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Failure to Convince Patient of Urgency of Follow Up Leads to Patient Death

March 26, 2021

Although every step in test result management is important and interrelated, patient notification errors tend to result in more adverse events.1 Communicating a critical or significantly abnormal test result requires more than simply distributing the result to the patient. The patient should understand the criticality of the result and how to follow up. Communicating the urgency of the circumstances may require an extra effort if the patient has low health literacy or cognition deficits.

doctor giving patient bad news

More Information About Communicating Critical Findings along the Continuum of Care

Overview: Healthcare Communication: Case Studies and Best Practices for Communicating Critical Findings

Part 1: From Radiology to ED

Part 2: From Anatomic Pathologist to Ordering and Primary Care Physician

Part 3: From Primary Care Physician to Patient


The physician’s failure to convince the patient to seek urgent treatment contributed to her death.

Case File

A 75-year-old patient with multiple health conditions and early-stage dementia was hospitalized after a fall. During her week-long hospitalization, she was diagnosed with atrial fibrillation and was started on warfarin. She was discharged after a week in the hospital. Two days after discharge, the patient was examined by her long-term FP. He noted that her atrial fibrillation had converted spontaneously and told her to stop taking the warfarin. At her two-week follow-up, she admitted she had not stopped taking warfarin. The FP again told her to stop and ordered INR levels. The lab report indicated the patient’s INR was 17.5. He called the patient and told her to go immediately to the ED because of her dangerously elevated INR. The patient refused. She died the next day. The patient’s family sued the FP, alleging his negligent management of the patient’s anticoagulation caused her death.


The patient had become increasingly noncompliant, which the FP assumed was associated with her cognitive decline. The physician had not thoroughly discussed the risks of warfarin or when to expect over-anticoagulation because he assumed the patient would stop taking the medication as he had directed. Unfortunately, the FP failed to document the patient’s increasing confusion, her noncompliance, and his efforts to appropriately manage her care. There was no documentation of a discussion of the risks of warfarin or of the telephone discussion with the patient about the risks of refusing to be hospitalized after learning of her dangerously elevated INR. The lack of documentation significantly complicated his defense in the lawsuit.

Risk Management Recommendations

A patient with cognitive deficits or low health literacy may not understand the urgency of completing follow-up studies and treatment. Consider the following strategies:2,3

  • When ordering a test that may have a critical or urgent result (e.g., INR levels), prepare the patient for responding promptly.
  • Discuss the significance and urgency of test results with patients, the benefits of compliance, the risks of noncompliance, and strategies for complying with follow-up plans.
  • Use communication strategies to increase patient comprehension and retention.
    • Speak slowly and clearly, moderating communication style in relation to the patient’s sensory or cognitive deficits.
    • Avoid medical jargon, technical terms, and complex, multi-instruction sentences.
    • Summarize frequently and use the repeat-back method to ensure patient understanding. When summarizing, make the message shorter and simpler.
    • Provide ample opportunities to ask questions. Patient questions can alert you to misunderstandings of instructions.
  • Actively listen and respond to the patient’s questions and concerns.
  • Document discussions with patients about compliance with follow-up instructions.
  • Consider involving a family member in the discussion, with the patient’s consent, if you have concerns about patient compliance or understanding.

If you have done your best, but still worry that a patient may not have completely understood your follow-up instructions, consider having a staff person contact the patient to follow up.

This content originally appeared as part of the April 2017 release of the NORCAL Group Risk Management publication, Claims Rx, “Communicating Critical Findings — A Three-Part Series, Part 3: Primary Care Physician to Patient.” This release and many others are available in the Claims Rx Directory for download. Policyholders will also find instructions for obtaining CME credit for select releases.


1. Nancy C. Elder, Timothy R. McEwen, et al. “Management of Test Results in Family Medicine Offices.” Annals of Family Medicine. 2009;7(4):343-351. DOI: 10.1370/afm.961

2. Thomas E. Robinson II, George L. White Jr., et al. “Improving Communication with Older Patients: Tips from the Literature.” Family Practice Management. 2006 Sep;13(8):73-78.

3. Paula A. Rochon. “Drug Prescribing for Older Adults.” UpToDate. Literature review current through Jan. 2021. Last updated 6/8/2020.

Filed under: Case Study, Patient Care



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