to improve care. For further assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.