Claims Case Study: Communication Breakdown in Management of Post-Op Care 

Post-operative follow-up care isn’t always routine. When patients present with abnormal symptoms during recovery, it’s critical that physicians prioritize their complaints and fully investigate the issue as quickly as possible. If further testing is needed, urgency is typically a factor, and must be noted on requests to expedite approvals while the physician and staff continue to maintain contact with the patient throughout the process. 

In this post, we review how an OB-GYN’s failure to prioritize and escalate a patient complaint, properly document patient conversations, mark the urgency of testing requests, and follow up with the patient resulted in additional surgery, prolonged hospitalization and recovery, and emotional damage. 

 The Case: 

 A 44-year-old patient underwent a seemingly successful laparoscopic tubal ligation by Curi’s insured OB-GYN provider and was discharged home for recovery. Three days following the surgery, she contacted the office with complaints of vomiting, difficulty passing gas, and abdominal pain, and the physician recommended ibuprofen and Zofran. The following day, the patient called again to tell the staff that her symptoms had not resolved, and she was given the same recommendation of ibuprofen and Zofran. 

On post-operative day six, a Thursday prior to a holiday weekend, the patient again contacted the practice and reported the same symptoms, along with bloating and new onset right-side pain. At the request of the physician, the patient came to the office and exhibited a distended abdomen that was moderately tender to palpation. The physician felt her presentation was out of proportion to what would be expected and ordered a CT scan of the abdomen and pelvis and informed the patient to have the testing completed the following morning at a local radiology office, or go to the emergency room if that was not possible.  

The radiology office staff received the order for the CT scan but did not attempt to obtain insurance approval for the study on an urgent basis, particularly over a holiday weekend, as there was no indication of urgency on the order. Testing was not completed at this time, and the ordering physician did not follow up with the radiological practice or the patient. 

Five days after the in-office appointment and 11 days after her tubal ligation, the patient contacted the practice with worsening complaints of pain, stating that she had not received authorization for the CT scan.  

While waiting for approval for the CT scan, the patient presented to her local emergency department, where she was admitted and diagnosed with peritonitis due to a bowel perforation. The patient underwent multiple surgical procedures, including an ileostomy and multiple bowel wash-outs, and had a lengthy hospital stay. Her ileostomy was reversed approximately one year after the original tubal ligation, but she continued to have abdominal pain, digestive/bowel issues, and anxiety/depression related to her prolonged hospitalization and recovery. 

What Went Wrong? 

Early on, it was clear that this case would be difficult to defend. The plaintiff experts alleged that the insured physician and the office staff were negligent in failing to have the patient return to the office when she initially complained of nausea and vomiting on post-operative day three, and that she had been brought back to the office, the bowel injury would have been diagnosed earlier and appropriate treatment would have been started.  

Defense of this case was further complicated by the fact that when the patient presented to the office on post-operative day six with continued complaints of pain, nausea, and vomiting, the CT scan was not ordered as “urgent.” Furthermore, there was no documentation in the record as to the physician’s instructions that the patient should go to the ED to complete study if she could not get an appointment at the radiology office. Finally, there was confusion between the provider and the office staff about the urgency of the CT when the office staff was contacting the insurance company for authorization. When the patient contacted the office again, four days after the order for the CT scan was made, the office still had not received authorization nor followed up on the request.  

The case was settled outside of court. 

Key Takeaways: 

To avoid the devastating consequences of potentially delayed treatment, Curi reccomends the following:  

• When outpatient testing is ordered for any reason other than routine, physicians should make sure there the urgency is clearly communicated 
• Physicians should follow up with patients after providing orders for additional outpatient testing 
• If patient presents to the office, all staff should maintain documentation of verbal recommendations  
• Practices should have procedures in place for how to deal with closures and reduced staff during holidays 

For further guidance on similar issues, Curi members are encouraged to reach out to our risk management experts at Curi Advisory by calling 800.662.7917.