I think this is a very interesting case of MISCOMMUNICATION that led to a big settlement despite the ankle tap being considered a contaminant.
I agree that Dr. T could have prevented this lawsuit perhaps if he had only COMMUNICATED with someone else. If I took this call as a provider oncall who did not know the patient, I would have just CALLED THE OFFICE and spoke with the PCPs office staff to inform them. I ALSO make it a habit to CALL the patient as well. If I was called from the hospital lab, I would ask them "is this patient still in the hospital?" If so I would call the floor and make sure the hospitalist was aware of the information. Since this patient had been discharged I would CALL THE PATIENT since cell phone numbers are in the hospital system and discussed it with them as well. Directly communicating with the patient helps prevent problems down the road including preventing lawsuits!
The above takes a matter of 5-10 minutes. I would do this SINCE I was called from a HOSPITAL LAB with a CRITICAL VALUE. In these cases, I ALWAYS make sure that someone else is aware of this. Even though we look at culture results all the time, I think there is more importance to this particular type of result.
The above all comes down to COMMON SENSE and TAKING CARE OF THE PATIENT. Attention to details especially when YOU the provider are involved in an unexpected clinical situation that may result in a bad outcome is of KEY IMPORTANCE. In fact, I just called the ER after my shift 2 days ago to follow up on a patient with early pregnancy who had a send out beta hCG with no follow up. Patient was out of town and came in for pelvic pain and positive hCG. So as an OBGYN who also does ER work, I made SURE that I communicated the results to the patient and there was follow up ASAP. Patients like this never have a good means of follow up. I made sure this patient knew the results and could be seen the following day. If this resulted in a ruptured ectopic with emergency surgery it's obvious what would happen when the request for records came around. It is hard to make sure patients get follow up even though we stress this in the ER when they are seen. LUCKILY, WE DO HAVE A SYSTEM IN PLACE FOR LAB FOLLOW UP IN THE ER TO HELP PREVENT THOSE IMPORTANT LAB RESULTS THAT MAY GET OVERLOOKED WITH NO COMMUNICATION TO ANOTHER PATIENT OR HEALTHCARE PROVIDER. WE SHOULD NEVER ASSUME THAT IT WILL BE TAKEN CARE OF BY SOMEONE ELSE PERHAPS SIMILAR TO THIS CASE.
Reviewing MedMal cases like this definitely help to prevent these problems in the future.
I completely agree. There are so many errors in medicine that could be easily prevented with just a little bit of follow-through and close loop communication. Near misses, similar to this actual miss, are exceedingly common. Unfortunately, our medical system is a very reticulated Swiss cheese. Until we move to a universal EMR with better continuity and follow up (never), providers exercising good communication, and follow-through are the only things protecting patients from these errors.
I once got burned with a false positive culture for what was an aseptic Charcot joint all along. So it happens.
But all this computerized EMR/EHR actually in many ways makes communictation worse, as there is a false assurance in technology for information transfer.
At my hospital system, results that come back after a patient is discharged goes to the ordering physician.
Hospitalists need to work out a system of cross coverage to handle their inboxes when theyre "off-service". Literally every other medical profession does it, they need to figure it out.
I think kicking it back to the ordering physician is what most places do... its the easiest name for lab techs to find, Anything else and the techs are going to have to start digging through the chart and make judgment calls.
While the crux of the case involves systems and communication issues, it’s hard to fathom how the diagnosis remained in doubt over the course of a 5 day hospitalization. It would seem that in order to justify admission, there must have been concern for septic arthritis; and yet he did not undergo arthrocentesis until day 3 of his hospitalization (admitted 12/6, tapped 12/9). It’s surprising he wasn’t tapped in the ED. As an EP, I would have a hard time convincing a hospitalist or orthopod to admit a patient for anything but septic arthritis as suggested by the clinical scenario and lab data, including CRP, ESR, WBC and above all synovial fluid analysis.
