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Medico-legal risk and use of medical directives in the emergency department

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Abstract

Purpose

The medico-legal risk associated with application of medical directives in the emergency department (ED) is unknown. The objective of this study was to describe and analyze factors associated with medico-legal risk in cases involving medical directives in the ED.

Methods

We conducted a descriptive analysis of closed medico-legal cases [hospital complaints, regulatory authority (i.e., College) complaints, and civil legal actions] involving emergency physicians in Canadian EDs involving medical directives (alternate terms including “standing order”, “nursing initiated”, “nurse initiated”, “nursing order”, “triage initiated”, “triage ordered”, "directive", "ED protocol", and "ED's protocol"). We used data from closed cases involving the Canadian Medical Protective Association from January 2016 until December 2021. We abstracted descriptive factors of the cases and used a framework for contributing factors classification.

Results

From 2016 until 2021, 43,332 cases were closed and 1957 involved emergency physicians for which there was medico-legal information available for analysis. In all, 28 involved emergency physicians and medical directives. Situational awareness, team communication, and issues with clinical decision-making were the most important factors contributing to harm and medico-legal risk. Peer experts were critical of physicians not reviewing all results available for patients when initiated through a directive, misinterpreting test results, a less than thorough initial assessment, and of failing to reassess patients or re-order investigations when indicated.

Conclusion

Our findings suggest that the medico-legal risk exposure from the use of medical directives in the ED is low. Emergency departments may consider implementing systems to support adherence to medical directive policies, ensure physicians are alerted when medical directives are completed in a timely fashion, and leverage tools to notify the healthcare team when results have not been reviewed.

Abstrait

But

Le risque médicolégal associé à l’application des directives médicales au service des urgences (SU) est inconnu. L’objectif de cette étude était de décrire et d’analyser les facteurs associés au risque médicolégal dans les cas impliquant des directives médicales à l’urgence.

Méthodes

Nous avons effectué une analyse descriptive des cas médicolégaux clos (plaintes d’hôpitaux, plaintes d’organismes de réglementation (c.-à-d. le Collège) et poursuites civiles) impliquant des médecins d’urgence dans des SU canadiens comportant des directives médicales. (Autres termes, y compris « ordre permanent », « initiative infirmière », « initiative infirmière », « ordre infirmier », « initiative de triage », « ordre de triage », « directive », « protocole DE » et « protocole DE »). Nous avons utilisé les données des cas clos impliquant l’Association canadienne de protection médicale de janvier 2016 à décembre 2021. Nous avons résumé les facteurs descriptifs des cas et utilisé un cadre pour la classification des facteurs contributifs.

Résultats

De 2016 à 2021, 43 332 cas ont été fermés et 1957 ont impliqué des cas d’urgences pour lesquels des renseignements médicolégaux étaient disponibles aux fins d’analyse. Au total, 28 concernaient des médecins d’urgence et des directives médicales. La connaissance de la situation, la communication en équipe et les problèmes liés à la prise de décisions cliniques étaient les facteurs les plus importants contribuant au préjudice et au risque médicolégal. Les pairs experts ont critiqué le fait que les médecins n’examinent pas tous les résultats disponibles pour les patients lorsqu’ils sont initiés au moyen d’une directive, qu’ils n’interprètent pas les résultats des tests, qu’ils ne procèdent pas à une évaluation initiale moins approfondie et qu’ils ne réévaluent pas les patients ou n’ordonnent pas de nouveau les examens au moment indiqué.

Conclusion

Nos constatations indiquent que l’exposition au risque médicolégal découlant de l’utilisation des directives médicales à l’urgence est faible. Les services d’urgence peuvent envisager de mettre en œuvre des systèmes pour appuyer le respect des politiques sur les directives médicales, s’assurer que les médecins sont avertis lorsque les directives médicales sont remplies en temps opportun et tirer parti des outils pour informer l’équipe de soins de santé lorsque les résultats n’ont pas été examinés.

