An omission in medical treatment is nearly impossible to defend when there is a written protocol specifically addressing the failed act. That is why an open dialogue between physician and staff on office policies and procedures is necessary to avoid patient injuries.
A 6-year-old boy visited an urgent care center with his mother for right thigh pain over 3 days, reporting that the site was sore to the touch and hurt when he walked. The mother reported that there had been no recent trauma. Dr UC, an urgent care physician, evaluated the patient, who was in general good health with a low-grade fever of 99.3 °F. Dr UC noted pain in the muscle but not the femur.
Dr UC's working diagnosis was an infection or inflammatory process, and she prescribed amoxicillin and acetaminophen. She gave the mother ER precautions and set up a follow-up visit for 2 days later. Instead of returning, the patient's mother mentioned the urgent care visit to the patient's pediatrician, Dr PD, during a pediatric visit by the patient's sibling. The pediatric practice noted the mother's comments about the patient's urgent care visit in the patient's chart.
The next day, the mother called Dr PD's practice to request an x-ray for her son. A note in Dr PD's chart reflected "the mother discussed with [Dr PD] at the sibling's visit yesterday and she was okay with it." Dr PD's staff ordered an x-ray of the right thigh.
That same day, after Dr UC's staff called to follow up on the earlier visit, the mother brought her son in to see Dr UC. On examination, the young boy's fever had improved but he still had pain when the acetaminophen wore off. An x-ray was taken, and Dr UC noted no acute changes after reviewing the x-ray. Dr UC advised the mother to have her son continue with the acetaminophen, follow up in 2-3 days, and visit the ER if conditions worsened.
Dr UC's staff attempted to follow up with the family 3 days later, but the voicemail left by staff was not returned.
Medscape Editor's Key Notes:
• Double-check that test results have been interpreted by the appropriate specialist.
• Ensure that test results are conveyed to patients and caregivers, and document that results were communicated.
• Consider implementing staff protocols that will catch results that fall through the cracks.
Eleven months later, the mother called Dr UC's office requesting a copy of the x-ray taken at the urgent care center and informed Dr UC that her son had been diagnosed with Ewing sarcoma a month earlier.
After that call, Dr UC discovered that the x-ray taken at the urgent care practice was never sent out for a formal interpretation, even though the office policy was to send out all x-rays taken in-house for a board-certified radiologist's interpretation.
At the mother's request, Dr UC then sent out the x-ray for interpretation. The receiving radiologist noted a large bone lesion involving the right femoral neck, the intertrochanteric region, and the proximal shaft. The x-ray and the radiologist's report, which included a recommended MRI to evaluate the potentially malignant lesion, were sent to the mother.
The patient's family sued Dr UC, alleging a 10-month delay in his cancer diagnosis, which included pulmonary and pelvic soft tissue metastases. The dispute was resolved informally.
Office protocols are not "set and forget." They need to be actively reinforced with staffers. It's important to reinforce a continuing dialogue between physicians and staff, with the goal that protocols will not only be better understood but probably also constantly improved.
This case comes from the "Case of the Month" column featured in the member newsletter published by the Cooperative of American Physicians, Inc. The article was originally titled "Office Protocols Can Fail - So Training Must Be Constant."
© 2021 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.