Case 2
The case shows communication errors in the transition of a patient from one facility to another.
Claimant is a 50 year old male who alleges failure by hospital 1 (H1) ED nursing staff to communicate preliminary blood test results to hospital 2 (H2), after he was transferred; he also alleges failure by H2 to follow up on test results (allegedly) provided to the attending physicians.
Co-Defendants included Hospital 1 (ED), Hospital 2 (ICU), H1 ED Physician, 2 Neurosurgeons, 2 Infectious Disease specialists, Radiologist, Neuroradiologist, and nurses from both hospitals.
Case Summary
(Day 1) The patient initially went to the ED of a local hospital (H1) with complaints of fever, lower back pain, hallucinations. ED physician ordered back x-rays and urinalysis, which were unremarkable. He was diagnosed with strep throat/pharyngitis and back pain. The patient was discharged as stable, to home, with prescriptions for pain medication (penicillin and Darvocet), and instructed to follow up with his primary care physician (PCP).
(Day 3) The patient returned to the same ED, this time with complaints of continued fever and back pain, plus progressing neurological deficits (complete paralysis of lower extremities and partial paralysis of upper.) Blood was drawn for C & S studies, but results were not available when it was decided to transfer the patient to a tertiary care hospital (H2) for emergent MRI scan of the spine.
The patient was admitted to H2’s ICU, with differential diagnosis of epidural abscess and transverse myelitis. An MRI was done but no spinal abscess (infection) was seen. An Infectious Disease consulting physician started the patient on a high dose of IV antibiotic therapy, even though at the time, the physician was not aware of the positive blood culture results.
A factual dispute arose regarding the sending and receiving of the blood test results. ED Nurse (H1) alleged that she provided the report of positive blood culture study to the ICU (H2), by fax and phone. She noted the same in the nursing progress notes. However, the ICU nurse attending the patient (at H2) testified that she did not see a fax report nor take a phone call. There was no documentary evidence of the report in the medical record, and no notes confirming that anyone received a fax or took a call from the ED nurse. Moreover, the ED Nurse could not identify the person to whom she spoke or the number she had called. (Note: Some physician experts opined that, since the antibiotic given in the ICU was appropriate treatment for the patient’s bacterial infection, whether or not the test report was received in the ICU was a moot point.)
(Day 5) The patient was transferred and admitted to a larger university-affiliated hospital (H3). Repeat MRI on day 2 of admission revealed evidence of a small epidural abscess and osteomyelitis. The patient remained at this hospital for 6 weeks, during which time he underwent a series of procedures, including drainage of the abscess, cervical decompression and stabilization. He was next transferred to a physical rehabilitation facility for about 6 weeks, and then discharged to home.
In the years since, the patient has suffered multiple medical complications related to his paralysis. He is permanently wheelchair bound and dependent for all activities.
Case Outcome
The lawsuit was settled without trial, on behalf of H2 and the ICU Nurse at H2. Suit was dismissed as to all other defendants.
Risk Issues
- The transferring hospital had a duty to ensure that an accurate record of the patient’s completed and pending tests were sent along with the patient at time of transfer. The attending physicians at the “receiving” hospital might have made a diagnosis of bacterial spinal infection sooner, in light of the lab result and clinical condition of the patient, had they been aware of the critical positive blood test results, in a timely manner, from the “transferring” hospital.
- Questions could be raised about whether all appropriate tests were ordered by the ED physician during the patient’s first ED visit.