MPL Case: Could Closing the Loop Have Saved This Patient’s Life?

Take-Away: Confirming a colleague’s receipt and understanding of serious findings is part of patient safety. Further, closed-loop communication expresses mutual respect, which contributes to professional satisfaction.

The Case: A patient was referred to a urologist by an urgent care facility for complaints of recurrent urinary tract infections. The urologist’s plan of care included a CT of the abdomen and pelvis, as well as a cystourethroscopy. Although the CT was read by the radiologist as showing no abnormality with the urinary tract and kidneys, the patient had a thickening of the sigmoid colon with enlarged lymph nodes suspicious for malignancy. The radiologist suggested a follow-up colonoscopy. The urologist signed off on the review of the electronic report but did not recall reading the report. About seven months later, the patient returned to the urgent care facility, complaining of abdominal pain and rectal bleeding. The urgent care practitioner reviewed the EHR, read the CT report, and ordered a colonoscopy. The colonoscopy, which was completed within one week, showed stage IV colon cancer with metastasis to the liver and lung. The patient underwent a colon resection and palliative chemotherapy but died within a year of diagnosis. After this unfortunate outcome, the urologist’s office changed its process and now sends copies of reports to all referring practitioners whenever tests are performed.

Analysis: The urologist’s oversight was significant; also, the radiologist should have called the urologist with this abnormal finding suspicious of malignancy, as well as urgent care and/or the primary care physician and the patient. Just sending the report to another practitioner, without bringing a serious abnormal finding to their attention, isn’t enough.

This case example comes from a recent study analyzing 11,122 closed medical malpractice claims and suits from the loss years of 2013 through 2023.¹ Analysts began with the guiding question: Do contributing factors differ between malpractice claims with no payment and claims with indemnity payments?

This question investigates an industry-wide concern: The frequency of medical malpractice claims is down, yet their financial severity keeps going up. Previous studies by The Doctors Company, including studies on social inflation and high-indemnity verdicts, have led to this analysis of differences between no-payment claims and indemnity-paid claims.

Four subcategories of contributing factors showed statistically significant differences between their prevalence in no-payment vs. indemnity-paid claims. All were more prevalent in indemnity-paid claims: (1) patient assessment, (2) selection and management of therapy, (3) communication among providers, and (4) insufficient / lack of documentation. The third factor, communication among providers, stands out in this case.

Tips for Malpractice Risk Reduction: Connecting Patient Safety to Collegiality

For clinicians, news related to test tracking is seldom exciting—and if it is exciting, it’s seldom good. Test results that are missed, then discovered, may be followed by poor patient outcomes, accompanied by elevated liability risks. And while solid test tracking can improve patient safety and mitigate liability risks, the tracking itself is experienced by many practices as a source of chronic frustration and inefficiency.

Communicating About Serious Findings

Test tracking is ultimately a communications issue, although the human communication aspect can be obscured by administrative details and technological shifts. After all, for most of us, it’s been a while since we heard about paper records falling behind a filing cabinet. But the more things change, the more they stay the same, as the saying goes, because our constant stream of electronically delivered information has brought alert fatigue and unsafe cognitive loads—the new filing cabinets for results to fall behind.

Healthcare practices and systems that can smoothly and reliably integrate test tracking into their workflows—and into practice cultures of respectful collegial communication—increase both patients’ safety and professionals’ satisfaction, while reducing liability.

Communicate: Across a variety of specialties and settings, patient safety researchers have consistently tied safer healthcare to stronger teamwork, which rests on respectful communication. They have identified our famously fragmented healthcare system, which promotes gaps in communication and teamwork, as a source of safety risk to patients, and thus liability risk for practitioners.

Transitions in care, whether between shifts or between settings, can represent especially high-risk moments in care delivery calling for careful consideration of our communication to these team members—whether they work in another specialty or another healthcare system.

Close the Loop: Confirming receipt of serious findings requiring critical and timely action ensures that they do not fall through the cracks. In this way, we protect our patients and each other from the missed details and mistakes that humans inevitably make.

Show Respect: Part of teamwork is showing respect for colleagues. This can take many forms, and closed-loop communication is one of them. Mark David Siegel, MD, put this perfectly in a recent essay on professionalism written to his residents at the Yale School of Medicine: “We practice in teams, collaborating with other physicians, APPs, nurses, therapists, pharmacists, and social workers. We must practice closed-loop communication and respect the contributions of others. Good teammates assist overwhelmed colleagues, expecting no favors in return.”

When we live by this advice in how we communicate with colleagues—about test tracking and the many other care details passing through our hands each day—we protect not only our patients, but ourselves.

This discussion of contributing factors to increased liability risks is based on “Contributing Factors to Medical Malpractice Claims: Study Examines Difference Between No-Payment and Indemnity Claims,” published by The Doctors Company.

Daniel Kent Cassavar, MD, MBA, is Medical Director of The Doctors Company and TDC Group.

Jacqueline Ross, PhD, RN, CPAN, is Coding Director, Department of Patient Safety and Risk Management, for The Doctors Company, part of TDC Group.

¹CRICO-Candello Clinical Taxonomy Manual, V4.0, 2021. Copyrighted by and used with permission of Candello a division of The Risk Management Foundation of the Harvard Medical Institutions Incorporated, all rights reserved. As a member of the Candello community, The Doctors Company participates in its national medical malpractice data collaborative.