Page 9 - Risk Reduction Series Effective Systems Part 2

SVMIC Risk Reduction Series: Effective Systems

CASE STUDY

John Stevens, a 55-year-old male saw his PCP for a routine

physical examination complaining of urinary problems. In
the course of the examination, the PCP noted an enlarged

prostate and ordered a PSA along with other labs. The
PCP discussed the possibility of referring Mr. Stevens to

a urologist if the PSA came back elevated, but when the
patient questioned the seriousness of the concern, he was

told “not to worry, it may only be an infection”. Believing it to
be prostatitis, the PCP prescribed him antibiotics. The labs

returned with an elevated PSA of 4.8. The PCP instructed
the medical assistant to make an appointment with the

urologist and send over the labs and office note. Rather
than calling Mr. Stevens, the PCP notified Mr. Stevens of the

lab results and urology appointment via the patient portal.
There was no mention again of the importance of following

up on the elevated PSA. The patient completed the course
of antibiotics, and because he felt better, he canceled the

appointment with the urologist. He returned to the PCP
six months later for his follow-up. Neither the PCP nor the

urologist tracked the follow-up appointment,
and the patient was subsequently diagnosed

with prostate cancer. He filed a medical
malpractice lawsuit against both physicians.

This case illustrates the importance of tracking all referrals and
consultations, as well as documenting your communications

with both your patient and the specialist. As discussed earlier,
tracking failures account for a significant source of malpractice

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