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Office Protocols Can Fail — So Training Must Be Constant

This month, we feature a popular “Case of the Month” from the archives written by CAP’s former General Counsel Gordon Ownby

An omission in medical treatment is nearly impossible to defend when there is a written protocol specifically addressing the failed act. That is why an open dialogue between physician and staff on office policies and procedures is necessary to avoid patient injuries.

A six-year-old patient visited an urgent care center with his mother for right thigh pain over three days, reporting that the site was sore to the touch and hurt when he walked. The mother reported that there had been no recent trauma. Dr. UC, an urgent care physician, evaluated the patient, who was in general good health with a low-grade fever of 99.3. Dr. UC noted pain in the muscle but not the femur. Dr. UC’s working diagnosis was an infection or inflammatory process and she prescribed Augmentin and Tylenol. She gave the mother ER precautions and set up a follow-up visit for two days later.

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Instead of returning, the patient’s mother mentioned the urgent care visit to the patient’s pediatrician, Dr. PD, during a pediatric visit by the patient’s sibling. The mother’s comments regarding the patient’s urgent care visit were noted in the patient’s chart at the pediatric practice. The next day, the mother called Dr. PD’s practice to request an X-ray for her son. A note in Dr. PD’s chart reflected “the mother discussed with [Dr. PD] at the sibling’s visit yesterday and she was okay with it.” Dr. PD’s staff wrote a prescription for an X-ray of the right thigh.

That same day, after Dr. UC’s staff called to follow up on the earlier visit, the mother brought her son in to see Dr. UC. On examination, the young gentleman’s fever had improved but he still had pain when the Tylenol wore off. An X-ray was taken and Dr. UC noted no acute changes. Dr. UC advised the mother to have her son continue with the Tylenol, follow up in two-to-three days, and visit the ER if conditions worsened.

Dr. UC’s staff attempted to follow up with the family three days later, but the voicemail left by staff was not returned.

Eleven months later, the mother called Dr. UC’s office requesting a copy of the X-ray taken at the urgent care center and informed Dr. UC that her son had been diagnosed with Ewing’s Sarcoma a month earlier.

After that call, Dr. UC discovered that the X-ray taken at the urgent care practice was never sent out for a formal interpretation, even though the office policy was to send out all X-rays taken in-house for a board-certified radiologist’s interpretation.

At the mother’s request, Dr. UC then sent out the X-ray for interpretation. The receiving radiologist noted a large bone lesion involving the right femoral neck, the intertrochanteric region, and the proximal shaft. The X-ray and the radiologist’s report, which included a recommended MRI to evaluate the potentially malignant lesion, were sent to the mother.

The patient sued Dr. UC alleging a 10-month delay in his cancer diagnosis, which included pulmonary and pelvic soft tissue metastases. The dispute was resolved informally.

Office protocols are not “set and forget” but need to be actively reinforced with staffers. Through the reinforcement of a continuing dialogue between physicians and staff, protocols will not only be better understood, but probably also constantly improved.