by Laura Hale Brockway, ELS, Vice President, Marketing, and
Susie Edwards, Senior Risk Management Representative
A 30-year-old woman came to Ob-gyn A for prenatal care of her first pregnancy. Following a normal prenatal course, the patient went into labor at 39 weeks. Ob-gyn A admitted the patient, but later performed a cesarean delivery because of the patient’s elevated blood pressure. A boy was delivered, and the patient was kept in the hospital for several days to control her blood pressure.
On June 19, three days after being discharged from the hospital, the patient called Ob-gyn B reporting a headache, high blood pressure, and a temperature of 104 degrees that had decreased to 101 degrees. Ob-gyn B had assisted in the patient’s cesarean delivery and was on call for the OB group. She told the patient to go to the emergency department (ED).
At the ED, Emergency Medicine (EM) Physician A called Ob-gyn B before seeing the patient and suggested that the patient had preeclampsia. But Ob-gyn B thought it was sepsis because of the patient’s fever and suggested a sepsis work-up.
EM Physician A said it would take five hours to complete the work up and he would get back to Ob-gyn B with the results. Ob-gyn B did not go to the ED, but told EM Physician A that the patient could be admitted under her care if necessary.
EM Physician A ordered a sepsis work up and a head CT. He also learned that the patient had not filled or taken her blood pressure medications as instructed when she was discharged from the hospital after delivery. The patient’s blood pressure was 171/98 mm Hg when she arrived at the ED.
The results of the head CT were negative for hemorrhage or edema, and the results of the CBC showed that the patient had a significantly low platelet count of 51,000. This result was noted in the medical record. The patient’s urine was visibly bloody and had a 3+ urine protein. EM Physician A did not call Ob-gyn B after receiving the lab results.
EM Physician A treated the patient with oral pain medication and her symptoms improved. Her blood pressure returned to within normal limits. The patient was discharged with a prescription for nifedipine and informed of a nearby 24-hour pharmacy so she could fill the prescription on the way home. EM Physician A’s final diagnosis was “mild hypertension, cephalgia, and infection of urinary tract.” The patient did not fill the prescription for nifedipine.
At home that evening, the patient was vomiting and unable to sleep. She was found unresponsive by her husband the next morning (June 20).
EMS transported her to the hospital. Her blood pressure was 188/90 mm Hg and a CT scan showed a large, new, and patchy intracerebral hemorrhage. Differential diagnoses included thrombotic thrombocytopenic purpura and HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome.
A CT scan taken the next day showed worsening hemorrhage, brain edema, and mass effect with midline shift. She was declared brain-dead on June 22 and died at 4:20 a.m.
A lawsuit was filed against EM Physician A, Ob-gyn B, and the hospital. The suit alleged that based on the patient’s symptoms and lab results, she should have been diagnosed with postpartum preeclampsia and admitted to the hospital for monitoring and treatment. Failure to do so led to the patient’s worsening condition and death.
Physicians who reviewed this case both for the defense and the plaintiffs were critical that the patient was not admitted to the hospital when she came to the ED. Given her low platelet count, high blood pressure upon presentation to the ED, and noncompliance with taking nifedipine, consultants felt the failure to admit the patient fell below the standard of care.
This case was complicated by a discrepancy between Ob-gyn B and EM Physician A regarding the patient’s care in the ED. According to Ob-gyn B, she was waiting for EM Physician A to call her with lab results before going to the hospital to evaluate the patient. She did not receive a phone call, was not aware of the patient’s lab results, and was not given the opportunity to admit the patient.
EM Physician A testified that Ob-gyn B told him he could discharge the patient if the sepsis work up was negative, which is what he did. Ob-gyn B disputed this.
After their phone call, EM Physician A ordered labs, a chest X-ray, and a CT scan of the head. He received the results of the CBC and urinalysis at 6:25 p.m. and 7:50 p.m. There were no calls documented or phone calls placed to Ob-gyn B after the labs, urinalysis, or imaging results were received. Likewise, Ob-gyn B did not follow up with EM Physician A.
Ob-Gyn B testified that if she had known about the patient’s abnormally low platelet count, she would have gone to the ED and assessed the patient.
Causation was also a factor in this case. A CT scan of the patient’s brain in the ED on June 19 was read as normal. If the patient had been admitted on June 19, the hemorrhage would likely still have occurred. Defense experts testified that admission, monitoring, and treatment with medications such as magnesium or calcium-channel blockers would likely not have prevented the patient’s intracerebral hemorrhage and death.
Noncompliance further complicated this case, as the patient failed to take her blood pressure medication after discharge from the hospital (after delivery) and discharge from the ED.
This case was settled on behalf of EM Physician A and Ob-gyn B.
Risk management considerations
In a recent study, the Joint Commission reported communication failures as the root of more than 70 percent of sentinel events. (1) Potential for patient harm whether minor or severe is introduced when a provider receives information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed. Expectations can be misaligned between the sender of the information and the receiver. (2)
In this case, EM Physician A did not follow up with Ob-gyn B regarding the outcome of the labs after the 5 hours of lab work-up. The patient’s blood work revealed low platelets indicating preeclampsia; had Ob-gyn B known these test results, she may have admitted the patient for continued care and treatment. Instead, Ob-gyn B stated she was waiting for EM Physician A to call her with the results of the labs. This call was never made according to the call history, nor did Ob-gyn B call the hospital to follow up on the patient and lab results.
When Ob-gyn B initially discussed the patient with EM Physician A on the phone, she failed to document this conversation. A phone note should have been entered in the patient’s chart detailing the discussion, as the call contained valuable information that affected the patient’s care. A record of this conversation may also have helped Ob-gyn B’s defense.
Another missed opportunity for documentation occurred when EM Physician A failed to document a differential diagnosis of postpartum preeclampsia along with sepsis since the symptoms were similar. However, sepsis was the noted diagnosis and work up included labs, head CT, and chest X-ray.
- Dingley C; Daugherty K; Derieg MK; et. al. Improving patient safety through provider communication strategy enhancements. Advances in Patient Safety: New Directions and Alternative Approaches, Volume 3: Performance and Tools. August 2008. Available at https://www.ncbi.nlm.nih.gov/books/NBK43663/. Accessed August 8, 2023.
- The Joint Commission. Sentinel Event Alert 58: Inadequate hand-off communication. September 12, 2017. Available at https://www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-58-inadequate-hand-off-communication/. Accessed August 8, 2023.