Case Study
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)
This is a fictitious case that illustrates commonly encountered issues and is for educational purposes only. Any resemblance to real persons, living or dead, is purely coincidental.
This page is an excerpt of the full Candello report: Malpractice Risks in the Diagnostic Process.
Diagnostic Process Report Contents
See More MPL Cases
Medication Mix-up Contributes to Patient’s Death
EHR Routing Failure Leads to Delayed Cardiology Follow-Up
When Performance Management and Medical Leave Intersect
