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The following case abstract is from closed malpractice claims in the Harvard medical system. Some details have been changed to mask identities. For more information, refer to this case study in our "Are You Safe?" collection.

Guest Commentator

Terese Berry, MD


An eight-year old girl with a history of forearm fractures and osteopenia was referred to an endocrinologist, who made an interim diagnosis of idiopathic juvenile osteoporosis (IJO). The patient was referred to a gastroenterologist to rule out celiac disease as the underlying cause. An upper endoscopy, performed by a different physician, indicated all structures appeared normal. But five days later, the pathology report was positive for celiac disease.

Over the next three years, the child was treated by her gastroenterologist, endocrinologist, and orthopedic surgeon for idiopathic juvenile osteoporosis. When she developed abdominal pain and constipation, a new endocrinologist conducted a celiac test, which was positive. When the endocrinologist asked the gastroenterologist if a patient could become celiac positive three years after a negative test, the gastroenterologist saw the positive results from three years prior in the patient’s chart. (Neither the first endocrinologist nor the referring gastroenterologist had ever reviewed them.)

When the parents were notified, they said they had been told the initial test results were negative, but couldn’t recall by whom. With a gluten-free diet, the girl’s condition gradually improved. The family sued the original endocrinologist and the gastroenterologist, alleging negligent delay in diagnosis of celiac disease. The case was settled in the mid-range.

To help us look at the patient safety and risk management aspects of this case. We are joined now by Dr. Terese Berry. Dr. Berry is a pediatrician and physician consultant for CRICO, the group of malpractice insurance and patient safety companies owned by and serving the Harvard medical community.

Q.) Dr. Berry thank you for joining us.

A.) Thank you for having me, Tom.

Q.) Misdiagnosis is a leading cause of malpractice suits that we see, and they can be very expensive, and reflect real suffering by patients and their families. In this case, we see a problem with test result management, which is also a common contributor to these diagnostic failures. When you start to review this case, what are your first concerns?

A.) My first concerns when I first started to review this case were that the patient had multiple providers and whenever we see a patient with multiple providers, you have to worry about care coordination. So in this particular case, the young lady was being followed by her private pediatrician who sent her to an orthopedic surgeon who sent her to endocrinology and then eventually to the pediatric gastroenterologist who referred the patient to a pediatric GI proceduralist who actually performed the test. Again, communication needs to be paramount when you have a patient like this because we don’t want the patient falling through the cracks as it were.

Q.) And that can easily happen with these cases with multiple providers and the test result that goes out and maybe comes back to one person.

A.) That’s exactly correct. The other reason you want to have care coordination is because you don’t want tests or procedures duplicated and that you want to make sure that test results are shared with all providers, so again, one provider doesn’t know that the other provider had already ordered the test.

Q.) So this happens more than we’d like to see, but what are the best ways to prevent that kind of thing?

A.) In the ideal world the best case scenario would be that test results such as this one would be shared with all the providers. So this child had a procedure and upper endoscopy, a biopsy, and that biopsy result ideally should have been shared with the list of providers that I referenced earlier. Minimally, the ordering provider should have a copy of the test results, and again, ideally a significant positive test result like in this case, a phone call would be appropriate to make sure that the ordering provider actually knew the test results. Other ways that we can minimize a test result being missed would be to have the patient schedule a follow-up appointment even before they leave the office, even before they’ve had the procedure, so that we know that they are going to come back and discuss the test results, be they positive or negative, at some future time. Then the provider themselves don’t have to rely on their memory or waiting for a test result to come back. The patient themselves or the parents will come back to the provider to get those test results. A third way that I think is really coming into vogue and can be quite useful are advances in patients being able to access their medical records, their test results, depending on the care system that they’re in. Things like Open Notes or patient portals where test results are posted for the patients to see can be very useful. Even if they don’t understand what they’re seeing, that’s a trigger for them to call back to their provider and say can you explain this test result to me.

Q.) So once the test result was initially mishandled, the error seems to continue and it affects care down the line for years. In this case the malpractice suit actually names two subsequent providers. How does that happen and how do the subsequent providers try to intercept?

A.) Again, someone needs to be responsible for the patient and that goes back to care coordination, but it’s simple as that, that that one provider needs to be sure that everything is coming back. All the test that were ordered have been not only done because sometimes we’ll order a test on a patient, they don’t get it done, or that they’ve been reviewed, again either positive or negative. While we understand that demands and practices are excessive, physicians are busy that it’s really important to be proactive and to try and make some kind of system in your practice that addresses test result management. In a case like this unfortunately, this young lady was seen by multiple providers through the years. It’s not that she didn’t have any follow-up. The parents were actually quite diligent in bringing her back for all of her follow-up appointments. No one ever went back and looked back at any of the test results from the other provider. That was, that was the basis of the, of the claim against the providers and then the subsequent settlement.

Q.) Because the court, the law, isn’t going to just hold that initial provider accountable who didn’t act on that test result. The law is going to hold subsequent providers accountable in some way.

A.) In this particular case they were, they were the providers that specifically asked for and talked about having the test. So the endocrinologist who, who referred the child to the gastroenterologist and the gastroenterologist who scheduled the actual procedure that neither one of those providers ever followed up on the test results.

Q.) So do all of these various physicians automatically know who’s doing what?

A.) No, and again, that’s really important too. And the other important piece would be how much you’re communicating with the providers who are referring patients to you, in this case out in the community. So it’s incumbent upon them to again go back and say, ‘didn’t you tell me that Dr. So and So ordered this test for you, whatever happened to that? And if you don’t know, let me find out because that’s an important piece of information that we need to have.”

Q.) Thank you. Dr. Terese Berry. Dr. Berry is a pediatrician and consultant with CRICO, the group of malpractice insurance and patient safety companies owned by and serving the Harvard medical community. I’m Tom Augello.

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About the series

Even in the safest healthcare setting, things can go wrong. For more than 40 years, CRICO has analyzed MPL cases from the Harvard medical community. Join our experts as they unpack what occurred and the lessons learned for safer patient care from the causes of these errors.


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