On 7/16/2014, a patient saw an endocrinologist after being referred by her gynecologist for concerns about “not feeling well” and for questions about whether her hypothyroidism needed additional evaluation and management.
The patient described how the endocrinologist told her to throw out her other medications prescribed by her trusted long-term gynecologist, go on an antidepressant, and see a therapist. This advice was upsetting to the patient.
At the close of the visit, the patient went to the laboratory and gave a blood sample for testing. When the patient did not hear of the test results from the clinic after about 10 days, she contacted the clinic and was told that the results could not be found.
In a response to the complaint by the patient that she did not receive timely test results from the endocrinologist, the endocrinologist stated, through her lawyer, that the results were available through a patient electronic record portal called eCare. However, the patient had not enrolled in eCare and thus did not have access to the test results. The endocrinologist stated she planned to disclose and review the test results with the patient at a return visit in 3 months. The patient eventually established care with another endocrinologist.
The endocrinologist’s treatment of the patient fell below the standard of care when the endocrinologist failed to timely communicate the test results which showed the patient’s Hemoglobin A1C was at 6.1%. This test result is within a range that can be characterized as “prediabetes,” signifying that a patient may develop a diagnosis of diabetes within 10 years. A diagnosis of diabetes requires a test result of 6.5% or higher.
The Commission stipulated the endocrinologist reimburse costs to the Commission, complete a course on how to maintain and improve communication between physician and patient, and write and submit a paper of at least 1000 words, with annotated bibliography, on the importance of timely communication of laboratory results to patients and others with a need to know.
Date: October 2016
Medical Error: Failure of communication with patient or patient relations
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
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