In virtually every physician-patient interaction, accurate information about the patient’s past history is vital for decision making. Proper documentation is essential for care that may be provided in the future by yourself or others. Coordination of care is as much of a patient safety challenge as is making an appropriate diagnosis or ordering the successful treatment. The path of care from the initial complaint to completion of treatment is far from seamless. Indeed, it is full of cracks—opportunities for losing, misunderstanding or not seeing important information—that may pose serious risks for the patient. Many medical liability cases involve poorly coordinated care that results in a missed or delayed diagnosis.
In one study done by CRICO, the medical liability company for the Harvard Medical System, coordination of care lawsuits were found to be split evenly between the mismanagement of tests, the mismanagement of referrals and the mismanagement of handoffs. Our experience is very similar.
The following case studies provide examples of the challenges faced in the coordination of care:
Case Study #1:
A 68-year-old female is admitted for sepsis. She does well and blood cultures reveal Methicillin-Sensitive Staphylococcus Aureus (MSSA). A two-week course of antibiotics is suggested by the infectious disease (ID) physician, as no source of infection was found. On the day of discharge, an echocardiogram shows endocarditis. This result is not noted by the discharging physician. The nursing home physician discontinues the antibiotics after two weeks per the discharge summary. The patient develops back pain and leg weakness two weeks later. She eventually develops paralysis from an epidural abscess. The ID physician consults again and states he would have given the antibiotics for six weeks if he had known of the echocardiogram results. A lawsuit ensues.
In 2009, the Journal of General Internal Medicine1 reviewed the charts of 668 patients. Even though all patients had some tests pending, only 25 percent of discharge summaries mentioned these pending tests. The study’s conclusion was that discharge summaries are inadequate. A more recent study addresses discharges to sub-acute care. In 2011, the Journal of General Internal Medicine published a study where approximately one-third of patients had tests pending at the time of transfer. Only 11 percent of these pending tests were documented in these summaries. Both of these studies reflect the care that we saw in the above case study. Tests slipping through the cracks at the time of discharge are a source of concern.
Case Study #2:
A 43-year-old male is admitted for cellulitis which quickly resolves. A microcytic anemia of 32 is incidentally found and the patient admits to recent rectal bleeding. The patient is told to follow-up with his primary care physician (PCP) at a later date. No note of the anemia is made in the discharge summary. The patient does not have a PCP and does not see a physician until 18 months later. At that time, the patient presents to the emergency room with an acute abdomen and is found to have metastatic colon cancer at surgery. When asked, the patient mentions that his father had colon cancer at an early age. A lawsuit is filed.
Younger patients can get colon cancer. Three percent of all colon cancer occurs in patients under 40 years of age. Factors increasing that risk include a positive family history, inflammatory bowel disease or familial polyposis. Anemia without an obvious explanation should be evaluated. Rectal bleeding should be investigated with one of the tests that can visualize the colon.
A 2007 article in the Archives of Internal Medicine revealed that in a cohort of 693 hospital discharges, 240 different outpatient workups were suggested. Of these workups, 36 percent were not completed. An available discharge summary at the time of the first follow-up visit increased the chance of these tests being completed. The authors concluded that non-completion of suggested workups (as we saw above) is common.
Case Study #3:
A 50-year-old female is evaluated for a self-discovered lump. The physician refers her to a surgery specialist who does not feel the mass. The subsequent mammogram is equivocal. The surgeon suggests “follow-up should be done at one month.” He does not specify who that would be with. The patient is not seen for nine months and returns with a worsening mass that is diagnosed as breast cancer. She was not sure about what she was told after her visit nine months ago, and she was not sure whether the PCP or the surgeon was following up on the mass.
This case demonstrates that providers need access to all information of importance and need to establish a clear understanding of who will take responsibility for the follow-up of that information. It is also important to involve patients in their own care, so they have the necessary information, clearly understand who they should see, and know what the next steps should be.
These cases are reflective of a myriad of examples of care that were not properly coordinated. Several suggestions would help these issues:
- You cannot rely on memory alone to order the right tests, treatment or follow-up. Whether one’s system is paper or electronic, tracking systems are critical to avoiding the preventable adverse outcomes demonstrated in these studies and illustrative cases.
- When a significant issue is apparent, you need to discuss it with the patient and, at the very least, explain the ultimate risk if a problem is not evaluated. Documentation of this discussion is critical to your defense should an adverse outcome occur because the patient was noncompliant with the recommendation.
- Be the patient’s advocate and help arrange that important test, follow-up or referral.
- Enhance closed loop communication with other providers and be aware of the multiple places where handoffs occur.
- Always remember that discharge is a high-risk handoff time. Take care with your discharge summaries and make sure worrisome issues are addressed and, if possible, workup is arranged.
- Involve the patient in his or her own care and shared decision making. Enabling patients access to their own information and subsequent care plans is critical to avoiding preventable adverse outcomes.
1 Were, MC et al. J Gen Internal Med 2009; 24(9): 1002-6.
2 Walz SE et al. J Gen Internal Med 2011; 26(4): 393-8.
3 Moore C. Archives of Internal Medicine 2007; 167(12): 1305-11.
Created by MagMutual from materials provided by COPIC as part of MagMutual and COPIC’s alliance to improve patient safety and quality of care for all of our PolicyOwners.