It would be helpful to know if the patient presented with a fever or had risk factors for septic arthritis such as IVDA. About the synovial fluid, not much is said other than the results were “negative”. What were the cell count, gram stain and crystal results that favored pseudogout? In our ED, we are tasked with following up daily on the final lab and radiology results of our colleagues’s patients as they appear in our inbox and acting on them as needed; once I click on the result or report, I own it and document any ensuing change in diagnosis or treatment and every communication I have with the patient or colleague. In this case, the ball was dropped by multiple players. Or in the fateful words of the Captain in Cool Hand Luke, “What we have here is a failure to communicate”.
Yeah I wish they would have included the full synovial fluid results... seems like this may have been one of those very tricky cases where a septic joint has normal initial results. Reminds me of the "common myths" part of this blog post: https://emblog.mayo.edu/2014/10/03/septic-arthritis-myth-busting/
I would be very curious to know the WBC of the joint aspirate. I had a patient who had some crystals on a hip arthrocentesis, but I admitted the pt cuz the WBC was over 100k. Ended up growing Serratia.
The defense of the ID expert that the Staph in the aspirate was a contaminant is completely absurd given that's the same organism the pt was infected with on subsequent hospitalization. It's usually the plaintiff's experts that seem to be more unethical, but not this time.
I do think it would make more sense to inform the inpatient team, who has access to the patient's chart, of the result, than the patient's PCP.
I agree that joint should've been tapped in the ED. Maybe the ED doctor just wasn't comfortable tapping an ankle (I myself have actually never done one) so admitted for IR or ortho to tap?
"The fact that the critical result was called to the patient’s PCP office instead of the ordering or discharging doctor could be criticized."
What if the ordering provider AND discharging doctor are both off service given their hospitalist schedules? Should it go to the hospitalist on service who has never had any contact with the patient? PCP is a very reasonable choice here as the patient is now out in the community, and the PCP can make the decision to either call the patient and instruct them to return to ED immediately vs see/treat ASAP or decide it's meaningless. That being said, often, the PCP of record in the EMR is not actually the PCP, which is why we typically don't go that route, but then the on-call doc should have refused to accept the value on that basis.
Critical values require readback, and frankly, if the on-call doc's argument was *just* "it's a contaminant," (which I disagree with since it sounds like it was positive in <24 hours which is not typical of contaminants) while I disagree, I would completely understand their logic. I do not understand how the on-call PCP doc legitimately thought they were getting a critical value call on a currently admitted patient. They were not paying enough attention to what was being said and/or did not respect that the lab is obligated to make such calls rather than calling for funsies.
I agree, but I also think this case and some of the commentary surrounding it (by you and others) reminds me of several other incident reviews I have been involved in where people are, in my opinion, too quick to label things "system errors" when the system's vulnerability is the slightest reliance on a person acting appropriately/correctly. Unless we intend to design a healthcare system where humans are completely absent from all of the decision-making and delivery of healthcare, I think it's inappropriate to label some of the carelessness I see as "system errors."
Maybe it's just my bias as arguably the most regulated, objectively receipt-laden aspect of healthcare (certainly relative to say an H&P) but Dr. T, acting as an outpatient on-call physician for a PCP's office, accepting and giving read back on a critical value and then communicating that result to literally no one in any capacity, even as a just a note in the patient's chart, *because he thought that the patient was inpatient and thus the inpatient team was acting on it* is not a "system error."
When I worked full-time in the ED, I tried and tried to get the higher-ups to institute a rational aftercare and follow up system. I worked for a very large HCO that had thousands of employees: they might have seen fit to create a department, staffed by nurses and PAs and trained techs, to follow up on abnormal labs results. Instead, I would get calls in the ER at 2 am about a culture sent from the ER 3 days prior, that was now growing "gram positive cocci" but with no further information. The patient was invariably admitted or discharged home, and I had to take time off from the steady stream of patients in order to access the patient's chart to tell the lab tech the pt's dispo. I now work for a UC system that has an actual aftercare department. It's much better for pts and docs.
Seems like more places are getting follow-up nurses to call these people back. There are probably a lot of callbacks that are contaminant but its probably for the best to just automatically bring them back to the ED for full reassessment.
Cases like this have so little to do with the medical care and the physicians involved and are all about the systems we work in. As you said each physician did her/his job- and nothing more. But the system designed a poor process that left the patient at risk.
