failure to inform patient of procedure failed to report infections

by Dr. Alisha Hudson 9 min read

Frequency of Failure to Inform Patients of Clinically

6 hours ago  · First Example: Failure to Notify Patient of Mass Found on Chest X-Ray. Take, for instance, the following hypothetical ( based on an actual case): A patient with chest pain visits … >> Go To The Portal


Is failure to contact a patient about abnormal test results medical malpractice?

Appreciate that failing to contact a patient about abnormal test results is a source of successful malpractice claims. Learn the legal standard that is applied to a failure to contact a patient about test results that require follow-up action. Describe some steps that might reduce the harm from failure to act on abnormal test results.

What happens if a doctor fails to communicate test results?

Research indicates that doctors can fail to communicate test results to their patients over 7% of the time. This may not seem like a common problem, but such failures can result in serious injury or complications, even if the test results do not indicate that anything is wrong.

Why would a doctor fail to disclose test results?

A doctor might fail to disclose test results for several reasons. For one, they may simply forget to tell the patient about the test results. More often, test results can be lost or confused along the chain of communication in a hospital .

Can a hospital be held liable for negligent failure to communicate results?

Depending on the case, it may also be possible to hold the hospital itself, responsible for patient harm due to negligent failure to communicate the results of medical testing.

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What are the consequences of failure to report in healthcare?

Failure to report errors may subject clinicians to disciplinary action and increased risk for legal liability. Beneficence and nonmaleficence are ethical concepts that are violated when an error is not reported. Practitioners often fear they will gain a reputation for committing mistakes and may not self-report.

What happens if informed consent is violated?

If a doctor fails to obtain informed consent for non-emergency treatment, he or she may be charged with a civil offense like gross negligence and/or a criminal offense such as battery or gross negligence which is the unauthorized touching of the plaintiff's person.

What can be the result of failure to obtain informed consent?

When a doctor or another medical professional fails to disclose the risks of treatment, they take away a patient's right to make an informed decision. If you or someone close to you suffered harm because of a failure to obtain informed consent, you may be able to file a claim against the at-fault party.

What is an example of lack of informed consent?

What is an Example of Lack of Informed Consent? The most common examples of a lack of informed consent includes a physician not letting a patient know the known risks associated with the procedure.

Is lack of informed consent negligence?

In both medical and legal terminology, this is called "informed consent." If a doctor does not get informed consent from a patient, and the patient is injured, the patient may have grounds to sue the doctor for medical malpractice.

What legal action can be taken if you fail to obtain consent?

Failure to obtain consent properly can lead to problems including legal or disciplinary action against you, or rarely criminal prosecution for battery (contact with an individual without consent.)

What is meant by lack of the informed consent?

A lack of informed consent refers to a physician or hospital neglecting to provide a patient appropriate information about the risks, benefits and alternatives to a surgery or treatment with medication in a non-emergency setting.

Why is informed consent important?

Informed consent creates trust between doctor and patient by ensuring good understanding. It also reduces the risk for both patient and doctor. With excellent communication about risks and options, patients can make choices which are best for them and physicians face less risk of legal action.

When do you not use informed consent?

Several exceptions to the requirement for informed consent include (1) the patient is incapacitated, (2) life-threatening emergencies with inadequate time to obtain consent, and (3) voluntary waived consent.

What is the importance of informed consent where as medical negligence is concerned?

In most situations the doctor cannot act without a patient's "informed consent." In order for patients' consent to be "informed" and thus valid, they must be able to make a well-informed logical decision. If they agree to the treatment, understanding what it involves, they have given informed consent.

What are the 4 principles of informed consent?

There are 4 components of informed consent including decision capacity, documentation of consent, disclosure, and competency.

What happens if you don't get informed consent in research?

Informed consent is a crucial part of enrolling in a clinical trial because it gives the potential participant all the information they need to understand what they are volunteering for. Without informed consent the subjects may not fully understand what they are participating in.

What happens if you are not educated about your treatment?

If this negligence caused you to suffer financial damages, you could be entitled to recover compensation for these damages through a medical malpractice claim. To learn more, contact our team at Baizer Kolar, P.C. today to set up your initial consultation in our Chicago office.

Is failure to disclose medical information a malpractice?

Failure to disclose any relevant information about a medical procedure is an act of medical malpractice because it robs the patient of the ability to provide his or her informed consent to the procedure. Patients have the right to know what is being done to their bodies and why. They also have the right to decide not to undergo a specific medical treatment, which is a determination frequently made after weighing the risks and benefits of the procedure.

Why did the nurse not notify the ICU practitioner?

The nurse noted the results in the health record, but did not notify the ICU practitioner because he assumed the practitioner was returning to the unit to reassess the patient. The patient’s blood pressure two hours after the second unit of plasma was reported as 63/21 mmHG. The nurse notified the on-call resident of the blood pressure and ...

How long after stat order was blood available?

The blood bank records indicated that the blood was available 20 minutes after the stat order was received. One hour later, the ICU nurse had not received the blood and noticed the oncoming shift had arrived. He gave the oncoming nurse report regarding the patient and even though both nurses were concerned that the blood had not arrived ...

