Contradictory Text Messages Contributed to Patient Misinterpretation of Care Instructions

Texting presents unique communication challenges. The brevity and casual nature of text communication that makes it convenient can also make it inappropriate in a healthcare setting. One key to using text messaging in healthcare is to know when an in-person or telephone conversation is necessary. Telephone conversations allow for important information to be exchanged with greater ease, and a more natural opportunity for questions and responses.

The following injury likely would not have occurred if the patient had spoken to her physician instead of attempting to interpret the multiple text messages from the physician’s nurse.

Case File

Issue: The patient incorrectly interpreted conflicting directions from the physician and nurse that were sent via text messaging.

A patient developed lymphedema in her arms and torso following a mastectomy. Her past surgical history was significant for liposuction of her back. Her physician recommended a compression garment, which was placed at an office visit for the lymphedema.

Concerned that the garment provided was not adequately compressing her back, the patient added her own corset to increase compression. She texted her physician’s nurse telling her to advise the physician that she was wearing the corset for additional compression. The nurse texted back that the patient should “remove any compression garment that was not placed by the physician.” However, she followed up this text with a forwarded text from the physician: “I want her upper back compressed.” Because the patient’s corset did compress her upper back and the other garment did not, the patient disregarded the nurse’s direction to remove her corset, believing the physician’s comments about upper back compression overrode it.

When the patient was seen a week later, the physician noted a large area on her back that had compromised soft tissue and full thickness necrosis. When the wound healed, it left a large, pronounced scar. The patient filed a malpractice lawsuit against the physician and nurse alleging the negligent directions associated with compression caused her injury.

Discussion

Defense experts believed the patient’s injury was caused by the addition of the corset to the physician-placed compression garment. They also believed that the patient’s prior liposuction may have predisposed her to the type of injury she sustained. However, the defense team determined the patient’s misinterpretation of the text messages was understandable and would resonate with a jury if the matter went to trial.

Risk Reduction Strategies

Clinicians and Staff

• If your message will require more than a few sentences, use an alternative method of communication.
• When texting, have a low threshold for picking up the telephone and discussing a treatment issue instead of attempting to clarify via additional text messaging.
• Avoid forwarding someone else’s text messages.
  
  

Operations

• Establish clear indications and contraindications for text messaging with patients.