Medicolegal Savvy

The health services in both the Public and Private Sectors are under threat from litigation as never before. The average quantum claimed for a case of cerebral palsy is currently about R20, 000,000 and where the hospital is found to be negligent, the claims are deducted from the hospital’s operating budget. This can and does negatively affect service delivery and results in a vicious circle with further litigation. Cases against the State are often settled, not because there was negligence but because of inadequate recordkeeping. The following points should be adhered to by all paediatric staff.

Avoiding Litigation

Practice within your Scope of Practice. RMMCH is an academic teaching hospital with a well-established hierarchy of expertise and support. When in doubt ALWAYS consult with the next level.

Dosage Errors. Children obviously vary tremendously in mass, surface area and metabolic function and therefore drug dosage is complex and often not intuitive. Always re-check your dosage calculations. Stock solutions of drugs are often not “paediatric friendly” and dilution is often necessary. Ten-fold dosage errors are common. If a nurse or pharmacist questions your prescription you are usually in error!

Note Keeping. The patient records are a legal document and copies are available to patients and their lawyers. Write legibly and sign your notes. Record your IN or MP number in the notes. Always include a date and time. Avoid obscure abbreviations and symbols. At the completion of each entry summarise briefly and give reasons for changes in management or new investigations. Do not write flippant or derogatory comments into the record. Do not scratch out or tippex errors or alterations. Draw a line through the error and write the correct version. Do not change your notes “after the fact”.

Adverse Events. When unexpected or adverse events occur write extensive notes. Note all the details around the onset and progression of the problem. Do not cover up accidents or errors. Record the events accurately and dispassionately and avoid ascribing blame. Notify your superior as soon as possible regarding the event. Note, in detail, your response to the adverse event. Preserve the notes that are made and keep a photocopy for yourself. Do not give original records to the patient or their lawyers.

Communication with your Colleagues. In a busy hospital such as RMMCH, we frequently, temporarily hand over the care of our sick patients to our colleagues. This should preferably be done face-to-face at the bedside and a note should be made to reflect the nature of existing and potential problems in a “Red Flag List”.

Communication with your Patients and their Parents. A large percentage of litigation can be prevented by good communication with your patients and their families. When things go wrong, honesty is the best policy. They are naturally angry when accidents occur but are far more likely to litigate when they perceive a “cover-up”. Avoid arguing and displays of emotion; rather allow a cooling off period and arrange a meeting, chaired by a senior colleague. Try to maintain professional behaviour no matter how badly provoked. Be factual regarding events but don’t admit to negligence or liability. Where possible, make sure that a third party is available to witness altercations. Retreat from physical encounters!

Medical Protection Society. Join the MPS. Once you suspect or are aware that a patient intends taking action against you, then contact MPS and let them handle the matter. Comply with their requests; they are experts in these matters.

Specific Cases. The most common cause for litigation, currently, involves birth asphyxia and resultant cerebral palsy. Do not make scathing or derogatory notes about midwives or obstetricians. Accurately record the child’s condition at birth. Note the presence or absence of meconium. Accurately assign Apgar scores at one, five and ten minutes. Note the time taken until the first spontaneous breath. Perform an arterial (or venous) blood gas as soon as possible after birth. Rewrite the results into the neonatal records. Record the presence or absence and grade of Neonatal Encephalopathy in the first few days of life. This requires observation of tone, reflexes, level of consciousness and any suspected or obvious seizures. The standard of care for asphyxia now includes the consideration of cooling as a method of minimising brain damage. Consult the SOP for this mode of treatment. As soon as possible, inform the parents regarding their infant’s condition.