Claim Review: Healthcare Risk Management Considerations
Hindsight as we all know is 20-20. However, there are lessons to be learned, or at least reviewed in this situation.
Test Results & Follow-Up: The significant fact in this case is that the positive blood culture was not medically addressed in a timely manner. Who was responsible to react to the test results? What processes, at the physician offices or the hospital, were in place to ensure that follow-up was performed?
Recall that the blood culture was ordered by the Cardiologist Group. The culture results were sent to the hospital unit four days after the patient was discharged. While the Nurse Practitioner was found to have acted appropriately by faxing a copy of the report to the Internist’s office, following up with a call to make sure they had received it, and notifying her Cardiology Group who ordered the test, no one initially acted upon the results.
1. A physician’s office staff must communicate all laboratory results to the physician or the physician on-call. Procedures must be in place to assure that all laboratory results and tests are documented as read by the physician, placed in the patient’s medical record, and addressed in a timely manner.
Furthermore, the procedures should address critical-value laboratory results, in which special care must be taken to ensure expedient follow-up has occurred. If the Internist or Cardiology office had implemented a procedure of documenting either on the laboratory result or another designated area of the patient’s chart that the laboratory result had been read and addressed, either a staff member or the physician would have had to check to see that the patient was being adequately treated for the positive value. This kind of tickler system may have resulted in a call to the Cardiologist Group and a discovery might have been made that the patient was not being treated.
2. The hospital also has a responsibility when a patient has been discharged and a critical laboratory report is positive. While no information is available that discusses the hospital’s actual procedures for notification of lab results, a similar process must be implemented that defines who receives the lab results, such as the ordering physician, and any special procedures to address post-discharge results, such as including the primary care physician, if known, as a recipient.
Consultant/Primary Care Physician Relationships: Communication among providers of care is one of the hallmarks of good risk management. Communication among primary care and consultant physicians regarding who has responsibility for current and follow-up care is critical. Appropriate roles before and after treatment should be clear. Good and frequent communication is an asset in any consultant arrangement and can serve as a safety net for breakdowns in procedure. See the Risk Management section of this issue of Risk Review for more details on this topic.
Red Flags: This patient should have been identified as a high-risk patient due to the multiple physical problems and history of noncompliance. High risk patients may require not only more specialized medical care but they often require more education and more hands-on management. A patient who expresses a need to change providers should raise a red flag. That circumstance says "let’s review the case more closely, and with all providers." Dissatisfied, unhappy patients or family members are more likely to pursue litigation.
Summary: This case is discussed because it represents the importance of communication and a policy and procedure for the communication of critical laboratory results. The reporting of critical lab values is even addressed in the JCAHO National Patient Safety Goals for hospitals (Goal 2A). However, physician offices must also have a policy and procedure for the communication and follow-up of test results. Had a procedure been in place in the hospital and the physician’s offices, and physician roles in a consulting relationship been predetermined, this litigation may not have occurred.
Questions and/or suggestions are welcome. Call the Risk Management Department at 1-866-RX4-RISK
