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A Failure to Communicate Results in Patient's Death

It doesn't matter how well a surgery or procedure goes if the communication afterward is a failure.

Leonard Jones underwent a surgical fusion of his T9 thru L2 vertebrae. There were no complications with blood pressure, oxygenation, heart rate or ventilation identified. Throughout the first two days of his inpatient stay, Leonard was intubated and sedated while he recovered from his surgery.

On the third day, he began to regain consciousness and follow commands. He was evaluated by a cardiologist who noted his lungs were clear to auscultation and there were no abnormal findings and tube feedings were ordered.

On the fourth day, Leonard was being extubated when his feeding tube became dislodged. It was reinserted but the nurse, Eric Davies, mistakenly put it down Leonard's trachea and into his left lung instead of his stomach. Nurse Davies neglected to confirm its proper placement afterward.

Later that morning, an order was entered by resident Dr. Alice Hick for an abdominal x-ray to confirm placement of the feeding tube. Dr. Matthew Roberts, a radiologist, dictated a report that the feeding tube did not follow the course of the esophagus and stomach and recommended that it be repositioned. This critical finding required immediate, accurate and direct verbal communication to the health care team and/or ordering physician.

Dr. Roberts did not call the floor nurse or the ordering physician to inform them of the misplaced tube. Dr. Hick also failed to review the abdominal x-ray to determine proper placement. As a result, the feeding tube was never taken out and repositioned.

Another provider, Dr. Marcos Tumi, supervisor for Dr. Hick, documented that he had reviewed imaging, laboratory and other studies. Despite the report and the x-ray imaging showing that the feeding tube was not in Leonard's esophagus, Dr. Tumi gave no orders to reposition it. 

Nurse Cindy Reinhart had not received permission or clearance from the ordering physician, Dr. Hick, to begin using the tube. And, despite information being readily available to show that it was likely in Leonard's lung, she began to administer feeds, medications and water into the feeding tube. Additionally, Nurse Reinhart documented that the placement of the feeding tube was verified by auscultation and x-ray verification, both of which were inaccurate.

As the day progressed, Leonard's family members pleaded with the nurses that something was wrong, pointing out that Leonard had gurgling sounds in his airway. Nurses failed to respond to the family’s concerns and refused to contact a physician to examine him.

That evening, Nurse Beth Stack documented that Leonard's breath sounds were “diminished,” he had a weak cough and he had “upper airway congestion.” She did not, however, contact a physician to evaluate Leonard. She, too, inaccurately documented that she verified the placement of the feeding tube. Further, she reported the family was anxious and still complaining that something was wrong.

Late into the evening, Leonard was seen by a respiratory therapist. At the time, the therapist documented that he had upper airway congestion and performed chest physiotherapy. After the therapy, respirations were 28, breath sounds were diminished, his SpO2 had dropped to 94% and she reported that he did not tolerate the treatment. The therapist did not check Leonard's airway nor did she notify a physician of his respiratory status. An hour later nursing staff recorded his pain as high with shallow breaths, tense fascial expressions and tension in his muscles.

Two hours later, Nurse Stack noted his breathing was shallow. No one requested a physician to come and evaluate Leonard. In the early morning hours of the fifth day, his respiratory status continued to decline, SPO2 declined, and he was unresponsive. Blood gases and a chest x-ray were ordered. The blood gases were a significant change from previous blood gas results.  A chest x-ray showed Leonard's left lung was full of fluid after the feeding tube was removed.

Nurse Sue Murray-Case noted that the x-ray showed the feeding tube to be in the airway and not in Leonard's stomach. A bronchoscopy was performed to suction the fluid out of the lung. Another x-ray taken after the bronchoscopy was performed, still showed the left lung with a substantial amount of fluids. Leonard died shortly after the bronchoscopy procedure was concluded.

What Can We Learn

Communication breakdowns between clinicians are one of the most common causes of medical errors and patient harm. A lack of communication of test results is problematic and can negatively impact patient safety, patient care and patient outcomes. Poor or lack of communication regarding diagnostic test results can lead to allegations of a missed diagnoses, delayed diagnosis and/or patient harm.

Radiologists are responsible for communicating test results to the health care team and, in some cases, directly to the patient. In situations where the test result is life-threatening or is a critical finding (abnormal), radiologists should always communicate test results directly to the ordering provider and/or the health care team members providing care to the patient.

Developing an effective process to ensure communication of test results occurs and occurs timely includes identification of the following: 

  • Who needs to receive the test results
  • How and when are the results are to be communicated
  • How and to whom abnormal/life-threatening test results must be verbally communicated
  • How communication is acknowledged (documented)

Clear Communication

Your process for communication of test results should also include:

  • The clear delineation of responsibilities for staff and providers
  • Clear definitions of key terms (abnormal, critical, etc.)
  • Use of alerts
  • Outline steps to be taken for fail-safe and timely communication of test results especially those of a critical or significant risk to patient safety

A “critical results/critical finding policy” should be developed and updated annually and must state that a provider must verbally relay critical results directly to the ordering physician and/or nurse lead, when appropriate.

To improve communication of test results in the hospital/in-patient setting consider the following:

  • Sign and date (authenticate) the test result acknowledging your review of the information.
  • Ensure test results are communicated to someone responsible for the affected patient's care. (i.e. ordering physician, floor nurse, nurse lead, etc.)
    • Document the time/date, person’s name, title, details of your discussion and any instructions provided.
  • Ensure that test results are timely communicated to a backup provider in the event that the ordering provider is not available.
    • Document the time/date, person’s name, title, details of your discussion and any instructions provided.
  • Critical results/findings should be immediately and clearly verbally communicated to the ordering physician and/or nurse caring for the patient.
    • Document the time/date, person’s name, title, details of your discussion and any instructions provided.

To improve communication in the outpatient setting consider the following:

  • Sign and date (authenticate) the test result acknowledging your review of the information.
  • Explain the test results directly in the portal.
    • Document your discussion and instructions.
  • Give patients personalized information, when possible, to help them understand the results and/or your recommendations.
    • Document your discussion and instructions.
  • Create standards on timing and best practices for the release of normal and abnormal test results to the portal.
  • Critical results/findings should be immediately and clearly verbally communicated to the ordering physician.
    • Document the time/date, person’s name, title, details of your discussion and any instructions provided.

If you would like to discuss a particular situation, please contact our risk management division at 888-336-2642 or email.

The information provided is offered solely for general information and educational purposes. It is not offered as, nor does it constitute, legal advice or opinion. You should not act or rely upon this information without seeking the advice of an attorney.

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