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    Telephone triage can jeopardize patient safety, lead to litigation

    Staff must document all calls where medical advice, information is given to patient

    Brianne Goodwin, JD, RNBrianne Goodwin, JD, RNTelephone triage is an inextricable component of health care today. Telephone medicine accounts for more than a quarter of all patient care, according to an Oct. 1, 2002 AAP News article (bit.ly/AAPphonetriage). Lawsuits involving telephone triage tend to allege failure in a physician’s duty to treat, abandonment of the patient, or provision of sub-standard care. Take the following two cases:

    Case 1. A 15-year-old boy with history of ureteropelvic junction obstruction complains to his mother that he has pain with urination. The mother calls the urology clinic and speaks to a nurse, who encourages the patient to come in and provide a urine sample. A sample is collected and sent, and the physician places the boy on trimethoprim-sulfamethoxazole (Bactrim) for a week while the results are pending.

    Also by Brianne Goodwin, JD, RN: How surgical time-outs may (or may not) lower litigation risk

    On day 2, the mother calls the urology clinic again and speaks to a nurse. Her son is feeling worse, with a low-grade fever and some nausea and vomiting. The nurse opines that the antibiotics need more time to “kick in” and does not report this call to the physician. On day 3, the mother calls with the same complaints and a nurse provides a similar response, that the antibiotics need more time. A physician is not notified of this call.

    On day 4, the patient has an acute abdomen and is transferred to the hospital where he is diagnosed with a perforated appendix. He spends 8 days in the hospital and then is sent home with a peripherally inserted central catheter line for antibiotics. In the course of treatment, he develops hearing loss and vestibular damage from gentamicin (Garamycin). The urologist is sued for a failure to diagnose appendicitis.

    Next: Case 2

    Brianne Goodwin, JD, RN
    Ms. Goodwin is manager of clinical risk and patient safety at Cambridge Health Alliance, Cambridge, MA.

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      I believe that one critical component of the process has not bee stressed in this article. While it is proper to document the positives and the negatives, there must be a way to let the physician know that there was a communication from the patient. If the physician has no reason to open the record of a patient, he may not see the note until the extreme situations described have already occurred. With a paper chart, a note on the front with a request to review the record is an easy way to have it reviewed. With EMR, a log should be kept so that the physician can review the notes and make a decision about how to proceed. If this were part of the protocol, these 2 poor outcomes might never have happened.

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