The following Claim Reviews are based on actual professional liability claims, but the fact summaries do not reflect the events and proceedings exactly. Some facts have been modified to emphasize risk considerations. Each illustrates how inadequate communication of an abnormal test result can compromise quality care.

Case 1

This case demonstrates some common errors in critical test value communication:

·         failure of lab staff to report the CTR to the responsible provider

·         incorrect assumption by staff that the responsible provider is already aware of the result

Claim/Lawsuit Allegations

The Claimant alleges that defendants failed to inform him of results of abnormal blood culture performed in ED of community hospital. He also alleges failure to timely diagnose and treat endocarditis, which resulted in his suffering a stroke with resultant permanent injuries, including weakness on left side from his stroke.

Co-Defendants included the emergency group, the hospital, the treating emergency physician, hospital staff pathologist and the patient’s primary care physician, a family practitioner.

Case Summary

The 57 year old male patient presented to the local hospital ED with complaints of severe left lateral back pain, lethargy and fever. Chest x-ray was interpreted as showing retro-cardiac infiltrates and WBC was elevated (12.5). On physical exam, the ED physician found crackles and wheezes in the left lung. Blood cultures were drawn during the ED visit.  A diagnosis of pneumonia was made. The patient was treated with antibiotic and discharged to home on a ten-day course of antibiotic. Written discharge instructions stated to take meds as prescribed and contact his family doctor if he had any of the following symptoms: trouble breathing, increased fever, chest pain or blood in cough; if not better in 2 days; not completely better in 10 days or if he experienced any new or severe symptoms.  

Approximately 20 hours later, the pathology lab called the ED and advised the nurse that the preliminary blood cultures showed gram positive cocci in chains. The nurse brought this to the ED physician’s attention, and he called the patient soon after. There is a factual dispute, however, as to what happened during this call. The ED physician documented this call on a “Call Back Documentation” form. He wrote, “Called patient and updated him of results. Negative fever. Less pain. Negative cough. Negative nausea/vomiting. Negative lightheadedness. Will follow-up with family doctor. Return ED PRN.”  He also noted, “positive blood culture: gram positive cocci in chains.” According to the patient, the ED physician simply asked him if he planned to call his PCP and the patient replied that he would. 

The patient testified that the next day he called his primary doctor’s office, spoke with office personnel and told them he had been diagnosed with pneumonia at the Hospital ED. He did not make an appointment to see the doctor at that time, because (as he later testified), he was feeling better on the medication. The PCP did not call the patient, but initialed the message note. 

The final pathology report of patient’s blood culture study revealed “viridans streptococcus group isolated both aerobic and anaerobic bottles.” This report automatically printed on the ED printer, according to the Pathology Lab director. (This report became available on the same day as patient’s call to his doctor’s office; also, there was another ED physician on duty that day.) The patient was not informed of the final test results, and the PCP did not see this final test result report.

Six weeks later, the patient went to his PCP with complaints of fatigue and body aches.  At that time, the PCP obtained the prior lab results and learned that the patient’s blood culture tested positive for viridans strep, which can cause endocarditis.  Also during this office visit, the patient first reported having had extensive periodontal work done in the month before the first ED visit. The PCP’s differential diagnosis after this visit included endocarditis, lung cancer and pneumonia.

When repeat blood cultures, drawn during that visit, came back positive for the same organism, the PCP admitted the patient to the hospital for IV antibiotic therapy. During this admission, a cardiac echo was interpreted as showing findings consistent with endocarditis with vegetation on the aortic valve.  The patient was subsequently discharged to home after 4 days, with a treatment plan for continued IV antibiotics via a PICC line. Two days later, the patient suffered a stroke; he was initially brought to the community hospital, but then transferred to a tertiary hospital for further care.

The patient has permanent disability related to the stroke: Impaired neurological function of the left arm and leg; significantly impaired gait; and, he sometimes uses a cane to walk.

Case Outcome

The lawsuits were settled without trial, on behalf of the Hospital, Primary Care Physician, and ED Attending Physician.

Risk Issues

• Delay or failure to diagnose often arises when patients see several different healthcare providers who don’t communicate with each other, or when patient’s complaints aren’t taken seriously. In this case, blood cultures were ordered and begun while the patient was seen in ED, but was discharged home before results were available. The responsibility for notifying the patient or his PCP with critical test results was not clearly spelled out.  

• The patient did not understand significance of his test result.  To him, the information that he had a “positive blood culture” and was to follow-up with his family doctor did not mean he needed to see the doctor, but rather just that he should call the office and tell them of the ED visit.

• Final lab results were sent to the ED printer two days later, but not seen by the ordering ED physician.  There was not a system in place that would ensure that an ordering ED physician actually reviewed results.

• Preliminary results were not communicated effectively to the patient’s PCP.

• PCP office staff did not follow up the patient’s phone call to try to obtain any lab test reports and bring them to the physician’s attention.