Page 18 - 2020 Risk Reduction Series Effective Systems_Part 1_Flipbook

SVMIC Risk Reduction Series: Effective Systems

of discharge. Let’s take a look at the following case:

CASE STUDY

A 13-year-old adolescent female patient was seen
for a well checkup at the pediatrician’s office. Her

mother raised concern of her daughter “spacing out“ at
home and not completing sentences. Concerned, the

pediatrician ordered an EEG to rule out seizures. A week
later the mother called the office for the results and was

informed the results had not been received. A few days
later the EEG returned and findings were consistent with

non-convulsive generalized epilepsy. The pediatrician
ordered a neurology referral but did not contact the

mother. Office staff attempted to notify the mother, but
the documentation of this attempt was nondescript

and limited to “left message to call back”. As the case
unfolded, the mother stated that after not hearing from

the pediatrician’s office, she called the office again to
obtain results and was allegedly told by someone that

it was “OK”. Unfortunately, as a result of an electronic
health record (EHR) update, the neurology referral was

not sent to the referral coordinator who would have been
responsible for setting up the referral. There was no

process in place to ensure the referral was completed,
and there were no other documented attempts made by

the office to notify the mother of the abnormal results
or the referral. Nine months later, the

teenager arrested, and resuscitation was
unsuccessful. The case was settled for a

significant sum.

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