Most of the cases involving hospitals are the result of the System. And not the care deliverers… staffing, policies, service availability.
This is also a great example of why making notes and labs available to patients is so important. But they need context to understand what they mean.
Imagine a lab system AI that knows what a critical result is and can send emails, texts, and check to make sure follow up (office visit, ED, Admission) occurs.
Given the length of his hospitalization and the timing of his arthrocentesis, he probably had significant co-morbidities that were being managed. If he was chronically ill, he was likely colonized with Staph that could opportunistically become invasive at any time. That positive culture, contaminant or not, was a lost opportunity to re-evaluate him. It was unfortunate that the only plan for a pending culture, even if clinically they weren’t worried about it, was to default to the single communication modality of a lab tech calling a PCP, neither of whom was involved in the patient’s care, and no one told the patient.
I think Dr T may have dropped the ball. If a patient was admitted to the hospital for a septic joint, Dr S should of been informed by Dr T so that he could follow up with the patient to ensure abx and proper treatment was rendered post discharge.
It would seem that an aspirate would be sent for evaluation of crystals, gram stain, and cultures. Gram stain would have likely documented organisms not just white cells.
It is not clear if there was a prior medical history of crystalline synovitis or diabetes. Not always is there fever present, but fever is not documented in this summary. High fever most likely correlates with a septic joint.
Maybe things have changed based on shift working hospitalists and physicians, but I was taught as an intern, that if you order a test you are responsible to check that test result. One is supposed to practice as a physician not a mechanic or technician. Many medical errors these days are caused by handoffs and assumptions.
I suspect this was one of those rare septic joint cases in which all of the other synovial fluid tests were negative. Sensitivity of WBC >10,000 is 90% which means you'll still miss a lot of septic joints. Totally agree that communication and handoffs are high risk for error.
The fact the patient was never informed of the positive culture result is the craziest part in my opinion.
I think this is a very interesting case of MISCOMMUNICATION that led to a big settlement despite the ankle tap being considered a contaminant.
I agree that Dr. T could have prevented this lawsuit perhaps if he had only COMMUNICATED with someone else. If I took this call as a provider oncall who did not know the patient, I would have just CALLED THE OFFICE and spoke with the PCPs office staff to inform them. I ALSO make it a habit to CALL the patient as well. If I was called from the hospital lab, I would ask them "is this patient still in the hospital?" If so I would call the floor and make sure the hospitalist was aware of the information. Since this patient had been discharged I would CALL THE PATIENT since cell phone numbers are in the hospital system and discussed it with them as well. Directly communicating with the patient helps prevent problems down the road including preventing lawsuits!
The above takes a matter of 5-10 minutes. I would do this SINCE I was called from a HOSPITAL LAB with a CRITICAL VALUE. In these cases, I ALWAYS make sure that someone else is aware of this. Even though we look at culture results all the time, I think there is more importance to this particular type of result.
The above all comes down to COMMON SENSE and TAKING CARE OF THE PATIENT. Attention to details especially when YOU the provider are involved in an unexpected clinical situation that may result in a bad outcome is of KEY IMPORTANCE. In fact, I just called the ER after my shift 2 days ago to follow up on a patient with early pregnancy who had a send out beta hCG with no follow up. Patient was out of town and came in for pelvic pain and positive hCG. So as an OBGYN who also does ER work, I made SURE that I communicated the results to the patient and there was follow up ASAP. Patients like this never have a good means of follow up. I made sure this patient knew the results and could be seen the following day. If this resulted in a ruptured ectopic with emergency surgery it's obvious what would happen when the request for records came around. It is hard to make sure patients get follow up even though we stress this in the ER when they are seen. LUCKILY, WE DO HAVE A SYSTEM IN PLACE FOR LAB FOLLOW UP IN THE ER TO HELP PREVENT THOSE IMPORTANT LAB RESULTS THAT MAY GET OVERLOOKED WITH NO COMMUNICATION TO ANOTHER PATIENT OR HEALTHCARE PROVIDER. WE SHOULD NEVER ASSUME THAT IT WILL BE TAKEN CARE OF BY SOMEONE ELSE PERHAPS SIMILAR TO THIS CASE.
