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The (Very) Thin White Line — When We Exceed Safe Speed Limits

We’ve all heard the term “speed kills.” Just like a road or freeway is engineered with consideration of vehicles in motion towards an established maximum safe speed, the medical office, too, is designed for efficient, safe care at a maximum limit. When those limits are exceeded, there is a proportionate relationship to speed and risk of patient harm. Just like weather affects the safety of a roadway, the “weather” in the medical office likewise must be assessed on an ongoing basis to know if you can “punch the throttle” or slow down— there may be hazards ahead, as the following case illustrates:

In August 2013, an employee reported to his employer’s designated workers’ compensation health center after being injured. The employee, now the patient, presented to the health center for evaluation of right leg, lower back, and elbow pain. A physician assistant (PA) student documented the patient‘s history of diabetes, obesity (BMI 32), arthritis, and consumption of Advil. The health provider ordered lumbar spine and right knee X-rays. After reviewing the results, the provider diagnosed the patient as having a lumbar spine strain, right knee and elbow contusions, and severe back and knee arthritis. The patient was discharged with prescriptions of Vicodin and Ibuprofen.

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For several months, the patient continued to be seen at the health center for his back and leg pain. During this time, the patient was seen almost exclusively by PAs until he was cleared by an orthopedic physician for surgery. Despite the patient’s fear of surgery, he elected to undergo a lumbar decompression to alleviate his continuing pain. Surgery was performed without any intraoperative complications. However, the patient’s post-operative course was wrought with infection and wound healing issues. An infectious disease (ID) specialist was consulted and opined that the patient most likely had a polymicrobial infection due to Arava, an immunosuppressive medication, which inhibited wound healing. There was no prior documentation in the medical record that the patient had been taking Arava. The ID specialist discontinued the Arava and initiated an aggressive poly antimicrobial therapy. Although the patient’s condition initially improved, he later succumbed to sepsis.

The patient’s family filed a wrongful death action alleging the failure to discontinue Arava as a cause of the uninhibited infections that ultimately resulted in death. The matter subsequently resolved informally prior to trial, yet there are several points to be considered in the outpatient management of this case:

Review of Prior Health Records

When the patient first presented to the health clinic in October 2013, a more thorough evaluation of the patient’s health history records would have revealed that the patient had rheumatoid arthritis (RA) and was taking Arava. This same entity who provided care to the patient for his work injury had also performed the patient’s pre-employment examination. The patient’s history of RA and use of Arava is documented in the prior records which were in the clinic’s possession.

Supervision of PAs and Student PAs

A student PA obtained the patient’s medical history during his October 2013 visit. The medical history documented by the student was simply “arthritis,” with no mention of the type of arthritis, in this case, RA. Further questioning of the patient regarding his arthritis may have elicited he was taking the immunosuppressant medication Arava, in addition to the Advil that was reported. Additionally, since the patient was almost exclusively seen by PAs until cleared for orthopedic surgery by a physician, the adequacy of PAs and student PAs comes into question.

Too many clinics, too many patients

The workers’ compensation provider operated several clinics whose staff performed 10,000 pre-employment physicals each month in addition to managing injured worker healthcare caseloads. With high patient volumes, it could be construed that students were were managing patient volumes beyond the scope of licensed staff. An overriding concern is whether the clinic’s volume exceeded its capacity. Were staff “speeding” and processing patients too fast, and not taking the time to investigate matters further? If your bandwidth that day is only allowing for one lane of traffic, then try closing the other three lanes to manage the current conditions. For example, maybe you have several staff members out and cannot manage the the flow. Remember that the collisions that take place become your liabilities. If you need to use students to manage patient volumes beyond the scope of licensed staff, you’re speeding. If you have a patient traffic jam every day in your office, you’re not managing the traffic. Patient safety starts with the onramp of your office and doesn’t stop until they exit.

Medical Record Systems and Documentation

Handwritten paper medical records were used by the clinic when the patient was initially seen for his pre-employment exam. This is a daunting record-keeping system considering the huge patient volume seen by the clinic staff. Prior to the patient’s injury and surgical evaluation, the clinic transitioned from paper charts to an EHR. The patient’s history of RA and immunosuppressant medication history was not uncovered and carried over to the EMR. Consequently, this information was not in the records reviewed by the surgeon who cleared the patient for the lumbar decompression.

Several system issues in the outpatient management of this patient may have contributed to the failure to communicate pertinent information to the operating surgeon, and discontinuation of the Arava prior to the spinal surgery.

The case illustrates the dangers to patient safety with a “herdlike” approach to patient volume. With a focus on maintaining patient volumes and throughput, there can be a tendency to overlook the safety variables inextricably interwoven which exceed the limits of safe patient-to-provider volumes. Is safety being sacrificed by staff and providers to meet certain metrics or incentives?

The moral of the story is that a medical practice needs its own internal “highway patrol,” as a lack thereof will be gladly taken up by plaintiff lawyers and the medical board.   


Dona Constantine is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to

Lee McMullin is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to