Malpractice Threats in Well-Intended Patient Handoffs

Mark Crane


October 04, 2012

In This Article

Five Handoffs That Became Perilous

The classic fumble in the patient handoff is when the specialist thinks the primary care doctor is going to take care of some aspect of follow-up, and the primary care doctor thinks the specialist is handling it.

Malpractice insurers that we interviewed gave these examples of handoff errors:

A 38-year-old woman detected a lump in her breast and was referred by her primary care physician to a surgeon. The surgeon found no mass, but recommended that she be reexamined in 1 month. Each physician assumed that the other would follow-up, Dr. Lembitz said. Nine months later, the patient returned to her doctor with a larger mass and was diagnosed with breast cancer.

A healthy newborn boy was treated by a neonatologist within the first 12 hours of his life. Although a bilirubin test was ordered, the covering neonatologist discharged the child within 24 hours, unaware of the laboratory results. At 60 hours, the baby was seen by a pediatrician at an ambulatory care center; a bilirubin test was again ordered before that doctor left for vacation, expecting that the laboratory would contact the parents and her call coverage physician.

The covering pediatrician (from a different group practice) didn't have accurate contact information for the mother. The next day, when the regular pediatrician saw the fax from the laboratory, he contacted the mother and asked that the baby get to the hospital as soon as possible.

The patient was admitted at 77 hours but died of kernicterus, a preventable disease if had it been recognized on the basis of the 2 previous laboratory results. The bilirubin level was 16 mg/dL at 12 hours of age, 32 mg/dL at 60 hours of age, and 44 mg/dL on admission at 77 hours.

A test result requiring immediate action was called to a night doctor, "who not only did nothing, but also failed to tell the day doctor about it," said Stella Fitzgibbons, MD, a hospitalist in Houston, Texas, who reviews malpractice cases. "That day doctor, for his part, was 'just filling in' and left the problem for the 'regular doctor' to deal with, causing expensive and irreversible problems for the patient."

A 61-year-old woman was hospitalized with abdominal pain. A lesion was found in her spleen. Resection revealed an abscess with methicillin-resistant Staphylococcus aureus. An infectious disease specialist recommended a 4-week course of vancomycin.

One week later, the patient was transferred to a rehabilitation facility. An echocardiogram had shown subacute endocarditis, but the report on it was not returned until after discharge and was neither seen by nor relayed to the subsequent providers.

The patient's nonhospital physician assistant had no records on this finding and was not sure why she was still receiving vancomycin. He stopped the medication 1 week later, especially because maintaining intravenous access was difficult for this patient. Two more weeks after the medication was stopped, the patient presented with a spinal abscess and paralysis -- the result of a failure to transmit critical information.

"We're seeing the same patterns of claims over and over again," said Dr. Lembitz. "The inconsistent or incomplete handoff is what leads to the problem."