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References

  1. Canadian Institute for Health Information. Emergency Department Wait Time for Physician Initial Assessment. Published 2022. Accessed December 11, 2022. https://yourhealthsystem.cihi.ca/hsp/indepth?lang=en#/indicator/034/2/C5001/

  2. Bernstein SL, Aronsky D, Duseja R, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1–10. https://doi.org/10.1111/j.1553-2712.2008.00295.x.

    Article  PubMed  Google Scholar 

  3. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short-term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 2011;342(7809):d2983. https://doi.org/10.1136/bmj.d2983.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Doan Q, Wong H, Meckler G, et al. The impact of pediatric emergency department crowding on patient and health care system outcomes: A multicentre cohort study. CMAJ. 2019;191(23):E627–35. https://doi.org/10.1503/CMAJ.181426/-/DC1.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Todd KH, Ducharme J, Choiniere M, et al. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain. 2007;8(6):460–6. https://doi.org/10.1016/J.JPAIN.2006.12.005.

    Article  PubMed  Google Scholar 

  6. Kelly AM, Brumby C, Barnes C. Nurse-initiated, titrated intravenous opioid analgesia reduces time to analgesia for selected painful conditions. Can J Emerg Med. 2005;7(3):149–149.

    Article  Google Scholar 

  7. Fosnocht DE, Swanson ER. Use of a triage pain protocol in the ED. Am J Emerg Med. 2007;25(7):791–3. https://doi.org/10.1016/J.AJEM.2006.12.020.

    Article  PubMed  Google Scholar 

  8. Woolner V, Ahluwalia R, Lum H, Beane K, Avelino J, Chartier LB. Improving timely analgesia administration for musculoskeletal pain in the emergency department. BMJ Open Qual. 2020;9(1):e000797. https://doi.org/10.1136/BMJOQ-2019-000797.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Zemek R, Plint A, Osmond MH, et al. Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved emergency department efficiency. Pediatrics. 2012;129(4):671–80. https://doi.org/10.1542/PEDS.2011-2347.

    Article  PubMed  Google Scholar 

  10. Hwang CW, Payton T, Weeks E, Plourde M. Implementing triage standing orders in the emergency department leads to reduced physician-to-disposition times. Adv Emerg Med. 2016;2016:1–6. https://doi.org/10.1155/2016/7213625.

    Article  CAS  Google Scholar 

  11. College of Nurses of Ontario. Practice Guidelines: Directives. College of Nurses of Ontario; 2000. Accessed December 3, 2022. www.cno.org/docs..

  12. Singh D, Nagaraj S, Mashouri P, et al. Assessment of machine learning-based medical directives to expedite care in pediatric emergency medicine. JAMA Netw Open. 2022;5(3):e222599–e222599. https://doi.org/10.1001/JAMANETWORKOPEN.2022.2599.

    Article  PubMed  PubMed Central  Google Scholar 

  13. deForest EK, Thompson GC. Advanced nursing directives: integrating validated clinical scoring systems into nursing care in the pediatric emergency department. Nurs Res Pract. 2012;2012:1–13. https://doi.org/10.1155/2012/596393.

    Article  Google Scholar 

  14. Cabilan CJ, Boyde M. A systematic review of the impact of nurse-initiated medications in the emergency department. Australas Emerg Nurs J. 2017;20(2):53–62. https://doi.org/10.1016/J.AENJ.2017.04.001.

    Article  CAS  PubMed  Google Scholar 

  15. Ho JKM, Chau JPC, Cheung NMC. Effectiveness of emergency nurses’ use of the Ottawa Ankle Rules to initiate radiographic tests on improving healthcare outcomes for patients with ankle injuries: A systematic review. Int J Nurs Stud. 2016;63:37–47. https://doi.org/10.1016/J.IJNURSTU.2016.08.016.

    Article  PubMed  Google Scholar 

  16. Chaudhari H, Schneeweiss M, Rebinsky R, Rullo E, Eltorki M. An advanced nursing directive for children with suspected appendicitis: protocol for a quality improvement feasibility study. JMIR Res Protoc. 2021;10(10):e33158. https://doi.org/10.2196/33158.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Gilbert EH, Lowenstein SR, Koziol-McLain J, Barta DC, Steiner J. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27(3):305–8. https://doi.org/10.1016/S0196-0644(96)70264-0.

