Presentation
On July 11, a 26-year-old woman came to her obstetrician-gynecologist (Ob-gyn A) with reports that on July 9 she went to the emergency department (ED) with pain in her right lower abdomen. Her last menstrual period was on June 29.
Physician action
During this ED visit on July 9, the emergency medicine physician ordered blood work; a pregnancy test; and an abdominal CT scan. The results of both the patient’s CT scan and pregnancy test were negative.
During the July 11 office visit, Ob-gyn A noted the patient’s right adnexa was tender. After ordering a pelvic ultrasound, the patient was diagnosed with vaginitis and scheduled for a follow-up appointment on July 29.
On July 18, the patient called Ob-gyn A’s office and left a message that she was experiencing excruciating pain on her right side. The office called instructing the patient to come to the office for an ultrasound and evaluation. The patient never came in.
On July 21, the patient went to see another physician, Ob-gyn B, on referral from a friend. The patient told Ob-gyn B about pain on her right side and her menstrual cycle history. The physician ordered an ultrasound and urine pregnancy test. The results of the ultrasound were negative, but the pregnancy test was positive with the hCG level at 1264 mIU/mL. (Above 25 is considered positive for pregnancy.) These results were not communicated to the patient.
On August 4, the patient went to an urgent care center with reports of severe abdominal pain. The patient was transferred by ambulance to a medical center where she was diagnosed with a ruptured ectopic pregnancy. The on-call obstetrician, Ob-gyn C, performed a laparoscopic right salpingectomy to remove the patient’s right fallopian tube and ectopic pregnancy.
The patient was discharged the next day. She went to a follow-up appointment with Ob-gyn B on August 19. The patient was noted to be healing nicely.
Allegations
A lawsuit was filed against Ob-gyn B. Allegations included failure to:
- review lab results indicating the patient was pregnant;
- order appropriate follow-up testing; and
- timely diagnose and treat the ectopic pregnancy so the patient could avoid surgical treatment.
Legal implications
Consultant ob-gyns noted that the fragmented nature of the patient’s care contributed to the difficulty in diagnosing the source of her pain. They also agreed that the patient needed follow-up hCG testing; however, they acknowledged that the location of the pregnancy could not be determined by an ultrasound until the patient’s hCG levels exceeded 5,000 mIU/mL.
One consultant stated that had the ectopic pregnancy been diagnosed earlier, it could have been medically treated with methotrexate. However, there was no guarantee the patient would not require surgical treatment. Although the patient did not follow up with Ob-gyn A, she did follow up with Ob-gyn B within the recommended timeframe.
A consultant for the plaintiff noted that Ob-gyn B should have documented the positive pregnancy results and scheduled follow-up hCG and ultrasound testing. This consultant also stated that an early diagnosis could have been medically treated with methotrexate. The patient could have also received a linear salpingostomy to remove the pregnancy instead of the entire right fallopian tube.
The majority of consultants reviewing the case for the defense stated that the surgical removal of the patient’s fallopian tube was unavoidable. These consultants believed that even if Ob-gyn B had noted the hCG results in a timely manner, treatment with methotrexate was not an option for this patient.
Disposition
The case was settled on behalf of Ob-gyn B.
Risk management considerations
Establishing and maintaining strong follow up and communication policies and procedures can help enhance patient care. In this case, the patient’s condition and test results were not reviewed, acted upon, or communicated to the patient in a timely manner. Had clear follow-up procedures been established, this case may have had a different outcome and been easier to defend.
A physician who orders testing is responsible for reviewing results when received; documenting his or her review in the medical record; and initiating appropriate follow up. Ob-gyn B did not communicate the positive pregnancy result to the patient or schedule appropriate follow up testing.
A problem for many practices is the lack of a clearly defined tracking system for managing test results used across facilities, offices, laboratories, and other institutions. While tracking systems will vary from practice to practice, there are four basic steps physicians can follow to help ensure test results are managed properly:
- track tests until results are received;
- notify patients of the results;
- document that the notification occurred; and
- ensure that patients with abnormal results receive recommended follow-up care. (1)
Instituting a clear system for effective patient follow up is also recommended. In establishing policies and procedures, consider the following.
- Prioritize test results with “urgent,” “critical,” “action needed,” or “pending results.” A coding system may heighten awareness and trigger appropriate follow up.
- Standardize and simplify processes by using checklists, flow sheets, or tracking systems.
- Adopt technologies that employ built-in systems such as reminders, alerts, and the flagging of documentation issues. Recognize that these types of systems are only effective if there is a commitment to use them. (1)
- Avoid using the “no news is good news” approach for dealing with test results. Abnormal test results can be sent to the wrong office, misplaced, or accidentally filed without physician review.
- Consider enlisting your patients in helping you track test results. Encourage your patients to call if they have not received their test results within a previously agreed upon timeline. Another way to enlist patients in their own care is to hold them accountable to their follow-up appointments. Emphasize the importance of follow up and encourage them to keep their appointments.
While involving patients in their own care can help overall outcomes, their involvement does not relieve the physician of his or her responsibility to follow up. (1)
Source
1. Wenske W, Brockway LH. Tracking patient follow up and diagnostic test results. Reporter, Volume 3, 2019. Texas Medical Liability Trust. Available at https://hub.tmlt.org/reporter/reporter-q3-2019. Accessed January 29, 2020.
