Commentary
Lack of tracking and follow-up procedures, as well as poor communication, resulted in a delayed diagnosis and settlement of this case.
Case Details
A 12 YOM (5'3”, 176 lb), presented to his primary pediatrician’s office with his father for a sports physical. The patient’s primary pediatrician was on vacation, so another pediatrician who commonly filled in for the group saw the patient. The patient complained of having pain in the left groin for approximately two weeks, and had complaints of eczema and rhinitis. Upon examination, it was noted that the patient had tenderness in the left groin and was limping on the left side. Documentation in the medical record included “rule out suspected slipped capital femoral epiphysis (SCFE).”
The pediatrician prescribed amoxicillin and valisone ointment for the patient’s rhinitis and eczema, and wrote both prescriptions on one prescription form. A second prescription was written for bilateral hip x-rays to rule out SCFE. Documentation in the patient’s medical record noted that the patient was to return in one week for follow-up. The pediatrician testified she gave both prescriptions to the patient’s father. However, the patient’s father testified he was never given a prescription for x-rays. The father stated he was told the patient had a groin pull and to do stretching exercises.
Five days later, the ordering pediatrician had not received the patient's x-ray report and requested the medical assistant (MA) to follow up. The MA contacted the hospital where the x-rays were to be completed and was told the x-rays were never completed; the follow-up appointment was never scheduled. The MA called the home number listed on the patient’s contact information; there was no answer. No message was left for the patient, and no further attempt was made to follow up. The MA documented that a call was made with no answer. The MA did not communicate the information back to the ordering pediatrician.
The patient presented to his primary pediatrician’s office 18 days later with complaints of an “acute severe allergic reaction,” and was seen by yet another pediatrician. Neither the patient nor his mother mentioned or complained of hip or leg pain at this visit. Since the pediatrician did not review the chart, he did not know about the initial visit. As a result, the pediatrician did not follow-up on the complaints of tenderness in the left groin, limping, or the prescription written for the x-rays to rule out SCFE.
Approximately 10 months later, the patient was seen by his primary pediatrician, who was named as a defendant. The patient complained of pain in his left inner leg that had been occurring on and off for two months. At this time, the defendant pediatrician suspected SCFE and ordered x-rays of both hips and the pelvis. The films were completed and interpreted by a radiologist as “normal.”
Due to pain in his feet, the patient saw an orthotist eight months later. CT scans of his feet revealed a lesion in the area of the talonavicular joint of an osteochondral type. The patient continued to see the orthotist over the next four to five months. It was noted that the patient had a leg length discrepancy of 3/4-inches, and an x-ray of the left hip showed a SCFE. The patient was referred to a pediatric orthopaedic surgeon.
Surgery was performed about a year later for pinning of the left capital femoral epiphysis and a prophylactic pinning of the right hip. Five months later, the patient underwent a distal femoral and proximal tibial epiphysiodesis to equalize limb length. It was the opinion of the surgeon that the prognosis would have been better and the chance of future residuals would have decreased if the diagnosis had been made when the patient first presented to the pediatrician’s office.
The office follow-up procedure was lacking in completeness. There was no communication between the primary pediatrician and the on-call pediatrician, and there was no requirement for pediatricians to review charts of the patients who were seen in their absence. The chart was organized in such a way that documentation for sick visits and routine physical exams were in different sections, making cross-referencing visits difficult.
The plaintiff sued the primary pediatrician and his practice, alleging the practice was vicariously liable for the pediatrician that was filling in at his practice. The radiologist was also a named defendant.
Expert Testimony
The plaintiff’s experts testified in deposition that the standard of care had been breached while the defense experts had differing opinions as to the standard of care. There was no support for the radiologist regarding the standard of care.
Resolution
The case was settled for an undisclosed amount.
Risk Reduction Strategies
Explicit written policies, procedures, and responsibilities for test follow-up, documentation, and communication is essential for a thorough tracking process. Lapses in these processes can result in delayed diagnosis and treatment. Additionally, having a process in place for handoffs between clinicians to ensure that test results are communicated to the clinician responsible for follow-up care is an effective strategy in patient safety.
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