Multiple missteps in the referral process preceded patient’s death from cardiac failure

DiagnosTic Follow Up: Case Example

An 51-year-old female with a history of attention deficit disorder and hyperlipidemia had been treated by her primary care physician for 14 years. Her high cholesterol was treated with medications and she was otherwise asymptomatic. Due to a family history of cardiac disease, the patient requested a cardiology referral for evaluation. Her PCP ordered the referral and a stress test. The office reports sending the referral information to the patient, however, the patient did not receive it.

After the patient called the practice multiple times, a referral was scheduled (three months after initial request). On the day she was to have her cardiology appointment, the patient died.

Her death was attributed to significant coronary artery disease, with hyperlipidemia noted.

(Case settled: $150K)

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Excerpted from 2014 Annual Benchmarking Report, Malpractice in the Diagnostic Process.
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