Errors are inevitable, which is why good systems have redundancies. But when the “double-check” gets overlooked, all that effort can come to naught.
A woman in her mid-40s with a history of tubal ligation visited Dr. OB with lower left abdominal pain after having visited the emergency room 10 days earlier. An ultrasound by Dr. OB revealed an empty uterus with some fluid around the ovary. As it turned out, Dr. OB’s office had erroneously placed a report for a positive serum pregnancy test in the woman’s chart, causing Dr. OB to assess a probable ectopic pregnancy.
Dr. OB and the woman discussed options and agreed to proceed with surgery that day. The patient went to the hospital emergency department to get prepared for the exploratory surgery and consented to an “operative laparoscopy for ectopic pregnancy with possible partial salpingectomy.” In his note early that afternoon, the ED physician documented the patient’s constant abdominal pain. Immediately following his reference to the woman’s visit to her obstetrician, he noted: “Risk factors consist of pregnancy.”
From a blood sample collected at the hospital later that afternoon, however, the patient tested negative for pregnancy. Dr. OB did not learn of the negative test result prior to his surgery that evening.
At surgery, Dr. OB found no ectopic pregnancy but he did remove an ovarian cyst and performed an endometrial curettage in an effort to remove possible products of conception that might account for the original positive pregnancy test. Following surgery, Dr. OB realized that the positive pregnancy test was from another patient and he explained the error to the patient.
Though there were no complications from the surgery, the patient hired an attorney to initiate a claim that Dr. OB performed an unnecessary surgery and committed a battery by exceeding her consent. The legal dispute was resolved informally.
The electronic medical record lists Dr. OB as having ordered the pregnancy test at the hospital, but regardless of who ordered the test, someone thought it was a good idea but then failed to follow up.
For physicians, it is not enough to be respected for your knowledge: You also want to be known as the one who always dots your i’s and crosses your t’s.
Modesto Physician’s Privileges Reinstated – In 2014, we wrote about a California Supreme Court decision that strengthens the right of physicians to sue under a “whistleblower” statute written to help protect patient safety at health facilities. [Fahlen v. Sutter Central Valley Hospitals, “Case of the Month”, March 2014.] The Modesto nephrologist in that case who sued after losing his hospital privileges has now regained his staff position.
According to the Modesto Bee, the Memorial Medical Center in Modesto said that the parties mutually agreed to settle the matter: “Dr. Mark Fahlen was reinstated to the Memorial Medical Center medical staff, and we are pleased this is now behind us.” In the Bee article, Dr. Fahlen said he is glad the dispute is over so “we can all move on in a spirit of providing the best care possible.”
Gordon Ownby is CAP’s General Counsel. Comments on Case of the Month may be directed to gownby@CAPphysicians.com.