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Pre-Surgery Delay in Processing Abnormal Results Leads to Patient Death

March 26, 2021

Delays in staff processing of critical and significantly abnormal results can affect various aspects of a primary care practice. The following case shows how a delay in entering results into the EHR coupled with an FP’s failure to carefully investigate the patient’s fitness for surgery can result in patient death.

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

Allegation

Failure to discover abnormal lab results prior to preoperative evaluation caused the patient’s death.

Case File

A surgeon scheduled a 60-year-old male patient for surgery on April 10 for a bleeding peptic ulcer. On April 6, preoperative labs ordered by the surgeon revealed a significantly elevated platelet count. On April 7, the surgeon faxed the lab results to the patient’s FP. On April 8, a nurse from the hospital called the FP and asked her to evaluate the patient for surgery. The FP misunderstood the nurse and believed the patient was scheduled for surgery on that day — she believed it was an urgent request. The FP pulled up the patient’s records in the office EHR and saw nothing concerning.

Assuming preoperative labs had been done and that the labs had not yet arrived at her office, the FP asked the nurse if the patient’s labs are normal. The nurse stated the labs were normal and the FP indicated that the patient was medically stable to undergo surgery. The anesthesiologist relied on the FP’s statement to determine that the patient was an appropriate candidate for anesthesia. Following surgery, while still on the operating table, the patient coded and could not be revived. Autopsy indicated he died as a result of disseminated intravascular coagulation (DIC) and platelet thrombosis.

Many weeks later, the FP learned the patient had died following surgery. She reviewed the EHR again to see if she had missed something. She then realized that the preoperative labs had been faxed to her office by the surgeon April 7 but she had not been aware of them because they had not yet been scanned into the EHR. The patient’s family sued the surgeon, FP, anesthesiologist and hospital alleging the patient should not have undergone surgery with the severe case of thrombocytosis.

Discussion

Like many professional liability claims, this claim involved a combination of individual and systems errors that converged at the “perfect” moment to cause a patient injury. Experts believed, and the FP conceded, that the patient should not have been “cleared” for surgery due to the thrombocytosis. The FP would not have indicated that the patient was medically stable if she had seen the preoperative lab results. However, the defense of the FP was significantly complicated by her failure to review the results, which had been received in her office before the hospital nurse called.

Risk Management Recommendations

Once test results enter the office, there must be a fail-safe method for notifying clinicians that significantly abnormal results have arrived and making those results promptly available. Consider the following recommendations:*

  • Ensure timely processing of all test results and physician notifications.
  • Test result follow-up policies should clearly define key categories of test results (e.g., “critical,” “significantly abnormal,” “unexpected,” “abnormal,” and “normal”).
    • Use test result categories and other guidelines established by physicians to assist staff in prioritizing entry of abnormal results into the EHR and physician notification.
  • Clearly outline clinician and staff responsibilities.
    • Ensure that designated staff are licensed and qualified to triage test results.
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.

Reference

* Hardeep Singh, Meena S. Vij. “Eight Recommendations for Policies for Communicating Abnormal Test Results.” Joint Commission Journal on Quality and Patient Safety. 2010 May;36(5):226-32. DOI: 10.1016/S1553-7250(10)36037-5

Filed under: Patient Care

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