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Testing, results, and follow-ups are areas of common problems Contact Now

Hospital communication failures lead to unnecessary medical mistakes

Testing, results, and follow-ups are areas of common problems

“What we’ve got here is failure to communicate,” explained the Captain in Cool Hand Luke. This has to be one of the best known lines from a movie ever.

It also perfectly describes one of the most common causes of hospital medical malpractice, also a failure to communicate.

Hospitals are busy places. Doctors make orders for one patient and then immediately move on to see the next patient on their list. They frequently don’t follow up to make sure the tests are performed and that results don’t fall through the cracks.

Just today, I’ve been working on a medical malpractice case where an absurd number of surgeons, doctors, residents, physician assistants, and registered nurses behaved as if they were playing a game of hot potato as a trauma patient deteriorated into paralysis in front of their very eyes.

Doctors ordered routine MRI scans, rather than designating them as stat or as soon as possible, and then seemingly forgot about them. Five hours later, when the radiology department called a physician assistant with emergency results, it only triggered a routine order for spine surgery consult. Again, no urgency.

This case is not unique, though. A few weeks ago, I deposed two hospitalists who were in charge of overseeing medical care for our client, a patient who came to a Houston area hospital with severe abdominal pain. The patient had really wrapped up the case for the doctors on a silver platter. When she came into the emergency room, she told everyone that she’d had a similar bout of abdominal pain a few months earlier that was diagnosed with volvulus, or twisting of the bowel. It took an emergency surgery to decompress her and relieve the pain.

After an initial CT scan was inconclusive, hospitalists and nursing staff watched day by day as the patient got worse, yet they continued to give the same field treatment. Finally, a hospitalist realized that something was wrong and ordered a stat repeat CT scan of the patient’s abdomen. Unfortunately, the order was entered 15 minutes before the hospitalist ended her shift.

While the hospitalist was at home that night, the radiologist entered a report showing that the patient had an emergency small bowel obstruction and volvulus. The radiologist didn’t call anyone with the results. The nursing staff and the hospitalist didn’t check on the results either. It was not until the next morning that the hospitalist learned what was wrong.

In yet another case, a trauma patient arrived by ambulance at a Texas hospital emergency room after a high-speed motor vehicle collision. He was admitted to the intensive care unit, where overnight, a registered nurse repeatedly noted acute (new) neurological changes on his neuro checks. It started with a loss of sensation in his legs and feet and then the neurological deficits progressed upward.

According to the medical records, the nurse did not notify any doctor or physician assistant of these very concerning problems that required emergency evaluation and care from a surgeon.

The next morning, though, matters became worse. When the dayshift nurse arrived and assessed the patient, she noted that he was starting to have some problems with sensation and gripping things with his hands. A resident physician, still in her training as a young surgeon, ordered routine radiology studies of the patient’s spine, even though this was a medical emergency.

Five hours passed before the scans were performed and no one followed up. After the results showed a neck and cervical spine injury, the surgical resident and in attending general surgeon ordered a routine consultation with a spine surgeon. A few hours later, a physician assistant in the spine surgeon showed up to assess the patient. Their progress note ended with a vague note that the spine surgeon would come up with a surgical plan.

The only problem was, there was no plan. And, of course no one followed up. Not the general surgeon and resident who ordered the consultation. Not the nursing staff. No one. Even though the patient’s neurological problems were well-known by 8:30 in the morning, it took a full 24 hours to get him to surgery because of the lack of communication in any sense of urgency.

Medical experts realize that poor flow of information can lead to devastating injuries and medical malpractice, including:

• Delay in surgery because of a lack of or delay in communication of abnormal test results. This includes lab work and diagnostic radiology studies, including MRI and CT scans.

• Failure of nurses to promptly communicate a change in the patient’s baseline to a doctor. This prevents physicians from being able to make proper informed medical decisions for the patient.

• Poor communication between shifts. The accrediting organization The Joint Commission requires hospitals to train their nursing staff on making hand-off communications to avoid this error. When doctors and nurses don’t transfer important clinical information to incoming personnel, it can lead to a delay in diagnosis and treatment.

If you’ve been seriously injured because of poor medical, nursing, or hospital care in Texas, then contact an experienced, top-rated rated Houston, Texas medical malpractice lawyer for help in evaluating your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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