Episode 108: Adding Assumptions to the Wound

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J. Baugh: Hello everyone, and welcome to our episode today of Your Practice Made Perfect. We're going to be looking at another closed claim and to help me with that today, we have Katy Smith. Katy, welcome.

Katy: Thanks, Jay.

J. Baugh: Katy and I are both Claims Attorneys here at State Volunteer. Katy's been here 13 years. I've been here 19. So, we've seen a lot of cases while we've been here, and today we're going to discuss a case involving an ever too common saying about what happens to us when we assume something. Medicine is no exception to the assumption trap. For the most part, our assumptions materialize and all is well, but as we all know, problems arise when our assumptions do not develop as predicted. In this case, we have Ms. White, a young, morbidly obese, one pack-per-day smoker, who underwent abdominal gynecologic surgery on January 15th of 2017. She was given a prophylactic antibiotic preoperatively. And so Katy, how did the post-op unfold?

Katy: Well, it was uneventful at first, Jay. On postoperative day one, which was January the 16th, 2017, Ms. White's abdominal incision was confirmed to be clean and dry, and the Steri-Strips were intact. She was stable overall, and was recovering well from the surgery, and she was able to be discharged home that day. However, five days later, and this is January the 21st, 2017, Ms. White returned to the ER, and she was complaining of fever and drainage from her abdominal wound.

J. Baugh: So, things looked good at discharge, but her wound took a turn at some point in the next five days. Dr. Smith, a Gynecologist in the same group as the original surgeon, readmitted Ms. White to the hospital, where he ordered a culture of the abdominal wound, prescribed IV Ampicillin and Flagyl, and performed a dressing change with clean-out and repacking of the wound. The patient remained in the hospital for the next two days, receiving IV antibiotic therapy. During this time, her condition improved overall. By January 23rd, 2017, Dr. Smith determined that Ms. White was ready for discharge and he placed a telephone order for her discharge.

Katy: At this time, there was another partner in their group, Dr. Jones, who was physically present at the hospital when Dr. Smith gave the telephone discharge order. So, Dr. Jones, being helpful, went ahead and carried out the patient's discharge for his partner, Dr. Smith.

J. Baugh: So now we have the patient back at home and then the following day, the hospital's lab released a final report for Ms. White's wound culture of January 21st. And so what were the results of that culture?

Katy: Well, the wound culture advised as to the culture and sensitivity of the bacteria that was infecting her wound, which unfortunately, and perhaps predictably was not sensitive to the antibiotics that she was prescribed and was taking at home.

J. Baugh: Yeah. And a big issue here is that the final wound culture report was not disseminated beyond hospital walls. So neither Dr. Smith nor Dr. Jones were made aware of its findings.

Katy: That's correct. And so our patient is here at home taking these antibiotics that she had been prescribed at discharge, which were not effective to her infection. So not surprisingly, she returns to the ER two days later, on January the 26th, with continued and progressing complaints of fever and drainage from her abdominal wound. At this point, the infection was found to be quite advanced. She required extensive surgical and wound care over a prolonged period of time, but she was able to recover completely from the infection. Also, perhaps not surprisingly, Ms. White filed a lawsuit over her care and named Dr. Smith, Dr. Jones, their group, and the hospital as defendants.

J. Baugh: So we now have a situation where Ms. White is able to recover, but only after some extensive surgical and wound culture over a long period of time. That wound culture was a definite key medical record in this lawsuit. The question is why did the physicians involved, not pay closer attention to that wound culture report?

Katy: I think that the doctors simply fell into the assumption trap. They probably just assumed that the results of the culture would be reported to them one way or another, regardless of whether the patient was still an inpatient at the hospital, or whether she had already been discharged from the hospital. And so these assumptions about this outstanding wound culture report set in motion, serious complications for the patient, and served as the basis for their lawsuit.

J. Baugh: That's right. So, this case has several lessons that we can learn from it. The first lesson would be always, always follow up on outstanding test results. And we've said this a lot and we've heard it a lot, but it's important to repeat it again. If the testing was important enough to order, then it's important enough to follow up on. You can't just simply order a test and then not do anything afterwards to make sure that the test was done or what the results were. Something like that. And a doctor saying, "Well, I was too busy to follow up on it," that doesn't work very well with a jury. Does it, Katy?

Katy: That's not going to be helpful, especially if you have this patient injured because of the lack of follow-up on the test result.