    Article  CAS  PubMed  Google Scholar 

  18. McCleery A, Devenny K, Ogilby C, et al. Using medicolegal data to support safe medical care: a contributing factor coding framework. J Healthc Risk Manag. 2019;38(4):11–8. https://doi.org/10.1002/JHRM.21348.

    Article  PubMed  Google Scholar 

  19. Crosbie C, McDougall A, Pangli H, Abu-Laban RB, Calder LA. College complaints against resident physicians in Canada: a retrospective analysis of Canadian Medical Protective Association data from 2013 to 2017. Can Med Assoc Open Access J. 2022;10(1):E35–42. https://doi.org/10.9778/CMAJO.20210026.

    Article  Google Scholar 

  20. Crosby ET, Duggan L, v., Finestone PJ, Liu R, de Gorter R, Calder LA. Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association. Can J Anaesth. 2021;68(2):183. https://doi.org/10.1007/S12630-020-01846-7.

    Article  PubMed  Google Scholar 

  21. Lefebvre G, Devenny KA, Héroux DL, et al. Intraoperative injuries from abdominopelvic surgery: an analysis of national medicolegal data. Can J Surg. 2021;64(2):E127. https://doi.org/10.1503/CJS.010219.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Calder LA, Neilson HK, Whyte EM, Ji J, Bhatia RS. Medico-legal cases involving cardiologists and cardiac test underuse or overuse. CJC Open. 2021;3(4):434. https://doi.org/10.1016/J.CJCO.2020.11.018.

    Article  PubMed  Google Scholar 

  23. Zhang Z, Calder L, Finestone PJ, Liu R, Bucevska M, Arneja JS. Medico-legal closed case trends in canadian plastic surgery: a retrospective descriptive study. Plast Reconstr Surg Glob Open. 2021;9(8):3754. https://doi.org/10.1097/GOX.0000000000003754.

    Article  Google Scholar 

  24. Genco EK, Forster JE, Flaten H, et al. Clinically inconsequential alerts: the characteristics of opioid drug alerts and their utility in preventing adverse drug events in the emergency department. Ann Emerg Med. 2016;67(2):240-248.e3. https://doi.org/10.1016/J.ANNEMERGMED.2015.09.020.

    Article  PubMed  Google Scholar 

  25. Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: A systematic review and meta-analysis. Syst Rev. 2014. https://doi.org/10.1186/2046-4053-3-56.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Sethuraman U, Kannikeswaran N, Murray KP, Zidan MA, Chamberlain JM. Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department. Acad Emerg Med. 2015;22(6):714–9. https://doi.org/10.1111/ACEM.12678.

    Article  PubMed  Google Scholar 

  27. Barrett TW, Garland NM, Freeman CL, et al. Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings. Ann Emerg Med. 2022;80(3):235–42. https://doi.org/10.1016/J.ANNEMERGMED.2022.04.026.

    Article  PubMed  Google Scholar 

  28. Zeraatchi A, Talebian MT, Nejati A, Dashti-Khavidaki S. Frequency and types of the medication errors in an academic emergency department in Iran: The emergent need for clinical pharmacy services in emergency departments. J Res Pharm Pract. 2013;2(3):118. https://doi.org/10.4103/2279-042X.122384.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Silbergleit R, Kronick SL, Philpott S, Lowell MJ, Wagner C. Quality of emergency care on the night shift. Acad Emerg Med. 2006;13(3):325–30. https://doi.org/10.1197/J.AEM.2005.09.005.

    Article  PubMed  Google Scholar 

  30. Haroutunian P, Alsabri M, Kerdiles FJ, Abdullah HAA, Bellou A. Analysis of factors and medical errors involved in patient complaints in a European Emergency Department. Adv J Emerg Med. 2018;2(1):e4. https://doi.org/10.2211/AJEM.V0I0.34.

    Article  PubMed  Google Scholar 

  31. Edgerley S, McKaigney C, Boyne D, Ginsberg D, Dagnone JD, Hall AK. Impact of night shifts on emergency medicine resident resuscitation performance. Resuscitation. 2018;127:26–30. https://doi.org/10.1016/j.resuscitation.2018.03.019.