Why do people report incidents?

While these are convincing reasons to report incidents, they may not be persuasive enough. For an individual to report an incident, the most important factor is safety—not the patient's, but his or her own. The people must feel safe from undeserved disciplinary action or retaliation. A study of hospital nursing units found that higher reporting rates were correlated with unit members' perception of the risk of discussing mistakes openly. ( 17) Where there was a climate of fear, willingness to report mistakes was reduced. Other factors that are known to influence reporting ( 18) are: 1 uselessness (perceived attitudes that management would take no notice and was not likely to do anything about the problem); 2 acceptance of risk (incidents are part of the job and cannot be prevented); and 3 practical reasons (too time consuming or difficult to submit a report).

What are the factors that influence reporting?

Other factors that are known to influence reporting ( 18) are: uselessness (perceived attitudes that management would take no notice and was not likely to do anything about the problem); acceptance of risk (incidents are part of the job and cannot be prevented); and.

What happened to the child who received antibiotics?

First, the child received an overdose of antibiotics. By not acknowledging the mistake, the health care team made no attempt to inform the parent of what happened so that potential effects could be mitigated. Second, and just as important, a learning opportunity was lost.

What is the name of the antibiotic that is given to a 9-month-old infant?

The emergency department (ED) physician ordered Rocephin (the brand name for the antibiotic ceftriaxone), 450 mg intramuscularly (IM), for empiric treatment of a urinary tract infection (UTI) to be given immediately.

What to do if a patient cannot be reached?

Health care organizations can do the same. If the patient cannot be reached by the available contact information, try other means including online sources as warranted by the clinical importance of contacting the patient. Assess how reliably individual patients are likely to be contacted and customize your approach.

Why should medical records be documented?

Whatever is done should be documented in the medical record for the usual reasons: to communicate to others what has been done and to provide written or electronic documentation in case the failure to contact becomes the subject of a lawsuit.

Did the ultrasound technician notice the abnormal test result?

The ultrasound technician did not notice the abnormal test result or the fact that the chlamydia infection had not been treated. The following day, a different OB/GYN clinic nurse tried to call the patient with the ultrasound results, and again no one answered the phone.

Who dictates a report for a radiologist?

However, the radiologist or cardiologist dictates a formal report and sends it to the doctor who ordered the test. That doctor is responsible for following up the results, and if there is additional treatment or a further study required, the doctor who ordered the test is responsible for informing you.

Who noticed the X-ray report?

When the plaintiff then returned to pick up a copy of his X-ray at the office of the cardiologist, the cardiologist noticed the report for the first time, and he told the plaintiff then — for the first time — to get a CT scan.

What is a hypothetical case?

Take, for instance, the following hypothetical ( based on an actual case): A patient with chest pain visits her doctor, a cardiologist, who orders a routine chest x-ray before a planned cardiac catheterization. Unfortunately, due to the “routine” nature of the chest x-ray the cardiologist does not follow-up to review the x-ray images or radiology report, which revealed that the plaintiff had a sizeable mass in one of his lungs.

What is the purpose of a follow up CT scan?

The radiologist who interpreted the x-ray recommended that the plaintiff undergo a follow-up CT scan to obtain further information about the mass — specifically to determine whether it was cancerous. However, the report was simply filed away and the patient was never notified of the results.

Do you have to follow up on a diagnostic test?

If you have tests done in the ER or in your clinic, it’s important to be certain you always follow up on the test results. If you or a loved one has not received the critical results of a diagnostic test until long after the test was done, and you have a medical condition that has deteriorated as a result, you probably have some recourse under ...

Reporting Medical Test Results for Patients

According to medical research studies, patient test results are often reported improperly or not at all to physicians and medical professionals responsible for a patient’s care. When this occurs, a patient may suffer injuries or medical complications from an illness or disease.

Causes of Medical Errors and Improper Test Reports

Although medical testing is usually ordered by a patient’s attending physician, the actual test is typically administered by a medical technician in a laboratory, clinic, or hospital. When image tests are ordered, a trained radiologist or pathologist normally performs the test.

Filing Malpractice Claims and Lawsuits

Patients who suffer injuries caused by medical procedures and treatments can file a medical malpractice lawsuit based on medical negligence. While some diagnostic and testing errors may be seen as reasonable, patients can suffer harm that stems from inadequate communication as the result of negligence on the part of medical providers.

What happens if a doctor fails to disclose results of a medical exam?

If your doctor has failed to disclose the results of your medical exam, you may be entitled to legal relief. You should contact a personal injury lawyer as soon as possible while the events are still fresh in your recollection. An attorney can help specify your course of action if you have been injured as a result of your doctor’s errors.

Why do doctors not disclose test results?

A doctor might fail to disclose test results for several reasons. For one, they may simply forget to tell the patient about the test results. More often, test results can be lost or confused along the chain of communication in a hospital . Test results are often relayed between several different people, such as from a nurse to ...

Why is it important to keep medical records?

These records and receipts may be useful in reminding yourself and others what tests have been performed on you and what test results you are currently entitled to receiving.

Do you have to know the results of a medical exam?

