The Most Important Thing

“The single biggest problem in communication is the illusion that it has taken place.” George Bernard Shaw

In real estate, it is often said that the most important thing is location, location, location. In healthcare often the most important thing is communication, communication, communication. The following case is an unfortunate illustration of that principle.

Eve Adams (not real name) presented to her primary obstetrician on May 23, where she was found to be eleven weeks pregnant with a history of pre-term delivery and uterine fibroids. She had blood drawn that day, and a referral was made to a cardiologist for a maternal heart murmur. She was also referred to maternal fetal medicine (“MFM”) specifically for her history of pre-term labor and uterine fibroids. Patient records were faxed to the MFM office that same day. Labs received the following day indicated an abnormal anti-Kell result. These results were sent to the MFM office by fax along with other records on May 25. The lab results showing the abnormal anti-Kell results and other records were placed in the patient’s chart at the MFM office.

On June 9, Eve had her first MFM visit via telemedicine with Dr. Smith. Dr. Smith reviewed the patient’s records from the OB’s office, but only reviewed the records that were sent in the first fax. She thought that the records sent in the second fax were duplicates. A report of that visit was sent to the referring OB. The stated indications for the visit were fibroids, maternal heart murmur, and history of premature delivery. There was nothing in the report about the anti-Kell.

At the next visit with her primary OB, Eve was seen by a PA. She entered a note in their system stating that she reviewed the MFM notes from Dr. Smith. She noted that Eve was referred to MFM for Kell antibodies, and other concerns, and it appeared that they did not address the Kell antibodies issue. The PA put in that note that she called the MFM office to alert them to the Kell issue and to make a new appointment. The MFM office had no record of this call.

Eve saw the same PA at her primary OB office again a week later during which the PA recorded that Eve would see MFM the following week and that she would follow up on the anti-Kell test results after the MFM visit.

Over the following few months, Eve saw various physicians at the MFM office as well as regular visits with her OB. She did not see Dr. Smith, the original MFM physician, again for any of these visits. Each of the MFM providers relied on the notes from the immediately preceding office visit. None of the subsequent MFM providers reviewed all the records in the chart. Thus, there was never a comprehensive review of the chart that would have revealed the abnormal labs.

On September 19, a routine ultrasound by a MFM physician indicated hydropic changes. Eve was promptly admitted to a hospital for observation and testing, with the plan for an intrauterine transfusion. Based on her condition at the hospital, the treating physician decided it would be best to proceed with a caesarian section rather than the planned intrauterine transfusion. The infant was delivered at approximately 28 weeks. The child had permanent neurologic deficits.

The parents of the child filed a lawsuit alleging that the primary OB, her PA, Dr. Smith and all the other MFM providers who treated the patient were negligent.  

SVMIC insured the MFM providers and their group. The allegations against the MFM providers were that they had received the labs with the abnormal anti-Kell test results, and they failed to act appropriately in response to the information. Actions by the MFM would have included diligent monitoring and intrauterine transfusions if anemia appeared. This responsibility appeared to fall primarily on Dr. Smith as the first MFM specialist in the group to see the patient. It was not customary for subsequent treating physicians to review the records other than the last visit notes and any new information. At a mediation, Dr. Smith and her group reached an agreement with the parents to settle the case. Based on the facts of the case it was reasonable that subsequent MFM physicians relied on previous notes prepared by members of their group. The physicians who saw Eve after Dr. Smith did not settle and were dismissed from the lawsuit.

There was no dispute that the fax with the abnormal labs was received by the MFM practice, and those results were in the patient’s chart. Dr. Smith did not completely review the records having relied on the stated reasons for the referral. She thought she had all the information available and necessary to evaluate the concerns prompting referral. Dr. Smith also assumed the records were duplicates of the first batch of records. The patient never brought any other concerns to the attention of Dr. Smith or the other MFM providers. Although the PA documented a call to the MFM practice to alert them to the need for anti-Kell test follow up, there was no record of the call in the MFM records and no further follow up by the PA or OB. It is not certain that more intensive management would have resulted in a better patient outcome, but if the MFM providers had known about the lab results, they would have acted differently. It is clear to see multiple examples of ineffective communication in this case that resulted in treatment opportunities being missed, and a very unfortunate outcome.