ProAssurance Risk ManagementMarch 20215 min read

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

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.

Allegation

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.

Discussion

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.

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

Closed Claim Case Study: Failure to Communicate Critical Radiology Findings Leads to Loss of Testicle
Closed Claim Case Study: Failure to Close the Loop on Critical Findings Leads to Negligent Patient Death
Closed Claim Case Study: Ambiguous Radiology Report Results in Below-the-Waist Paralysis
Closed Claim Case Study: Failure to Follow Critical Results Reporting Policy Leads to Incorrect Diagnosis and Patient Death
Best Practices: Develop a Process for Communicating Results Based on Criticality to Improve Clinical Decision-Making

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

Closed Claim Case Study: Prioritizing Urgent Diagnosis List Over Medical Judgment Leads to Patient Death
Closed Claim Case Study: Failure to Directly Communicate Unexpected Cancer Finding Leads to Delayed Treatment
Closed Claim Case Study: Failure to Communicate a Significant Diagnosis Change Leads to Worsened Prognosis
Closed Claim Case Study: Failure to Communicate a Positive Biopsy Leads to Delayed Cancer Diagnosis
Best Practices: Develop a Policy for Timely Diagnoses Communication to Facilitate Prompt Treatment
Best Practices: Avoid Ambiguity in Pathology Reports to Improve Communication

Part 3: From Primary Care Physician to Patient

Closed Claim Case Study: Lack of Redundancy and Coverage Contributes to Patient Death
Closed Claim Case Study: Inadequate Follow Up on Abnormal Labs Leads to Permanent Injuries
Closed Claim Case Study: Poor Test Result Communication Process Leads to Patient Injury
Closed Claim Case Study: Lack of Follow Up with “No Doc” ED Patient Leads to Patient Injury
Closed Claim Case Study: Pre-Surgery Delay in Processing Abnormal Results Leads to Patient Death

References

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.