Reviewing MedMal cases like this definitely help to prevent these problems in the future.
I completely agree. There are so many errors in medicine that could be easily prevented with just a little bit of follow-through and close loop communication. Near misses, similar to this actual miss, are exceedingly common. Unfortunately, our medical system is a very reticulated Swiss cheese. Until we move to a universal EMR with better continuity and follow up (never), providers exercising good communication, and follow-through are the only things protecting patients from these errors.
I once got burned with a false positive culture for what was an aseptic Charcot joint all along. So it happens.
But all this computerized EMR/EHR actually in many ways makes communictation worse, as there is a false assurance in technology for information transfer.
At my hospital system, results that come back after a patient is discharged goes to the ordering physician.
Hospitalists need to work out a system of cross coverage to handle their inboxes when theyre "off-service". Literally every other medical profession does it, they need to figure it out.
I think kicking it back to the ordering physician is what most places do... its the easiest name for lab techs to find, Anything else and the techs are going to have to start digging through the chart and make judgment calls.
While the crux of the case involves systems and communication issues, it’s hard to fathom how the diagnosis remained in doubt over the course of a 5 day hospitalization. It would seem that in order to justify admission, there must have been concern for septic arthritis; and yet he did not undergo arthrocentesis until day 3 of his hospitalization (admitted 12/6, tapped 12/9). It’s surprising he wasn’t tapped in the ED. As an EP, I would have a hard time convincing a hospitalist or orthopod to admit a patient for anything but septic arthritis as suggested by the clinical scenario and lab data, including CRP, ESR, WBC and above all synovial fluid analysis.
It would be helpful to know if the patient presented with a fever or had risk factors for septic arthritis such as IVDA. About the synovial fluid, not much is said other than the results were “negative”. What were the cell count, gram stain and crystal results that favored pseudogout? In our ED, we are tasked with following up daily on the final lab and radiology results of our colleagues’s patients as they appear in our inbox and acting on them as needed; once I click on the result or report, I own it and document any ensuing change in diagnosis or treatment and every communication I have with the patient or colleague. In this case, the ball was dropped by multiple players. Or in the fateful words of the Captain in Cool Hand Luke, “What we have here is a failure to communicate”.
Yeah I wish they would have included the full synovial fluid results... seems like this may have been one of those very tricky cases where a septic joint has normal initial results. Reminds me of the "common myths" part of this blog post: https://emblog.mayo.edu/2014/10/03/septic-arthritis-myth-busting/
Sobering info..maintaining a high index of suspicion in the face of uncertainty is key.
I would be very curious to know the WBC of the joint aspirate. I had a patient who had some crystals on a hip arthrocentesis, but I admitted the pt cuz the WBC was over 100k. Ended up growing Serratia.
The defense of the ID expert that the Staph in the aspirate was a contaminant is completely absurd given that's the same organism the pt was infected with on subsequent hospitalization. It's usually the plaintiff's experts that seem to be more unethical, but not this time.
I do think it would make more sense to inform the inpatient team, who has access to the patient's chart, of the result, than the patient's PCP.
I agree that joint should've been tapped in the ED. Maybe the ED doctor just wasn't comfortable tapping an ankle (I myself have actually never done one) so admitted for IR or ortho to tap?
Wow, your case is literally one of the myths of septic arthritis from this post: https://emblog.mayo.edu/2014/10/03/septic-arthritis-myth-busting/ Solid catch.
ED tapping joints is very variable... I do knees and ankles periodically but dont see many patients that need other joints (i dont do hips)
"The fact that the critical result was called to the patient’s PCP office instead of the ordering or discharging doctor could be criticized."
What if the ordering provider AND discharging doctor are both off service given their hospitalist schedules? Should it go to the hospitalist on service who has never had any contact with the patient? PCP is a very reasonable choice here as the patient is now out in the community, and the PCP can make the decision to either call the patient and instruct them to return to ED immediately vs see/treat ASAP or decide it's meaningless. That being said, often, the PCP of record in the EMR is not actually the PCP, which is why we typically don't go that route, but then the on-call doc should have refused to accept the value on that basis.