    Article  PubMed  Google Scholar 

  32. Persico N, Maltese F, Ferrigno C, et al. Influence of shift duration on cognitive performance of emergency physicians: a prospective cross-sectional study. Ann Emerg Med. 2018;72(2):171–80. https://doi.org/10.1016/j.annemergmed.2017.10.005.

    Article  PubMed  Google Scholar 

  33. Dula DJ, Dula NL, Hamrick C, Wood GC. The effect of working serial night shifts on the cognitive functioning of emergency physicians. Ann Emerg Med. 2001;38(2):152–5. https://doi.org/10.1067/mem.2001.116024.

    Article  CAS  PubMed  Google Scholar 

  34. Smith-Coggins R, Rosekind MR, Hurd S, Buccino KR. Relationship of day versus night sleep to physician performance and mood. Ann Emerg Med. 1994;24(5):928–34. https://doi.org/10.1016/S0196-0644(94)70209-8.

    Article  CAS  PubMed  Google Scholar 

  35. Bradley EH, Herrin J, Wang Y, et al. Door-to-drug and door-to-balloon times: where can we improve? time to reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI). Am Heart J. 2006;151(6):1281–7. https://doi.org/10.1016/J.AHJ.2005.07.015.

    Article  PubMed  Google Scholar 

  36. Chhabra S, Eagles D, Kwok ESH, Perry JJ. Interventions to reduce emergency department door-to-electrocardiogram times: a systematic review. Can J Emerg Med. 2019;21(5):607–17. https://doi.org/10.1017/cem.2019.342.

    Article  Google Scholar 

  37. Yang Q, Zhang C, Hines K, Calder LA. Improved hospital safety performance and reduced medicolegal risk: an ecological study using 2 Canadian databases. Can Med Assoc Open Access J. 2018;6(4):E561–6. https://doi.org/10.9778/CMAJO.20180077.

    Article  Google Scholar 

  38. Bogh SB, Kerring JH, Jakobsen KP, Hilsøe CH, Mikkelsen K, Birkeland SF. Healthcare complaints analysis tool: reliability testing on a sample of Danish patient compensation claims. BMJ Open. 2019;9(11):e033638. https://doi.org/10.1136/BMJOPEN-2019-033638.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Gillespie A, Reader TW. The healthcare complaints analysis tool: development and reliability testing of a method for service monitoring and organisational learning. BMJ Qual Saf. 2016;25(12):937–46. https://doi.org/10.1136/BMJQS-2015-004596/-/DC1.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Reader TW, Gillespie A, Roberts J. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf. 2014;23(8):678–89. https://doi.org/10.1136/BMJQS-2013-002437.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We would like to thank Dr. Lisa Calder, Ms. Ewaen Akinya, Ms. Sue Macfarlane, and the emergency physicians and nurses of the Queensway Carleton Hospital.

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Authors and Affiliations

Authors

Contributions

MACL conceived the research study. MACL, KL, and RL designed the research methods. KL and RL performed the database search, abstracted data, and synthesized results. SW provided a second independent analysis of the data. FB and GG provided counsel, and oversight. All authors edited the manuscript. MACL drafted the manuscript, and all authors contributed to its revisions. MACL takes responsibility for the paper as a whole.

Corresponding author

Correspondence to Miguel A. Cortel-LeBlanc.

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Conflict of interest

MACL has received honoraria from the Canadian Association of Emergency Physicians for educational events, and from AbbVie for speaking engagements. He receives an honorarium from the Ontario Medical Association for serving as a member of the Physician Payment Committee. He has also received consulting fees for the provision of medico-legal expert opinions. KL, SW, RL, and GG are employees of the Canadian Medical Protective Association. FB has no potential conflicts of interest to disclose.

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Cortel-LeBlanc, M.A., Lemay, K., Woods, S. et al. Medico-legal risk and use of medical directives in the emergency department. Can J Emerg Med 25, 589–597 (2023). https://doi.org/10.1007/s43678-023-00522-1

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  • DOI: https://doi.org/10.1007/s43678-023-00522-1

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