How Documentation On Handoff Kept Her From Being Found Guilty

Here are some links mentioned in the podcast that may be helpful to listeners:   DNR vs AND: https://en.wikipedia.org/wiki/Allow_natural_death Excellent Webinar on POLST: https://www.wsma.org/wsma/education/on_demand_webinars/polst-and-your-practice-tools-to-improve-patient-conversations.aspx?_zs=vlUFd1&_zl=glgWA Serious Illness Conversation Guide: https://www.ariadnelabs.org/wp-content/uploads/2023/05/Serious-Illness-Conversation-Guide.2023-05-18.pdf

This episode talks about the three different ways acute coronary syndrome can present and how to avoid missing unstable angina as a cause of chest pain.   Dr. Charles Piltcher and Katie Wyatt NP-C discuss takeaways that can keep each of us from making the same mistakes with our patients. 

A 33-year-old woman arrives at the emergency room struggling to breathe—her symptoms alarming, her condition urgent. What follows is a rapid series of events marked by uncertainty, communication gaps, and a critical moment that changes everything. In this episode of Learning from Lawsuits, we unpack a heartbreaking case involving abnormal electrolytes, unclear documentation, and a sudden cardiac arrest that occurred just minutes after medication was reportedly administered. With the medical record unable to confirm exactly what was given—and when—we explore how breakdowns in communication, documentation, and clinical clarity can lead to devastating outcomes. More importantly, we focus on what healthcare teams can learn from this case. How do we ensure accuracy in high-pressure moments? What safeguards can prevent medication errors? And how can teams better communicate when every second counts? This episode is a powerful reminder that patient safety often hinges not just on clinical knowledge—but on systems, clarity, and connection.

In this episode, we unpack the case of a 40-year-old woman who came to the Emergency Department with right upper quadrant abdominal pain—an atypical presentation that led her care team away from considering appendicitis. Without the “classic” symptoms, the diagnosis was missed, and she was discharged home—only to return two days later with a ruptured appendix. We explore how cognitive biases, atypical presentation, and time pressures in the ED can impact clinical decision-making. More importantly, we discuss practical strategies to reduce diagnostic error: broadening differentials, recognizing atypical presentations, improving team communication, and strengthening safety-netting at discharge. This episode is a powerful reminder that uncommon presentations of common conditions can test even experienced clinicians—and that small shifts in thinking can make a life-saving difference.

In this episode hosts Katie Wyatt NP-C and Charles Piltcher MD discuss a sad case of a patient who was taken to the ED by law enforcement for medical evaulation, and because of violence against the nuse and law enforcement officers, the patient was evicted to jail without medical exam. The patient had a cardiac arrest in the jail 30 minutes after arrival. Listen for the details and tips on how we can avoid situations like this in the future.

This episode reviews a malpractice case where a psychiatric patient boarded in an ED for over 24 hours was restrained in a prone position, sedated, and left unmonitored, resulting in cardiac arrest and severe brain injury. We discuss failures in monitoring, documentation, restraint policies, and the broader problem of psychiatric boarding, plus lessons for clinicians to prevent similar outcomes. Many thanks to those of you who have donated to help cover the hard costs (about $1000/year) of Med Mal Insights. It means a lot to know that you appreciate the case stories and find them helpful. Donations are always welcome. Here's 3 ways to donate: Zelle: Open your bank's Zelle app using your mobile device. Enter MMI-LFL mobile phone number 2069158593 Venmo: Click this link to Venmo PayPal: Click PayPal and select a donation amount Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. Western Journal of Emergency Medicine, Vol 20 Issue 5 , July 22, 2019. Resources on Behavioral Health Crowding and Boarding in the Emergency Department (ED) Compiled by members of the ACEP Emergency Medicine Practice Committee, September 2019.  

Welcome to the Learning from Lawsuits podcast, where we review real medical malpractice lawsuit cases so healthcare providers can learn from them. In this episode a 62-year-old with WPW presents in atrial fibrillation; a nurse practitioner recognizes the case is beyond her scope and transfers care to the attending, documenting a detailed handoff. The patient later arrests after the NP’s shift but recovers and sues claiming PTSD. The appeals court found the NP not liable based on clear transfer documentation. Key takeaways: document handoffs thoroughly, customize templates with patient-specific details, communicate scope of care, and assign high-risk cases appropriately.

In this episode of Medical Manners, we share the story of a woman who came to the emergency department for abdominal pain. She was under the influence, declined care, and left—only to be found dead 12 hours later in a jail cell.   This case led to a lawsuit, but more importantly, it raises crucial questions about how we care for our most vulnerable patients. How do we balance compassion and clinical judgment when treating those we might label as “drug seekers” or “frequent fliers”?   Join us as we discuss the importance of slowing down, ensuring thorough evaluations, and remembering that every patient—no matter their background—deserves to be seen, heard, and cared for.