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Telehealth Risk Management in Ambulatory Care and Pre-Hospital Settings (2021)

Available at Amazon in Spring of 2021

Description  Telehealth is ubiquitous, and the pandemic has fueled additional  growth. Yet, professionalism and standards are lagging behind  the technology.  Can reliable guidelines, supportive technologies, and standards reduce the risk of medical malpractice?

This book examines emerging controversial trends and practices related to access, planned error recovery, new regulations about hospital readmissions and closed circle communications as it relates to informed consent in telephone triage. 21 malpractice case studies illustrate how recurrent errors can be remedied by new technologies and standards.

The Appendix includes  Supplemental Materials —   an interview with two legal experts and an earlier overview of the field with telehealth case studies. Ms. Wheeler was the first telehealth expert to describe common practice errors and to suggest practices to improve common telehealth malpractice error. 

Author Sheila Wheeler, MSN, RN. Since 1995, Ms.Wheeler has served as an expert witness for plaintiffs and defendants in 35 telephone triage malpractice cases.

Using over 50 real-life case studies, the book describes malpractice risks specific to telephone triage.  It also provides examples of how improving telehealth system—qualified staff, inadequate guidelines, standards, training and documentation—can reduce risk. Case studies are analyzed from the perspective of an expert witness, not as a legal expert.

Reviewed by California-based Nurse Manager:

“Right on target, Risk Management in Telepractice educates telephone triage nurses about the risk of malpractice, the importance of excellent communications and clear documentation. Once I started reading, I did not want to put it down.  The case studies were interesting.  Most of the poor outcomes were preventable; in a few, it appeared that the nurses either lacked knowledge, education or experience. It takes an experienced nurse with strong documentation skills to work as Advice Nurse. Reading the book made me want to sharpen my skills and encourage others to do the same.”

 Brenda Blain Danner, MSN, RN, CNL, Clinical Nurse Manager, Telephone Care Service 


“We don’t look for patterns of our recurrent mistakes, or devise and refine potential solutions for them. But we could, and that is the ultimate point” (Gawande, 2010)

This course examines recurrent patterns of error (medical malpractice) that contribute to delay in care in telephone triage. It also describes proactive approaches to reduce risk.  Many of the suggestions are based on Joint Commission and Institute of Medicine reports on standards to reduce error and the pioneering work of Avedis Donabedian, M.D. (1992). His model provides a framework for evaluating healthcare quality in categories: “structure” (context), “process” (transactions between patient and provider), and “outcomes” (effects of healthcare on patient health status).  A second influence on this work is a recent article about diagnostic error and risk management (Groszkruger, 2014), who suggests remedies to common problems.

It is the author’s opinion that telephone triage is a form of pre-hospital care which requires clinical expertise to estimate the urgency of presenting symptoms.  Recurrent errors result in failure to assess adequately in order to identify and then classify  potentially urgent symptoms by telephone.  Healthcare Systems often focus on cost-containment to the exclusion of safety. Timely access to care requires a developed culture of safety, sound structure and process for safe outcomes.  Telephone triage systems require quality systems and practice to achieve safety overall.

The 21 case studies used to illustrate legal principles are based on actual events. However, in some cases identifying information  has been omitted.

Standards for Technology

Guideline Design Criteria In Clinical Practice Guidelines We Can Trust (2011), the IOM sets forth seven criteria required for appraising guidelines. The IOM recommends that developers set forth design standards for the assumptions, analytic methods, and rationales used in any guideline development. Such design standards would also apply to all telephone triage guidelines. Yet, few guideline developers have provided evidence that their guidelines meet such standards, or allow their proprietaryproductstobetestedandcompared to others. Transparency is lacking in terms of the buyer and the end-user.

Risk of Working in an Information Vacuum   Clinical practice without learning the outcomes of one’s decisions has never been shown to improve practice, whereas specific feedback about outcomes enhances practice safety. AHRQ notes that reliable decision support and feedback systems do not yet exist (2017). Such mechanisms — known as planned error recovery  — allow practitioners access to the final diagnosis for patients evaluated on-site following telephone triage calls. This feature provides for both specific feedback for clinicians and reinforces improved practice.

Technology Can Support Professional Standards.Telephone Triage technology—electronic guidelines and EMR software has the potential to both track standardized triage outcomes as well as to insure planned error recovery. This feature provides mandatory feedback, helping to reduce human error. This essential error reduction strategy promotes a method to self-check or double-checks another person’s work (The Joint Commission).Integrating planned error recovery enables nurses to learn from their mistakes and successes, thereby reducing system error.

Available at Amazon in Spring of 2021

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