U.S. court: Suit over review of medical notes must be tried

Daily Record and the Kansas City Daily News-Press, Aug 6, 2006 by Ertel Berry

A hiker whose leg injury became infected two weeks after a physician's assistant stitched it can go to trial on medical- malpractice claims against the doctor who signed off on the assistant's treatment notes.

The July 5 ruling shows that a physician charged with reviewing a physician assistant's treatment notes may face liability for not spotting mistakes and taking steps to correct them - even if the doctor's review takes place after the patient's discharge.

That's what allegedly happened in Barton v. Ingledue, a federal case from the Western District of North Carolina.

Magistrate Judge Carl Horn III ordered a jury trial of the medical-malpractice claim, saying the evidence was sufficient to establish a causal link between the plaintiff's leg infection and an on-call physician's allegedly faulty review of a physician's assistant treatment notes.

In this case, the doctor didn't see my client, said the plaintiff's attorney, Thomas Sacchetta of Media, Pa. The physician's assistant did. But we claimed the doctor essentially approved the PA's treatment when she signed off on the chart. Whether that happened two days later or a month later was in dispute, but we argued she still owed a duty to my client.

What was interesting was the idea put forth by the defendant that she was not really the supervisor for this physician's assistant, Sacchetta said. They said that under the physician's assistant program at the hospital, this PA had a so-called supervisor, but that was not the defendant in this case.

Background

The plaintiff was vacationing in North Carolina when he cut the back of his lower leg during a hiking accident. A physician's assistant treated him at the Ashe Memorial Hospital emergency room in Jefferson, N.C.

According to the plaintiff's expert, the assistant's treatment notes indicated to him that the leg wound was very complex and grossly contaminated and invaded several layers of fat and muscle.

Two weeks after he was released, the plaintiff developed an infection that required skin grafts and left him with substantial muscle loss in his leg.

The plaintiff sued the physician's assistant, the doctor who was on call for patients who didn't already have physicians and Ashe Memorial. The suit alleged negligence against the individual defendants and vicarious and corporate liability against the hospital.

The assistant's alleged mistakes: merely irrigating the dirty wound instead of letting a surgeon clean it out under anesthesia, putting in sutures right away instead of letting the wound drain, giving the plaintiff an antibiotic to take if signs of infection arose - instead of ordering him to begin it immediately and not scheduling a follow-up with a doctor within a few days.

The doctor's alleged malpractice: Although the on-call physician, a family doctor, wasn't directly involved in the plaintiff's treatment, she had signed off on the assistant's treatment notes after the plaintiff was discharged.

The plaintiff's expert - a general surgeon who specialized in trauma care at a Charlotte, N.C., hospital - testified a proper review of the notes should have prompted the physician to contact the plaintiff, inform him to take the supplied antibiotic immediately, and either return to the hospital or see another doctor.

In her summary judgment motion, the on-call doctor argued that the plaintiff failed to show when she had reviewed the physician's assistant's notes - and therefore failed to show that preventive action could have been taken before the infection took hold.

The physician's assistant PA testified his treatment notes were usually reviewed by doctors within a day or two after treatment.

The on-call doctor said she couldn't remember when she reviewed these notes. She had not dated her signature or otherwise recorded the date of her review because hospital policy didn't require it.

The hospital required that the reviews be done as soon as possible, and the doctor said she sometimes only did them once a month.

Ruling

Judge Horn denied the doctor's summary judgment motion. His ruling was based in part on these holdings:

- A reasonable jury could accept the plaintiff's expert's conclusion that the physician's assistant's simple cleaning and stitching of the leg wound was unlikely to prevent infection and was a substantial causal factor.

- A jury could also conclude that the on-call doctor had reviewed the notes nearly two weeks before the infection occurred, and failing to contact the plaintiff was a proximate cause of his injuries.

- The timing of the review was indefinite only because the physician didn't date her signature, Horn said. Hospital policy required her to sign off as soon as possible, and the physician's assistant said that typically happened in a day or two.

- Although the plaintiff's expert, a general surgeon, practiced in a different medical specialty than the assistant or family doctor, he specialized in the type of care at issue - the treatment of complex trauma wounds. That qualified him as a proper expert, Horn said.