As the patient, you are entitled to know the results of your medical exams. All medical professionals are held to a high standard of medical care, and that standard of care includes informing the patient of the outcome of any medical test or examination, such as a colonoscopy or a mammogram, that is performed on them. Your doctor should also inform you of the purpose of the medical exam, and also of any dangers or side effects that might result from the exam.

Can you file a medical malpractice lawsuit?

Additionally , you may be able to file a medical malpractice lawsuit if your injury is particularly serious. You will have to prove in court that you received actual injuries as a result of the doctor’s failure to communicate test results. Also, you will need to prove that the failure to communicate test results is directly traceable to your doctor.

How many physicians do not notify patients of abnormal test results?

The same study also reported that one-third of physicians do not always notify patients of abnormal test results.

What percentage of medical malpractice cases are communication problems?

Research indicates that communication problems are a factor in up to 80 percent of medical malpractice cases. One study concluded that physicians did not acknowledge 36 percent of abnormal radiologic results. Another study found that 17-32 percent of physicians reported having no reliable method for ensuring that test results are received. ...

Why is misdiagnosis important?

Among the leading causes of medical misdiagnosis is a failure to communicate diagnostic test results. Communication of a diagnosis is arguably as important as the diagnosis itself. Patients deserve to know the results of the medical tests they receive in a timely manner. Test results should also be communicated from the lab or testing facility to the medical providers responsible for the patient’s treatment.

What happens if you report cancer test results too late?

For instance, if test results that reveal cancer are communicated too late and the patient has to then undergo intensive treatment because of the advanced stage of illness, the patient may be able to show that unnecessary harm was caused by the negligent delay in reporting the test results.

What is medical testing?

Medical testing can also be categorized as laboratory tests and imaging tests. The former includes testing of blood and other body fluids as well as tissue samples, while the latter includes tests such as X-ray, MRI, CT, and EKG.

What are the causes of communication problems?

Three scenarios, however, were identified as the leading causes of communication problems: Failure to notify the patient of the test result. Telling the patient an incorrect test result. Failure to notify the referring clinician.

Can a patient be sued for a failed communication?

Harm, however, must be suffered, as a patient who suffers no injury after a failed communication will probably have no basis for a lawsuit. Note, however, that harm can include the progression of an injury or condition.

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Risk Management Comments

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During the deposition of the admitting ICU practitioner, he testified that he was not informed of the second laboratory results or the patient’s vital signs until the patient went into respiratory distress. It is the defense expert’s opinion that by the time the patient was seen by our nurse she had already suffered significant bleedi…
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Resolution

  • At the onset of the claim, the estimate on the chance to prevail was 60 percent, however, throughout the investigation of the claim and while working with the other defendants there was significant finger pointing causing our nurse to suffer a greater apportionment and less of a chance to prevail at trail. Our estimate of the insured apportionment was 20 percent with a 40 p…
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Risk Management Recommendations

  1. Maintain competencies (including experience, training, and skills) consistent with the needs of assigned patients and/or patient care units.
  2. Maintain thorough, accurate and timely patient assessment and monitoring, which are core nursing functions.
  3. Timely implement practitioner orders.
  1. Maintain competencies (including experience, training, and skills) consistent with the needs of assigned patients and/or patient care units.
  2. Maintain thorough, accurate and timely patient assessment and monitoring, which are core nursing functions.
  3. Timely implement practitioner orders.
  4. Communicate in a timely and accurate manner both initial and ongoing findings regarding the patient’s status and response to treatment.

Guide to Sample Risk Management Plan

  • Risk management is an integral part of a healthcare professional’s standard business practice. Risk management activities include identifying and evaluating risks, followed by implementing the most advantageous methods of reducing or eliminating these risks. A good risk management plan will help you perform these steps quickly and easily. See the Risk Management Plan create…
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Case Objectives

  1. List common causes of medical errors.
  2. Appreciate the magnitude of underreporting of adverse events.
  3. List the common barriers to reporting adverse events and near misses.
  4. Discuss steps that individuals and institutions can take to increase reporting.
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Case & Commentary: Part 1

  • A well-appearing 9-month-old infant weighing 8 kg presented with urinary frequency and white cells in her urine. The emergency department (ED) physician ordered Rocephin (the brand name for the antibiotic ceftriaxone), 450 mg intramuscularly (IM), for empiric treatment of a urinary tract infection (UTI) to be given immediately. Several hours later,...
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Case & Commentary: Part 2

  • The nurse who had given this medication was very upset and spoke with the ED physician on duty about the event, as 450 mg of IM cefazolin is an overdose for an 8-kg baby. The nurse was informed that the medications were essentially equivalent and did not pursue the matter further or report the error to her supervisor or through the institution's incident reporting system. When th…
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References

  • 1. Committee on Identifying and Preventing Medication Errors, Institute of Medicine; Aspden P, Wolcott JA, Bootman JL, Cronenwett LR, eds. Preventing Medication Errors. Washington, DC: National Academy Press; 2007. 2. Weber RJ, ed. The Handbook on Storing and Securing Medications. Oakbrook Terrace, IL: Joint Commission Resources and the American Society of H…
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