- Know that failure to properly act on abnormal test results is a significant patient safety issue.
- Appreciate that failing to contact a patient about abnormal test results is a source of successful malpractice claims.
- Learn the legal standard that is applied to a failure to contact a patient about test results that require follow-up action.
- Describe some steps that might reduce the harm from failure to act on abnormal test results.
A 21-year-old woman presented to the emergency department (ED) with heavy vaginal bleeding. She was admitted to the obstetrics and gynecology (OB/GYN) service for management. She received a blood transfusion and a Depo-Provera injection (a hormone to stop the bleeding), and was discharged home the next day. As part of the evaluation for her vaginal bleeding, a chlamydia test was performed in the ED. This test returned positive the day after the patient was discharged.
Per a standard protocol, the positive laboratory result was sent through the electronic medical record (EMR) to a nurse who worked in the OB/GYN clinic. She followed standard procedure and tried to call the patient using the contact number in the EMR. No one answered, and the nurse called again on each of the next 4 days, but there continued to be no answer. She notified her clinic supervisor who noted the result, but made no further attempts to contact the patient.
One week later, the patient presented to the radiology department for an ultrasound that had been scheduled at the time of the initial hospitalization. The ultrasound technician did not notice the abnormal test result or the fact that the chlamydia infection had not been treated. The following day, a different OB/GYN clinic nurse tried to call the patient with the ultrasound results, and again no one answered the phone. She sent a letter by mail to the patient with both the ultrasound and chlamydia results. The patient received the letter and came to clinic 2 weeks later (now 26 days after her initial presentation) where she received appropriate antibiotics for the chlamydia infection (a single dose of azithromycin).
Despite this treatment, she developed fevers and abdominal pain and presented to the ED. She was diagnosed with chlamydial pyosalpinx (infection of the fallopian tubes) and peritonitis. This severe form of chlamydial infection likely developed because of the delay in treatment. The patient needed to be admitted to the hospital for intravenous antibiotics. The patient was discharged 3 days later and was expected to make a full recovery, although there is some risk of long-term complications including infertility and chronic pelvic pain.
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Table. Steps organizations can take to reduce the malpractice risk associated with following up test results.
1. Engage patients in following up on pending tests |
2. Obtain or verify contact information at each visit |
3. Customize the approach to patients based on their anticipated reliability |
4. Use the electronic medical record to provide alerts when patients need to be contacted |
5. Develop electronic systems that track test results |
6. Document all that is done |