“No Doc” patients (patients without primary care physicians) are often treated in the ED. In the following case, an on-call FP’s agreement to admit the patient to the family practice service, and her partner’s examination of the patient, established their responsibility for following up on results ordered by the ED physician.
Allegation
Failure to diagnose and treat meningococcal sepsis and meningitis resulted in brain damage.
Case File
On a Wednesday at 1700 a patient presented to the ED complaining of fever, chills, vomiting, diarrhea, sore throat, dizziness, body aches, headache, and petechial rash. Initial laboratory results included an elevated white blood cell count with a shift to the left and a low platelet count. The ED physician diagnosed gastroenteritis, dehydration, and thrombocytopenia. The patient did not have a PCP so the patient was admitted to the family practice service and the on-call FP. On Thursday morning, the FP made rounds at the hospital and saw the patient at 0930. The FP concluded that the patient could be discharged. He invited the patient to follow up at his family practice group, but the patient indicated he would most likely pick a practice closer to his home for primary care.
By Friday morning, the patient’s blood cultures had grown a colony of gram-negative diplococci. A laboratory technician called and faxed the results to the family practice group. Staff at the group had not set up a chart for the patient because the FP had reported the patient would establish care at a different practice. The person who took the call told the laboratory technician that she had no record of the patient and made no further effort to route the results to one of the FPs in the practice.
On Friday night, the patient collapsed at home and was taken back to the ED by ambulance. By the time he was examined, he was comatose. Meningitis was confirmed by a spinal tap. Lifesaving efforts succeeded but the patient suffered permanent brain damage requiring around-the-clock nursing care. His wife brought a lawsuit against the ED physician, the FP, his group, and the hospital alleging failure to diagnose and treat meningococcal sepsis and meningitis.
Discussion
According to experts who reviewed this case, a duty of care was established toward the patient when he was admitted to the on-call FP and he examined the patient. That duty of care included responding to the critical results that were delivered to the office on Friday, after the patient’s discharge from the hospital. Even though the patient had expressed a desire to establish outpatient care with another physician, the FP had no verification that the patient had done so. It would be unlikely that the patient had time to do so between his discharge from the hospital and the time the critical result was reported to the FP’s office. At the very least, the FP had an obligation to find out if the patient had established care elsewhere and to notify either the patient or the other physician (or both) of the critical result.
Risk Management Recommendations
When multiple clinicians are co-managing a patient, responsibility for test result follow-up may be ambiguous.* In addition, patients who are assigned to on-call physicians can easily fall through the cracks after discharge from the hospital. Test result processing policies and procedures can help staff and clinicians appropriately handle unusual circumstances. Consider the following strategies:
Administrators
- Create policies and procedures that clearly describe responsibility for test result follow-up and communication.
- Ensure that clinicians and staff understand their responsibilities pursuant to the policy through training and evaluation.
- Ensure that your office has effective telephone call policies and protocols for responding to critical, significantly abnormal, and unexpected test result reporting.
- Encourage staff to seek physician input when telephone calls require clinical judgment.
- Ensure that patients who establish a relationship with the group through the ED or hospital admission are accounted for in the practice’s follow-up processes.
Physicians
- If you accept a patient into your service at the hospital while serving on-call, ensure that your practice accounts for the patient in the office follow-up system.
- If you believe you have relinquished control of a patient’s management to another physician, confirm and document it.
- When you receive a report that includes an actionable finding that demands prompt follow-up and treatment, determine who is coordinating follow-up and treatment.
- If someone else is coordinating care, confirm that the patient or the treating physician has been informed of the finding.
- Document conversations with other physicians about follow-up responsibilities and with patients about follow-up needs.
Reference
* Hardeep Singh, Lindsey Wilson, et al. “Ten Strategies to Improve Management of Abnormal Test Result Alerts in the Electronic Health Record.” Journal of Patient Safety. 2010;6(2):121-123. DOI: 10.1097/PTS.0b013e3181ddf652