By Laura Hale Brockway, ELS, Vice President of Marketing and
Stacey Agnew, MBA, Risk Management Representative
Presentation
A 46-year-old man came to a general surgeon for treatment of inguinal and umbilical hernias.
Physician action
On October 10, the surgeon performed repair surgery using synthetic mesh. The procedure occurred without incident. Postoperatively, the patient was treated by a urologist for urinary retention and catheterization. The urologist prescribed ciprofloxacin. The patient was also diagnosed with diabetes during his hospitalization.
During an office visit with the surgeon on November 8, the patient was noted to be healing well. There were no signs of infection, though the surgeon took a culture of the wound and sent it to the lab. There was no indication in the medical record that the surgeon followed up on this culture and there was no lab report in the record.
The patient returned on November 15. The surgeon decided to keep him on ciprofloxacin. There was no mention of the lab test results in the record. Two more visits occurred, and the patient was showing improvement. The surgeon did not mention the missing lab results in the visit notes.
The patient’s condition changed, and he returned to the surgeon on January 25 with fever, pain, and swelling. Though it was not documented, the surgeon said the patient reported that he had been working in dirty water in his job as a plumber.
A CT scan showed fluid buildup, and the patient was re-admitted to the hospital. An interventional radiologist drained the fluid, which tested positive for MRSA. An infectious disease physician recommended vancomycin and the placement of a PICC line for the administration of long-term IV antibiotics. The patient was discharged.
At a post-discharge visit on February 8, the surgeon told the patient to continue the antibiotics. He also told the patient that because of the infection, it might be necessary to remove the mesh and replace it with biological mesh. The patient was upset about the infection and that the surgeon did not place biological mesh initially. When the patient was told that was not the standard of care, he became abusive to staff. The surgeon discharged the patient from his practice and told him to follow up with the infectious disease physician.
On April 27, the patient went to a new surgeon who removed the mesh in late June. Imaging studies conducted for the second surgery showed mesothelioma in the lining of the abdomen. The patient had additional surgeries in July and September.
Allegations
A lawsuit was filed against the surgeon. Allegations included:
- failure to properly diagnose;
- failure to obtain and act on the lab culture taken on November 8, which showed infection with MRSA;
- failure to note the absence of lab results on two repeat visits;
- poor surgical technique, including the selection and use of mesh; and
- failure to advise the patient that he needed immediate removal of the infected mesh.
Legal implications
A plaintiff’s expert — the surgeon who performed the patient’s second repair procedure — stated that the patient’s mesh infection was underestimated and not treated appropriately. This took away any chance that antibiotics would clear the infection and set a course requiring removal of mesh and debridement of the abdominal wall. As a result, the patient’s recovery was prolonged.
General surgeons reviewing this case for the defense supported his choice of mesh material and the procedure he used. The decision to use synthetic mesh is standard and in some cases is preferred to biologic mesh, which breaks down and may require further hernia repair. Any type of mesh can become infected, and it is difficult to clear any mesh of infection. Further, even if antibiotics had been started earlier, the mesh still might have needed to be removed.
Defense consultants were critical of the general surgeon’s failure to follow up on the lab results from the wound culture taken on November 8. Those results showed the patient had a MRSA infection and arguably led to the delay in treating the infection. According to these reviewers, the standard of care requires a physician to find out the results of any test they order.
Defense experts were also critical of the general surgeon for discharging the patient while he was still recovering from the procedures.
Disposition
This case was settled on behalf of the general surgeon.
Risk management considerations
In this case, the surgeon ordered a culture to rule out infection during a postoperative appointment with the patient. However, the culture results were never tracked or followed to confirm the lab’s receipt of the specimen or to obtain results. This lack of follow up caused a significant delay in diagnosis and treatment.
When patients are referred to consultants or to an outside source for lab or diagnostic tests, a tracking system is recommended to ensure the patient was seen, tests taken, and results received. If using an EHR, inquire with your software vendor about electronic order entry and tracking capabilities to help with tracking tests. If electronic tracking is not feasible, it is recommended to maintain a log or folder of “pending” labs, referrals, and diagnostic orders. These logs or pending folders should be updated when results are received and reviewed regularly for any outstanding reports.
Tracking systems vary from practice to practice based on needs and available resources. However, the four basic steps for managing patient test results remain the same:
- track tests until results are received;
- notify patients of the results;
- document that notification occurred; and
- ensure patients with abnormal results receive the recommended follow-up care. (1)
Follow-up appointments provide an additional opportunity to review previous encounter notes and to identify any outstanding test results. In this case, the patient returned to the office twice after the culture was submitted to the lab and both times the outstanding lab report was not pursued or noted in the patient record. In addition, if the patient does not keep a follow up appointment, review of the medical record for any outstanding test results or area of concern is recommended. Attempts to notify the patient or contact the lab should be documented.
Another issue that caused a delay in diagnosis and treatment in this case was the termination of the physician-patient relationship by the surgeon due to the patient’s abusive behavior to the staff. Patient termination during post-operative care can be complex and is not generally recommended, especially when patients have undergone surgery and are in the early stages of recovery, or when the physician is managing an active postoperative complication. (2)
Sources
- Wenske, W., Brockway, LH. CME: Tracking Patient Follow Up and Diagnostic Test Results. The Reporter, 3rd Quarter, 2019. Texas Medical Liability Trust. Available at https://hub.tmlt.org/reporter/reporter-q3-2019. Accessed November 30, 2022.
- Texas Medical Liability Trust. TrendsMD Podcast: How to terminate the patient/physician relationship. Available at https://hub.tmlt.org/podcasts/trendsmd-podcast-how-to-terminate-the-patient-physician-relationship. Accessed November 30, 2022.
Laura Hale Brockway can be reached at laura-brockway@tmlt.org.
Stacey Agnew can be reached at stacey-agnew@tmlt.org.
