Page 23 - APP Collaboration - Assessing the Risk (Part Two)
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SVMIC Advanced Practice Provider Collaboration: Assessing the Risk
C A S E S T U DY
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 EHR systems 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.
This tragic outcome may have been prevented by employing
highly reliable and consistently followed tracking procedures.
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