Medicolegal Liability
"Extra testing"—testing not warranted by findings on a medical
history—does not provide medicolegal protection
TABLE 25-7 -- Risk of potassium supplementation
*
|
Route of Administration |
|
Oral |
IV |
Oral and IV |
All Routes |
|
Patients (no.) |
1,910 |
2,192 |
819 |
921 |
|
Death |
3 (0.2%) |
3 (0.15%) |
1 (0.1%) |
7 (0.14%) |
|
Life-threatening reaction or death |
6 (0.3%) |
7 (0.35%) |
14 (1.7%) |
28 (0.57%) |
|
Hyperkalemia |
74 (3.9%) |
34 (1.6%) |
71 (8.7%) |
179 (3.6%) |
|
Other side effects |
53 (2.8%) |
18 (0.8%) |
33 (4.0%) |
283 (5.7%) |
|
Data from Lawson DH: Adverse reactions to potassium
chloride. Q J Med 43:433, 1974; and Lawson DH, Hutcheon AW, Jick H: Life-threatening
drug reactions amongst medical inpatients. Scot Med J 24:127, 1979. |
*One
in 200 patients given potassium supplementation dies or has a life-threatening reaction.
against liability (also see Chapter
89
). Studies show that 30% to 95% of all unexpected abnormalities found
on preoperative laboratory tests are not noted on the chart before surgery[111]
[122]
[137]
[143]
[145]
[146]
[157]
[158]
[159]
[160]
[161]
[162]
[163]
[164]
[165]
[166]
[167]
( Table
25-8
). This lack of notation occurs not only at university medical centers
but at community hospitals as well.
TABLE 25-8 -- Unrecorded abnormalities on preoperative tests
|
Series |
Type Test |
Unexpected Abnormalities
(n) |
Unexpected Abnormalities Noted
on Chart Preoperatively
*
(%) |
|
Lorenzi and Cohen
†
|
PT/PTT |
20 |
5 |
|
Rabkin and Horne[145]
[146]
|
ECG |
157 |
31 |
|
Kaplan et al[111]
|
CBC/PTT |
12
‡
|
17 |
|
Glucose/SMA 6 |
|
Robbins and Rose[157]
|
PT |
23 |
39 |
|
Wood and Hoekelman[143]
|
Hematocrit |
15
‡
|
27 |
|
Parkerson[158]
[159]
,
§
|
Multiple |
343 |
38 |
|
Multiple; >10% abnormal |
63? |
60 |
|
Williamson et al[160]
,
§
|
Urinalysis |
164 |
17 |
|
FBS |
63 |
32 |
|
Hemoglobin |
32 |
16 |
|
Huntley et al[161]
,
§
|
Multiple |
343 |
67 |
|
Daughaday et al[162]
|
Multiple |
167 |
60 |
|
Epstein et al[163]
|
T4
|
111 |
60 |
|
Wheeler et al[164]
|
Hemoglobin |
258 |
71 |
|
Kelley and Mamlin[165]
,
§
|
Multiple |
852 |
64–85 |
|
Wolf-Klein et al[137]
,
§
|
Multiple |
756 |
7–73(avg. 50) |
|
Lawrence and Kroenke[122]
|
Urinalysis |
180 |
29 |
|
Umbach et al[166]
|
Chest radiographs |
116 |
59 |
|
Narr et al[110]
|
Multiple |
160 |
40 |
|
O'Connor and Drasner[116]
|
Hemoglobin and urinalysis |
97 |
51 |
|
CBC, complete blood count; ECG, electrocardiogram; FBS, fasting
blood sugar; PT, prothrombin time; PTT, partial thromboplastin time; SMA 6, simultaneous
multichannel analyses of sodium, potassium, chloride, bicarbonate, urea nitrogen,
and creatinine levels in blood; T4
, thyroxine. |
*Recording
of an unexpected abnormality on the patient's chart, either preoperatively or at
any time other than on the laboratory test report printout.
†Personal
communication.
‡Abnormalities
potentially significant to perioperative management.
§Test not obtained preoperatively.
Moreover, the failure to pursue an abnormality appropriately poses
a greater risk of medicolegal liability than does failure to detect that abnormality.
[167]
In this way, extra testing increases the
medicolegal
risk to physicians. In addition, the HCFA is attempting to make failure to pursue
abnormalities grounds for charging physicians
Figure 25-3
Probability of at least one abnormal result on multiple
independent trials of tests, each with a probability (PN
)
of a normal result, for selected values of PN
.
(From Berwick DM: Screening in health fairs. A critical review of benefits,
risks, and costs. JAMA 254:1492, 1985.)
with inadequate practice. However, such lack of attention to unexpected abnormalities
is a completely reasonable response; the data discussed previously[168]
( Fig. 25-3
) indicate that
most unexpected abnormalities in asymptomatic patients occur in patients who are
actually healthy.
Furthermore, pursuit of unexpected abnormalities in asymptomatic
patients is more likely to harm than benefit such patients. It is logical that pursuit
of unindicated testing poses liability, as the tests were not warranted, and the
statistics of testing theory as well as data in the literature indicate that the
pursuit of such abnormalities is more likely to cause harm than to prove beneficial.
Thus, the problems associated with nonselective batteries
TABLE 25-9 -- Consequences of using nonselective batteries of preoperative tests
|
Consequences |
|
Direct risks to patients |
False-positive results (i.e.,
an erroneous "abnormality" on a radiograph or electrocardiogram) may initiate follow-up
activities that are harmful to the patient. |
|
False-negative results encourage
the overlooking of true problems or instill a false sense of security. |
|
Indirect risk to patients |
Diverts physician's attention to nonvital issues. |
|
Cost to society |
Reduces resources available to care for others. |
|
Cost to physicians |
Failure to pursue abnormalities increases medicolegal risks. |
of tests include both direct and indirect risks to patients and society ( Table
25-9
).
