Reducing Treatment Delays and Medical Malpractice Suits Through the SAFER Guides

More than one out of three cases of medical malpractice that result in death or permanent disability can be linked to inaccurate or delayed diagnosis, according to a study published in the peer-reviewed journal Diagnosis. One recent case was a Westchester Medical Center malpractice suit resulting in a $120 million verdict, the largest amount ever awarded in a malpractice suit in Westchester County, New York.  

The case dates to November 2018 when first responders transported a 41-year-old patient to Westchester Medical Center around 3 a.m., suspecting a possible stroke. Emergency department providers performed a CT scan to check for a clot, but no board-certified radiologist was onsite. Instead, residents read the scans and overlooked signs of a rare type of stroke. Some three hours later, an attending radiologist reviewed the scans and observed a basilar artery occlusion. 

Situations such as these may be avoidable through proactive interventions leveraging the SAFER Guides released by the Centers for Medicare & Medicaid Services (“CMS”). To promote the safe adoption and use of certified electronic health records (“EHR”) and health information technology, CMS announced that healthcare systems attest annually to their completion of the SAFER Guides. The SAFER Guides break down recommended practices into nine guides spanning infrastructure, clinical processes, and organizational responsibility.  

SAFER Guide 8, Test Results Reporting and Follow-Up, offers relevant recommended practices that can help prevent delays in diagnosis and treatment, such as those in this Westchester Medical Center case: 

•  2.7: Written policies specify unambiguous responsibility for test result follow-up with a shared understanding of that responsibility among all involved in providing follow-up care.  

It is imperative that organizations create policies governing test results follow-up for certain critical situations, such as code stroke. Policies should outline code stroke guidelines, including time to steps in care (i.e., door-to-CT interpreted is ≤35 minutes), specialties of providers who should be involved (e.g., neurology, radiology), and faculty supervision of residents. 

•  2.8: Workflows that are particularly vulnerable to mishandling of test results, especially critical ones, are identified, and back-up procedures ensure test results are received by someone responsible for the affected patient's care. 

In the event of a code stroke, following the appropriate workflows and protocols is of the utmost importance in ensuring timely diagnosis and treatment. For example, organizations should maintain a consistent emergency department workflow in which an attending radiologist is immediately available to read CT results within a prescribed timeframe. This can be done either onsite or remotely, but it is absolutely critical for code stroke. EHR technology can be leveraged to streamline code stroke workflows through pre-built tools (i.e., order panels that include required diagnostic tests with STAT priority) that build on best practices from CMS and The Joint Commission. Additionally, radiology dashboards can be configured to highlight high-priority imaging reads based on urgency that consider factors such as abnormal vital signs or the presence of stroke, STEMI, or trauma.   

• 3.1 As part of quality assurance activities, organizations monitor selected practices related to test result reporting and follow-up. Monitored practices include clinician use of the EHR for the test results review and clinician follow-up on abnormal test results. 

Regular monitoring of key metrics related to tests results review helps in identifying emerging areas of risks that may lead to delays in diagnosis and treatment. This helps the organization stay proactive in mitigating these risks and prevents them from turning into major issues. Careful monitoring of metrics against stated policies should be conducted regularly. Regarding code stroke protocols and preventing delays in diagnosis, example key metrics include door-to-neuro expertise time, door-to-CT performed, door-to-CT interpreted, and door-to-needle time.  

By following the SAFER Guides recommended practices, healthcare leaders can create a safe environment to protect both patients from potential delayed treatments as well as their health systems from medical malpractice lawsuits.