Critical values require readback, and frankly, if the on-call doc's argument was *just* "it's a contaminant," (which I disagree with since it sounds like it was positive in <24 hours which is not typical of contaminants) while I disagree, I would completely understand their logic. I do not understand how the on-call PCP doc legitimately thought they were getting a critical value call on a currently admitted patient. They were not paying enough attention to what was being said and/or did not respect that the lab is obligated to make such calls rather than calling for funsies.
Every callback policy is going to have some potential downfalls... hard to know which is the best option!
I agree, but I also think this case and some of the commentary surrounding it (by you and others) reminds me of several other incident reviews I have been involved in where people are, in my opinion, too quick to label things "system errors" when the system's vulnerability is the slightest reliance on a person acting appropriately/correctly. Unless we intend to design a healthcare system where humans are completely absent from all of the decision-making and delivery of healthcare, I think it's inappropriate to label some of the carelessness I see as "system errors."
Maybe it's just my bias as arguably the most regulated, objectively receipt-laden aspect of healthcare (certainly relative to say an H&P) but Dr. T, acting as an outpatient on-call physician for a PCP's office, accepting and giving read back on a critical value and then communicating that result to literally no one in any capacity, even as a just a note in the patient's chart, *because he thought that the patient was inpatient and thus the inpatient team was acting on it* is not a "system error."
When I worked full-time in the ED, I tried and tried to get the higher-ups to institute a rational aftercare and follow up system. I worked for a very large HCO that had thousands of employees: they might have seen fit to create a department, staffed by nurses and PAs and trained techs, to follow up on abnormal labs results. Instead, I would get calls in the ER at 2 am about a culture sent from the ER 3 days prior, that was now growing "gram positive cocci" but with no further information. The patient was invariably admitted or discharged home, and I had to take time off from the steady stream of patients in order to access the patient's chart to tell the lab tech the pt's dispo. I now work for a UC system that has an actual aftercare department. It's much better for pts and docs.
Seems like more places are getting follow-up nurses to call these people back. There are probably a lot of callbacks that are contaminant but its probably for the best to just automatically bring them back to the ED for full reassessment.
Cases like this have so little to do with the medical care and the physicians involved and are all about the systems we work in. As you said each physician did her/his job- and nothing more. But the system designed a poor process that left the patient at risk.
Most of the cases involving hospitals are the result of the System. And not the care deliverers… staffing, policies, service availability.
This is also a great example of why making notes and labs available to patients is so important. But they need context to understand what they mean.
Imagine a lab system AI that knows what a critical result is and can send emails, texts, and check to make sure follow up (office visit, ED, Admission) occurs.
Yeah you probably dont even need AI to do this for cultures... just a simple if/then program that calls/texts patients to come back to the ED.
Given the length of his hospitalization and the timing of his arthrocentesis, he probably had significant co-morbidities that were being managed. If he was chronically ill, he was likely colonized with Staph that could opportunistically become invasive at any time. That positive culture, contaminant or not, was a lost opportunity to re-evaluate him. It was unfortunate that the only plan for a pending culture, even if clinically they weren’t worried about it, was to default to the single communication modality of a lab tech calling a PCP, neither of whom was involved in the patient’s care, and no one told the patient.
I think Dr T may have dropped the ball. If a patient was admitted to the hospital for a septic joint, Dr S should of been informed by Dr T so that he could follow up with the patient to ensure abx and proper treatment was rendered post discharge.
Dr T is definitely the easiest to blame here.
It would seem that an aspirate would be sent for evaluation of crystals, gram stain, and cultures. Gram stain would have likely documented organisms not just white cells.
It is not clear if there was a prior medical history of crystalline synovitis or diabetes. Not always is there fever present, but fever is not documented in this summary. High fever most likely correlates with a septic joint.
Maybe things have changed based on shift working hospitalists and physicians, but I was taught as an intern, that if you order a test you are responsible to check that test result. One is supposed to practice as a physician not a mechanic or technician. Many medical errors these days are caused by handoffs and assumptions.
I suspect this was one of those rare septic joint cases in which all of the other synovial fluid tests were negative. Sensitivity of WBC >10,000 is 90% which means you'll still miss a lot of septic joints. Totally agree that communication and handoffs are high risk for error.