Closed Claims—Open Insights: Leaving Against Medical Advice Insights to Reduce Risk and Improve Practice

Background

A patient presented to the emergency department (ED) with vomiting and a history of self-catheterization. An emergency medicine physician evaluated the patient with assistance from a medical scribe. Intravenous hydration, antiemetics, and pain medication were administered. The patient reported improvement in symptoms when reassessed by the physician and was diagnosed with gastroenteritis. Laboratory results were posted to the electronic health record (EHR) after the physician’s discussion with the patient. The patient left against medical advice (AMA) before being reassessed by the physician. Laboratory findings showing an elevated white blood cell count and bacteria in the urine, both indicative of infection, were not reviewed by the physician and were not communicated to the patient. The patient returned to the hospital the following day and ultimately expired from urosepsis.

Allegations

• Failure to diagnose and treat infection, resulting in pain, suffering, and death

Case Review Insights

• The scribe had entered inaccurate documentation of diagnosis and assessment data, which was not corrected by the physician.
• There was no documentation that the patient had been informed of the risks of leaving against medical advice.
• Process gaps existed, which contributed to a failure to communicate abnormal lab results.

Resolution

The case was settled.

Lessons Learned

• Always document when a patient elects to leave against medical advice.
• Review scribe documentation for accuracy prior to signing the note.
• Track orders to diagnostic test results prior to final disposition. 

Risk Management Tips

• Assess and document the patient’s understanding of risks. Obtain and record a written refusal for AMA or declined care, note efforts if they refuse to sign, and attempt to contact and document patients who leave without discussing risks.
• Implement scribe documentation guidelines, audit regularly for compliance, and maintain the same quality and standards as other patient care documentation.

• Utilize a standardized process in which all diagnostic reports are reviewed and addressed in a timely manner by the provider prior to disposition.

Risk Management Resources

Curi Resources

If you have questions about this topic, please call 800-328-5532 to speak with one of Curi’s Risk Solutions Consultants, or consult the following:

• Risk Management Guide: Informed Consent & Informed Refusal
• Risk Management Guide: Test, Appointment, and Referral Tracking
• Sample Medical Scribe Documentation Policy

External Resources

• American Medical Association (AMA). Opinion 2.1.1 Informed consent. Code of Medical Ethics. https://code-medical-ethics.ama-assn.org/ethics-opinions/informed-consent
• US Department of Health and Human Services (DHHS). Informed Consent FAQs. https://www.hhs.gov/ohrp/regulations-and-policy/guidance/faq/informed-consent/index.html

Disclaimer

Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them.