J. Baugh: Yeah, that's right. The jury in that situation is not really going to be too concerned with your overall patient load. They're going to be concerned about the patient who has filed that particular lawsuit. And so if it's important enough to order, then it's important enough to follow up on, so that you can explain to the jury what happened.

Katy: That's right. And it also kind of communicates, I would think some questions in a juror's mind; did he forget about the test that he ordered? Is that why he didn't follow up on it? And it kind of creates an impression of, oh goodness. Being inattentive, not following up on all aspects of your care, not just this one single test.

J. Baugh: That's right. And it goes to the credibility of the physician.

Katy: Yes.

J. Baugh: About all of his other patients. What else has fallen through the cracks? What else has he not followed up on? So, it's very important to follow up on any tests that you order, because ultimately the ordering physician will be charged with bearing some degree of responsibility for knowing the results of the testing he ordered, regardless of what others did or didn't do concerning its final report.

Katy: Definitely. Another point, Jay, is if you have a partner or a call group who's assisting with your patient's care, make these covering physicians aware that there are test results still outstanding. Don't just assume that they're going to pick it up from the medical chart itself. It may not be immediately apparent to that covering physician, and that covering physician may need the results of that test. They may be important for the covering physician's care, determination.

J. Baugh: That's right. It's not just how you can better make sure that you are the one providing medical care to the patient, but it may be important to other healthcare providers to follow up on those test results.

Katy: And that other healthcare provider could be of assistance in following up on the test result. Is there some reason that the lab hasn't returned it? Is it timely that it's not returned? Perhaps it's surprising that it's not returned and you have another person who can help you follow up with what's going on with the test result.

J. Baugh: It's not just on the physician who ordered the test, but it might be a subsequent physician might ask some questions about, "Why don't I have the results of this test back?"

Katy: That's right. Communication.

J. Baugh: So, you need to make sure that you're covering physician is fully aware of all things going on with that patient, especially if you're waiting on test results.

Katy: Another point that you can make is pausing before you automatically discharge a patient. In this case, the patient was doing well. She was stable. She appeared to be recovering well. So, she is clearly a candidate for discharge, but perhaps you just pause right before when you're thinking about your discharge planning and consider, are there any test results still outstanding? If so, is discharge appropriate? If you ultimately determine that it is appropriate, you need to figure out a plan for following up on that outstanding test result. Make sure there's a plan in place, perhaps even going as far as enlisting the patient in the follow-up plan. Something like, "If you haven't heard from us within X many days about the results of your wound culture, call us back." Make sure that the patient understands any role that they have in the plan.

J. Baugh: That's a good point that you make about discharging the patient and taking a pause before you do that. Because, I would think that there are different reasons for wanting to discharge the patient. Either the hospital is wanting you to discharge the patient so that someone else can come in, or maybe the family, or maybe the patient themselves are saying, "Hey, I want to go home." And, you can't let those pressures keep you from making sure that you've got everything documented - the chart - that you've got all test results followed up on, make sure that you communicate with the patient about what is expected of him or her. And so, while you have pressures that may cause you to want to discharge the patient quickly, you've got to take that time out, take the pause and make sure that everything's in order before you do that.

Katy: That's right. And you can always communicate to the patient. "I know you're feeling great, but there's a significant test result, we're waiting for it to come back. It may result in some change in the treatment plan," which it would have in this case-

J. Baugh: Right.

Katy: Which would have been a material change, and probably had the wound culture been received, they would have started on an IV antibiotic, which perhaps would require still inpatient admission. So the pause is always a good thing.

J. Baugh: And so, when you're discharging a patient from the hospital, when tests are outstanding, you can leverage your existing in-office tracking system. While it may generally be true that the hospital's laboratory would or should inform you of the results of inpatient testing, you can't rely on that alone. Such an assumption may be detrimental to your patient's health. And, it may result in you being named as a defendant in a lawsuit that you could have otherwise avoided.

Katy: And I think that is the major takeaway of this case, is it probably was a lawsuit that could have been avoided. If the physicians had timely followed up on the wound culture report, perhaps they would have avoided the complication to the patient, thus avoiding the lawsuit. That did not happen here, so you had a lawsuit that was filed against the doctors in their group, as well as the hospital, ultimately mediation was held and a settlement was reached.

J. Baugh: So I think there was some valuable information that was provided by reviewing this closed claim. I think we learned some good lessons today. And so Katy, I want to thank you for being here today to discuss this closed claim.

Katy: Thanks, Jay.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host J. Baugh. Listen to more episodes, subscribe to the podcast and find show notes at svmic.com/podcast. 

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time. All names in the case have been changed to protect privacy.