Transfer of care can create problems
Of interest to all physicians
The Association has numerous examples of trouble arising from the transfer of patient care from one attending physician to another. This may involve emergency transfers, or a change of shift, or coverage for days off, weekends, and vacations.
The following case, although complicated by other factors, serves as an illustration.
The facts of the case
A 27 year-old female patient at eight weeks gestation presented to her family physician on a Friday morning with a chief complaint of vomiting.
Almost two years earlier she had been referred by that physician to an internist for assessment of hyperpigmentation and hypotension.
Addison’s disease had been considered but had been felt to be excluded by a normal serum cortisol.
Following assessment on this visit, the family physician diagnosed hyperemesis gravidarum and arrangements were made to admit her to the local community hospital later that day. Orders were written for an IV of five per cent dextrose and water to run at 100 cc/hour. Laboratory tests including electrolytes were requested for the next week day, i.e. Monday.
The following morning, Saturday, her care was transferred to a colleague who performed a consultation that day and documented a seven-pound weight loss over two weeks. That physician prescribed an antinauseant and agreed with the plan for rehydration. The covering physician reassessed her on Sunday and a progress note documented continued vomiting. He ordered an antinauseant, following a discussion with the patient regarding risks. No attempt was made to expedite the electrolyte testing.
When the original attending physician returned early Monday morning he noted that the patient had continued to vomit over the weekend. As he knew that the routine blood work ordered on admission would be carried out later that day, he took no further action at that time. He left the IV orders unchanged. He did not call back for the results.
The patient injury
The serum sodium result of 107 mEq/L was available to the ward at 0952 h but the physician did not learn of this result until Tuesday morning. The patient suffered significant and irreversible neurological sequelae. The hyponatremia was ultimately demonstrated to be due to Addison’s disease. Final diagnoses were:
Litigation ensued. The physician’s lawyer was unable to find expert support for the care by the family practitioners involved. Areas of concern included the fact that the past medical history was not available to the covering physician and the failure of the covering physician to review more closely the fluid and electrolyte status in view of continued vomiting.
This unfortunate case outlines certain difficulties as they relate to transfer of care. When you are transferring care you should consider the following questions:
This case also demonstrates the importance of having a mechanism in place so that significantly abnormal test results are made known to physicians in a timely fashion.