A patient saw multiple physician internal medicine practices for an upper respiratory complaint, including one practice in which a nurse practitioner (NP) ordered a chest X-ray.
"Some time after, the patient returned and saw a physician with a compliant of chronic cough," says Leilani Kicklighter, RN, ARM, MBA, CHSP, CPHRM, LHRM, principal of the Kicklighter Group, a Tamarac, FL-based risk management consulting firm. The physician ordered a chest X-ray, and the results stated that the lesion in the lung reported previously had progressed.
"In looking at the medical record, upon receipt of this report, the physician sees the previous report in the record was not followed up by anyone," says Kicklighter. "There are two problems here."
First, the results of the X-ray ordered by NP were not addressed by the practice when they were received. Kicklighter says a "fail-safe process" is to provide patients with results of all test results, normal or abnormal, with documentation of such notice. "The physician tried to blame the ARNP, but was reminded that the ARNP is an employee of the practice; therefore, the ARNP's exposure was the practice's," says Kicklighter.
Secondly, the physician failed to review the medical record when seeing the patient. "Had the record been reviewed, the previous visit assessment, conclusions, and orders would have been evident, and would have caused a review of the previously ordered X-ray report," says Kicklighter.
Tests never obtained
Steven Adler, CEO of Physicians Indemnity Risk Retention Group, a Plantation, FL-based provider of professional liability insurance, is seeing many more claims involving providers who failed to review test results or failed to follow up when patients didn't obtain a test. Here are some recent examples:
- A stat CT was ordered for a woman who presented with right lower quadrant abdominal pain, but the patient felt better and decided not to get the test. "The physician had no mechanism to remind them they needed the result of the test," says Adler. "The patient came back in three weeks and was referred to a GI." The patient's appendix ruptured and resulted in short bowel syndrome.
A patient who presented with severe chest pain was referred to a GI. The patient returned with unrelenting pain, but never obtained the stress test that was ordered because there were problems getting authorization.
The patient had a coronary event and expired. "There was no follow-up with the physician or the staff as to the status of getting this patient authorized," says Adler.
A physician ordered a CT scan after a diagnostic test revealed a suspected mass in a patient's lung, but the test was never done. "Months later, the doctor was called in as a consult when the patient was admitted months later for unrelated reasons," he says. "He never went back to his records to determine that the tests that had been ordered were never done." The patient later was diagnosed with advanced carcinoma of the lung and died shortly after.
During audits of physician's offices, Adler often finds there is no "tickler" system to remind the office that a patient never returned for a follow-up visit or obtained a diagnostic test.
"If you don't have a proper protocol, things are going to fall through the cracks," says Adler. "You just can't remember what you've ordered for 60 patients."