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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