Page 18 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

Likewise, there should also be a mechanism in place to track patients

discharged from the hospital. A patient who requires follow-up after
hospitalization has a risk of being lost by virtue of the fact that he/she is

not within the office confines at the time of discharge. Let’s take a look at
the following case.

C A S E S T U D Y

Allison Carney, 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, Allison
arrested, and resuscitation was unsuccessful and a medical

malpractice lawsuit was filed.

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