Mutual Matters

Coordination of Care: Keep Patient Info from Falling through Cracks

Posted by Bill Kanich, MD on Jun 8, 2017 1:00:00 PM

MMIC_physician_telemedicine.jpgAccurate information about a patient’s past history is vital for decision making in every physician-patient interaction. In addition, proper documentation is essential for care that may be provided in the future by yourself or other physicians. Coordination of care is as much of a patient safety challenge as making an accurate diagnosis or ordering the appropriate treatment. The path of care from the initial complaint to completion of treatment is far from seamless. Sometimes it can be full of obstacles – such as the potential to misunderstand or not see important information, including details that could pose serious risks for the patient. Many medical liability cases involve poorly coordinated care that results in harm to a patient.

In one study done by CRICO, coordination of care lawsuits were found to originate from the mismanagement of tests and referrals, all the way through to the mismanagement of handoffs.

The following case studies provide examples of the challenges faced in the coordination of care:

Case Study #1

A 68-year-old female is admitted for Systemic Inflammatory Response Syndrome (SIRS) and her blood cultures reveal Methicillin-Sensitive Staphylococcus Aureus (MSSA). A two-week course of antibiotics is recommended by the Infectious Disease (ID) physician, as no source of infection was found. On the day of discharge, an echocardiogram shows endocarditis; however, the diagnosis is not noted by the discharging physician. The nursing home physician discontinues the antibiotics after two weeks per the discharge summary. Two weeks later, the patient develops back pain and leg weakness. She eventually develops paralysis from an epidural abscess. The ID physician consults again and states that he would have given the antibiotics for six weeks if he had known of the echocardiogram results. A lawsuit ensues.

In 2009, the Journal of General Internal Medicine reviewed the charts of 668 patients and found that even though all patients had some tests pending, only 25 percent of discharge summaries mentioned those pending tests. The study’s conclusion was that discharge summaries are inadequate tools to communicate pending studies to subsequent providers.[1]

A more recent study addresses discharges to sub-acute care. In 2011, the Journal of General Internal Medicine published a study where approximately one-third of patients had tests pending at the time of transfer.[2] Only 11 percent of these pending tests were documented in the summaries. Both of these studies reflect not only a lack of coordination of care, but the dangers that arise when tests slip through the cracks at the time of discharge.

For another case study as well as our patient safety guidance on coordination of care, please click below. 

Find out more


[1] Were MC, et al. Journal of General Internal Medicine. 2009;24(9):1002-6.

[2] Walz SE, et al. Journal of General Internal Medicine. 2011;26(4):393-8.

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