ProAssurance Risk ManagementMarch 20217 min read

Inadequate Follow Up on Abnormal Labs Leads to Permanent Injuries

One aspect of controlling information overload is planning for the amount of time it will take to follow up on results when a test is ordered. Appropriate follow-up requires the physician to successfully complete numerous steps (e.g., review the result, communicate it to the patient, determine a treatment plan, discuss the plan with the patient, and then facilitate the treatment plan, if necessary). Any failed step during this process can result in patient injury.

In the following case, in an effort to manage a high volume of test results, receptionists were tasked with scheduling repeat labs on abnormal routine test results without the pediatrician’s review of the abnormal results. Unfortunately, one of the receptionists did not recognize the significance of an abnormal test result, and the delay in communicating the result to the patient’s parents led to significant patient injuries.

Allegation

Failure to promptly follow up on abnormal lab values resulted in permanent injuries.

Case File

An eight-year-old patient presented to a pediatrician for a well-child exam. The patient’s clinical presentation was unremarkable and she had no complaints. The pediatrician ordered routine labs. One of the values was significantly abnormal but not technically critical according to the laboratory’s results notification policy. Had it been critical, the laboratory would have directly communicated the result to the pediatrician. The value was not highlighted on the faxed lab report that arrived in the pediatrician’s office two days later although the normal range was listed next to it indicating that it was abnormal. According to office policy, when a patient’s values from routine labs were out of range but not designated as critical (which would be immediately referred to the pediatrician) a receptionist contacted the patient’s parent and set up an appointment to repeat the test, which occurred in this case.

A few days before the scheduled appointment to repeat the test, the child presented to the ED in critical condition. She sustained permanent injuries. The parents filed a lawsuit alleging the pediatrician’s failure to promptly advise them of the abnormal laboratory value resulted in delayed diagnosis and treatment.

Discussion

According to experts who reviewed this case, because the patient was exhibiting no signs of illness at her well-child exam, the pediatrician was not required to order routine blood tests. However, once she ordered the tests, she was required to review and follow up on abnormal results. The pediatrician admitted after the fact that she would have acted more promptly if she had seen this patient’s results when they were faxed to the office. However, pursuant to her own policy, she would have reviewed the initial test results only if the repeat results were also abnormal. If the second result was normal, the first abnormal result was considered a false positive, and she would save the discussion of normal results for the next well-child visit.

The pediatrician had unwittingly placed herself in a risky position by ordering routine laboratory tests for every patient. The laboratory she had used for many years had approached her with the idea of obtaining routine laboratory results for her pediatric patients. Although she agreed to this plan, she failed to anticipate the significant increase in her office’s receipt of laboratory results. She was quickly inundated with laboratory reports that she did not have time to review.

One of the issues the pediatrician had not considered when she agreed to the routine lab plan was her practice of retesting pediatric patients with abnormal labs that did not match their clinical presentation. She considered laboratory value ranges unreliable for pediatric patients because they were configured for adults. She believed sending every child with abnormal labs to a specialist would be impractical and unnecessarily costly. Therefore, once she received the repeat results, she formed a differential diagnosis or referred the patient to a specialist. Before she started doing routine laboratory tests on all of her patients she’d had sufficient time to review the results of tests she ordered.

Calls to parents to advise them of an abnormal result and the need to repeat tests were not consistently documented. In this case, the receptionist did not document her call to the parents about the abnormal result. By the time the lawsuit was filed, she could not recall whether she had contacted them. The parents denied being contacted. Without evidence of contacting the parents and lack of a policy that would have resulted in the patient receiving the prompt medical attention she needed, the pediatrician had little evidence to counter the plaintiff’s malpractice allegations.

Risk Management Recommendations

Overwhelming volumes of test result data can negatively impact patient safety.¹ Consider the following strategies:^1,2

Carefully consider the tests you order based on each patient’s clinical presentation, symptoms, and needs.
Review the results of the tests you order.
Establish strategies for communicating different categories of results (e.g., critical, significantly abnormal, abnormal, normal).
Establish time frames for delivering different categories of results to patients (e.g., critical results should be immediately and directly communicated to patients.)
Do not overly rely on laboratory definitions of critical values. Individualize critical values for patients. For example, a patient with kidney disease whose normal potassium level is above normal will have a different critical level than an average patient.
Document review of the results and plans for follow-up or treatment.
Document efforts to communicate and actual communication of results to patients.
Even if ordering a test is not required by the standard of care, once you order the tests you have to respond appropriately to the 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.

References

1. John U. Young. “Failure to Communicate Clinical Test Results - A Legal Analysis for Pennsylvania.” Center for Health Law, Policy & Practice. Policy Brief. 2011, citing, Eric G. Poon, Samuel J. Wang, et al. “Design and Implementation of a Comprehensive Outpatient Results Manager.” Journal of Biomedical Informatics. 2003;36:80-91. DOI: 10.1016/S1532-0464(03)00061-3

2. Angelica Montes, Michelle Francis, et al. “Assessing the Delivery of Patient Critical Laboratory Results to Primary Care Providers.” Clinical Laboratory Science. Summer;27(3):139-42.

3. John W. Beasley, Tosha B. Wetterneck, et al. “Information Chaos in Primary Care: Implications for Physician Performance and Patient Safety. Journal of the American Board of Family Medicine.” 2011;24(6):745-751. DOI: 10.3122/jabfm.2011.06.100255

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: Poor Test Result Communication Process Leads to Patient Injury
Closed Claim Case Study: Failure to Convince Patient of Urgency of Follow Up Leads to Patient Death
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