CLAIMS CASE STUDY: Failure to Follow Up on Concerning Lab Results 

A 69-year-old male patient visited an internal medicine provider in October 2016. He had previously been a patient of this physician and was seen for routine physicals from 2000-2009, but due to insurance coverage, he was under the care of another provider from 2009-2014. During his physical examination in 2016, a rectal exam revealed an enlarged, non-tender prostate without nodules, and the patient was prescribed Flomax. A urinalysis and PSA test were conducted, andris PSA was elevated at 9.11. He was diagnosed with benign prostatic hyperplasia (BPH). Previous tests of his PSA from 2000-2009 had been normal, and the patient was advised to return in four to six months to repeat the test, but he did not return. 

More than one year later, in November 2017, the patient returned to the physician’s office with complaints of sinus congestion, and our insured physician followed up on the elevated PSA results, explaining that they could be a result of prostate enlargement, infection, or cancer. The repeat PSA result of 8.49 was consistent with BPH, and the patient was instructed to return for a physical examination before the end of the year to re-check. He did not schedule a return visit.  

January 2018, the patient returned for a pre-op visit secondary to a right total knee replacement. The insured physician used this opportunity to re-check PSA levels, and bloodwork revealed further elevation to 10.86. The physician prescribed antibiotic for suspected prostatitis with instructions to return in four weeks. In February, the patient began treatment with Levaquin and received instructions to schedule a follow-up in mid-March, but he did not return. 

In early May, the patient returned with complaints of groin pain, secondary to physical therapy from his knee replacement. The insured noted an enlarge prostate with no nodules and a PSA test came back at 14.52. The patient was referred to urology, where eventual biopsy revealed Gleason 9 prostate cancer with metastasis to the bone, which was treated with a prostatectomy and subsequent chemotherapy and radiation.  

What Went Wrong 

Attorneys representing the patient alleged that the physician failed to follow up on his elevated PSA levels, leading to a delayed diagnosis and decreased life expectancy. Multiple internal medicine experts agreed that a referral during the 2016 appointment could have provided an earlier diagnosis of cancer, and the metastatic progression could have been avoided. Ultimately, the case was taken to trial and a defense verdict was returned in favor of the insured physician. Jurors viewed the patient’s failure to schedule the recommended follow-up appointments as a missed opportunity on his behalf for an earlier diagnosis.
 

Key Takeaways 

• Providers should always document attempts to have patients return for follow-up appointments with specific instructions, including a time frame and reason for the visit with an outline of the medical decision-making plan, including potential next steps. 
• Practices should have a tracking system for patients with abnormal labs who require follow-up before the next annual checkup, entering the patient in their recall system for those that do not schedule their appointment immediately.
• Patients should be informed of the risk of non-compliance to follow-up appointment requests, and this interaction should be well-documented in the medical record.

To avoid this scenario, it’s important that practices enable their EHR protocols for optimal reporting and tracking of information. For practices looking to explore more ways to achieve this goal, Curi has developed a program for practice managers called Curi Academy, offering actionable risk mitigation advice and resources. The program consists of four courses that are delivered through a case study approach and offer a certificate of completion. Members are invited to click here to access Curi Academy to learn more and participate. 

The opinions expressed herein are not intended as legal advice. We have found that the use of such information reduces the risk of medical malpractice claims, but we cannot guarantee that following this advice will prevent a claim against you or your practice.